The presence of symptomatic pericardial fluid is an indication for drainage, not surgery. Suspected or proven tamponade is best treated by pericardiocentesis which is accomplished easily under local anesthesia. General anesthesia for an emergent drainage procedure or window in this clinical setting is dangerous and should be avoided. Patients suffering from tamponade need increased endogenous catecholamines for circulatory support. The induction of general anesthesia inhibits these protective autonomic responses and may lead to circulatory collapse before drainage can be effected. With drainage, the acute crisis of tamponade is at least postponed. A single tap, however, is unlikely to prevent reaccumulation unless the underlying causes can be addressed. For infectious or postcardiotomy processes, antibiotics, steroids, and/or nonsteroidal agents may halt disease progression. Malignant effusions are usually a marker for advanced, systemic disease. Thus, expecting a patient to respond expeditiously to chemotherapy or radiation therapy is not practical. canadian health care mall
Given malignant cytologic findings or a proteinaceous effusion and a history of malignancy, definitive and durable drainage becomes the goal of treatment. These malignancies are presumed to be advanced, and efforts to minimize hospitalization and improve quality of life are paramount. The absolute indications for operative treatment of a malignant pericardial effusion remain abnormal results of cytologic study or recurrence of a symptomatic effusion. Table 3 lists the published techniques for definitive management of symptomatic malignant pericardial effusions. Pericardiocentesis alone is inadequate for long-term palliation, with recurrence rates as high as 90% within 90 days. Four of the remaining five techniques involve creating a window for fluid to drain to another reabsorptive cavity such as die pleura, peritoneum, or, in die case of a subxiphoid window, the preperitoneal subcutaneous space.
Table 3—Efficacy of Various Methods to Control Malignant Pericardial Effusions
|Technique||Control Efficacy at 3 mo, %|
|Pericardiocentesis with sclerosis||75|
|Thoracoscopy with window-||95|
|Thoracotomy with window||90|