Pericardial-peritoneal window: a novel palliative treatment for malignant and recurrent cardiac tamponade.

Transdiaphragmatic approach to the pericardium through a subxiphoid incision is a safe, rapid, and effective way to obtain drainage of the pericardium fluid in patient of disseminated malignancy with recurrent cardiac tamponade. No drainage tubes are needed; pericardial fluid is absorbed by the peritoneum; there is no need for double lumen tubes for single lung ventilation and the subxiphoid incisions are small and almost painless.

INTRODUCTION

The management of a patient of disseminated malignancy with recurrent cardiac tamponade is a therapeutic challenge. Treatment of such patients is directed at palliation only and a simple yet effective method of drainage is desired. There is limited literature on the management of recurrent pericardial effusion and treatment options include repeated aspirations, pigtail placement, balloon pericardiostomy, and surgical pericardial window.[123456] The current article describes the surgical treatment of a patient of disseminated malignancy with recurrent cardiac tamponade and review the literature on its management.

CASE REPORT

A 61-year-old male had presented to the hospital with symptoms of chronic cough with expectoration and hemoptysis since 6 months. He complained of sudden onset breathlessness since last few days. On evaluation, conventional radiographs of the chest demonstrated an enlarged cardiac silhouette [Figure 1a]. Contrast-enhanced computerized tomography (CECT) revealed disseminated lung cancer, bilateral pleural effusion, and massive pericardial effusion [Figure 1b]. An echocardiogram was performed which had features of massive pericardial effusion (6 cm space between the two layers of pericardium) and right ventricle diastolic collapse. Pericardial fluid was aspirated thrice before a definitive surgical procedure was planned. Cytology of the peritoneal fluid showed signs of malignancy. Patient was diagnosed to have recurrent cardiac tamponade secondary to disseminated lung malignancy.

Figure 1

(a) Chest radiograph shows significant enlargement of the cardiac silhouette. (b) Axial contrast-enhanced CT image of the chest shows a large pericardial effusion flattening the anterior cardiac contour, along with bilateral pleural effusion

In view of recurrent cardiac tamponade and patient being in an already compromised state dying of disseminated disease, a definitive surgical procedure was planned. Surgical pericardial-peritoneal window was planned through a subxiphoid approach under local anesthesia.

Technique

After the pericardial sac was exposed and the fluid evacuated, the diaphragmatic surface of the pericardium was examined. An opening of (4 × 4 cm) was created to join the pericardial and peritoneal cavities [Figure 2]. The cut edges of the pericardium, diaphragm, and peritoneum were sutured together with a few interrupted sutures. The dome of the liver prevents any abdominal viscera from herniating into the pericardial cavity. No drainage tubes are needed. The linea alba, subcutaneous tissues, and skin were closed in the usual manner. No complications were encountered and patient was discharged in 2 days. Patient experienced significant symptom amelioration after undergoing pericardioperitoneal fenestration.

Figure 2

Surgical photo of large pericardial-peritoneal window. After the creation of window, interrupted sutures are placed to hold all layers together and to ensure patency

DISCUSSION

Though the surgical management of malignant pericardial effusion is directed at palliation only; a simple, safe, and effective method of drainage is desirable. Success has been often measured on the symptom relief and the better quality of life (QoL). To be effective, the procedure must not only relieve cardiac tamponade immediately but must also prevent recurrence.

Many minimally invasive methods of treating malignant pericardial effusion have been proposed. However, they are not always effective. Pericardiocentesis alone was associated with a 60-100% recurrence rate even when repeated frequently.[12] Several pericardial sclerosing agents (chemotherapeutic agents, tetracycline) have been used with varying success rates.[34] Radiation treatment in radiosensitive tumor has been tried, but even in these patients, the response rate is only 50-60%.[7]

Pericardial resection by either the subxiphoid or thoracotomy approach has been demonstrated to be effective with very low recurrence.[689] Proponents of the thoracotomy approach emphasize the importance of wide pericardial resection, as larger pericardium removed appears to correlate with decreased long-term recurrence.[89] In the study of Wang et al.,[10] the thoracotomy approach is associated with a significantly higher postoperative morbidity (53%) and mortality (42%). In view of the higher morbidity and the present case being a disseminated lung cancer, we did not favor the thoracotomy approach. Larger pericardial windows can also be created through the subxiphoid approach.[611] Through the pericardial-peritoneal window, the subdiaphragmatic recess acts as a collection chamber for the pericardial fluid and the fluid is absorbed by the peritoneum.

Newer technique of pericardioperitoneal shunt insertion was developed in the hope of achieving improved palliation.[12] Though the procedure was simple and effective, it is commonly associated with shunt thrombosis and recurrence of effusion.[1213] Olson et al.,[14] in their 11 years of experience with 33 patients, the surgical pericardioperitoneal window reported no mortality directly related to the pericardial effusion or the procedure. None of their patients developed peritoneal carcinomatosis or diaphragmatic hernia and only one patient developed recurrent pericardial effusion.

CONCLUSION

The pericardioperitoneal window is low morbid surgical procedure in the treatment of recurrent pericardial effusion that is not only simple to perform, but also effective in achieving the goal of palliation for these patients with advanced underlying malignancy.