Controversy surrounds the mechanism for a successful pericardial window. Some investigators cite autopsy evidence fliat windows remain open long after the effusive process is over. Sugimoto et al believe that obliteration of the space is the goal of therapy and maintain pericardial drains on suction for between 3 and 28 days to effect visceral to parietal pericardial symphysis. These observations have led other groups to explore simple catheter drainage with the instillation of a sclerosant, much as is done with MPEs. One study with tetracycline showed control of effusions in 15 of 19 patients surviving longer than 1 month. Maher et al recently reported similar results using tetracycline sclerotherapy given via a percutaneously placed catheter in 85 of 93 patients referred with symptoms related to pericardial effusions. These clinicians achieved 30-day control of the effusive process in 73% of cases with a median of three sclerosing sessions per patient (range, 1 to 8). During their 15-year experience, tetracycline became unavailable, and doxycy-cline was used in the last five patients without any obvious decrement in efficacy. Other investigators have successfully used either doxycycline or bleomycin as pericardial sclerosants. cialis professional
The most aggressive approach to management of symptomatic pericardial effusions has been a limited anterior thoracotomy with anterior pericardiectomv allowing wide communication between the pleural space and the pericardium. Piehler et al correlated extensive pericardial resection with subsequent clinical efficacy. With the advent of video-assisted surgery, others have modified traditional open techniques to achieve similar pericardial resection via minimally invasive approaches. Both open and video-assisted thoracic surgical methods allow operators to simultaneously address coexistent pleural effusions or loculated pericardial collections, which afflict, on average, one third of patients.
As with MPEs, there are no definitive, prospective, comparative trials regarding optimal treatment for patients with malignant and symptomatic pericardial fluid collections. Clinicians and investigators must continue to search for safe, flexible, and durable modes to palliate these patients while simultaneously containing costs and preserving the quality of their limited remaining life span.