Case presentation

A 65-year-old woman presents with a recurrent pericardial effusion. Her history began 4 years earlier when she was diagnosed with adenocarcinoma of the breast. She underwent lumpectomy without adjunctive chemotherapy or radiation. Several months earlier, she had complained of shortness of breath and was found to have a large, malignant left pleural effusion treated with thoracentesis. Beginning 3 weeks prior to the present admission, she again developed progressive shortness of breath along with cough, fatigue and a 12-pound weight loss. Evaluation at a local hospital demonstrated an enlarged cardiac silhouette on chest x-ray consistent with a pericardial effusion, and a left-sided pleural effusion with mild pulmonary vascular congestion. A CT scan of the chest suggested neoplastic disease progression. There was left upper lobe atelectasis and consolidation, encasement of the pulmonary artery with a mass, pathological mediastinal lymphadenopathy, and a large pericardial effusion. She was referred for further management of the effusion.

Upon presentation, she was in mild distress from dyspnea, but remained hemodynamically stable with a blood pressure of 150/70 mmHg and, although physical examination confirmed elevation of the jugular venous pressure, there was no pathologic pulsus paradoxus. The electrocardiogram showed sinus tachycardia with low voltage and echocardiography revealed a large circumferential pericardial effusion (Figure 46-1) along with right ventricular collapse and right atrial inversion consistent with tamponade. She underwent pericardiocentesis with removal of 750 mL of serosanguineous fluid. Cytological analysis of the fluid subsequently confirmed adenocarcinoma. A pericardial drain remained in place and she was admitted for continued observation. Over the ensuing 2 days, more than 200 mL of fluid drained from the pericardial space each day. She was referred to the cardiac catheterization laboratory for a balloon pericardial window.

FIGURE 46-1 Transthoracic echocardiogram demonstrating a large, circumferential pericardial effusion (arrow).

Cardiac catheterization

The patient was positioned on the cardiac catheterization table with the head and torso elevated at roughly 45 degrees. The pigtail catheter drain placed 2 days earlier was removed from the pericardial space. Using sterile technique, and following administration of local anesthesia, a long solid-core needle was positioned into the pericardial space from the subxiphoid approach. An additional 60 mL of fluid was removed from the pericardial space. A 0.038 inch “extra-stiff” Amplatz J-tipped guidewire was advanced through the needle into the pericardial space and the needle was removed. After administration of additional local anesthesia around the entry site, the operator created a tissue tract by passing a 10 French dilator over the guide wire. A valvuloplasty balloon (3 cm long and 20 mm in diameter) was prepared with dilute contrast and advanced along the wire so that the entire balloon was below the skin and the balloon centered across the inferior pericardial border. Prior to this step, the patient was placed in a fully recumbent position to prevent kinking of the catheter and allow easier passage. Using a 60 cc syringe, the balloon was gently inflated under fluoroscopic guidance (Figure 46-2) and a prominent “waist” was noted where the balloon crossed the pericardium. Additional inflation of the balloon led to complete balloon expansion (Figures 46-3, 46-4 and Video 46-1). The balloon was then removed over the guidewire and replaced with a pigtail catheter to remove any residual fluid. The pigtail catheter was then withdrawn and an occlusive dressing was applied to the wound.

FIGURE 46-2 In this figure, a valvuloplasty balloon is centered on the pericardium and slowly inflated until a “waist” appears (arrow).

FIGURE 46-3 The valvuloplasty balloon is further inflated.

FIGURE 46-4 Full expansion of the valvuloplasty balloon creating a pericardial window.

Postprocedural course

A chest x-ray performed immediately after the procedure did not show any evidence of pneumothorax; a small left pleural effusion was present. The next day, an echocardiogram was obtained and showed no recurrence of the pericardial effusion. After discharge from the hospital, she received 11 cycles of chemotherapy (paclitaxel) and remained free of recurrent effusion at follow-up 19 months later.

Discussion

Recurrent effusion is an important limitation to pericardiocentesis and is particularly problematic for patients with malignant effusions, in whom life expectancy is limited. Percutaneous balloon pericardiotomy is an effective and less invasive alternative to a surgical pericardial window for palliation of recurrent malignant pericardial effusions.¹ Performed with a valvuloplasty balloon at the time of pericardiocentesis and creating a rent or tear in the pericardium, the procedure allows drainage of pericardial fluid into the pleural and/or peritoneal space, thus preventing reaccumulation of pericardial fluid and its hemodynamic consequences. This procedure is most effective in patients with malignant effusions and should be avoided in patients with uremic pericarditis because of the increased risk of bleeding. In a multicenter registry involving 130 patients with mostly malignant pericardial effusion, balloon pericardial window was successful in 85% of patients, with success defined as no recurrence or need for surgery. The procedure was unsuccessful in 18 patients (15%); complications consisted of bleeding requiring surgery in five patients (all of whom had uremic pericardial effusions) and recurrence in 13 patients.²

The procedure should be avoided in patients with active infections in the overlying tissues or pericardial space and in those with significant coagulopathy. Balloon pericardial window may not be effective in individuals with large left pleural effusions, as these may prevent adequate drainage to the left pleural space. It also may be ineffective in those who have had extensive chest radiation or surgical scarring, as these conditions may interfere with fluid reabsorption. Complications of percutaneous balloon pericardiotomy include significant pleural effusion, pneumothorax, hemopericardium, hemothorax, infection, and periprocedural pain.