Pericardial effusions can result from various clinical entities. Occasionally, pericardial effusion may result in cardiac tamponade requiring immediate drainage. In some patients, especially those with malignant pericardial effusions, the effusions may recur and require further therapy other than pericardiocentesis. Surgical pericardial window creation in critically ill patients requires general anesthesia and carries an increased risk of morbidity and mortality.1 Percutaneous balloon pericardiotomy (PBP) is a less invasive procedure that has been performed mainly in patients with malignant effusions, as well as in miscellaneous cases of pericardial effusion with tamponade, recurrent pericardial effusions, or for initial therapy at the time of pericardiocentesis.2–19 PBP is relatively contraindicated in cases of infected pericardial effusions.20 We present a patient with a purulent pericardial effusion who underwent successful PBP as an alternative for high-risk surgical pericardial window creation. Case Report. A 59-year-old African-American male presented to the emergency department with 5 days’ history of cough, fever, and pleuritic chest pain. He had a history of interferon non-responder hepatitis C, diabetes mellitus, chronic renal insufficiency, Barrett’s esophagus and schizophrenia. On physical examination, his pulse was 125 beats/minute, blood pressure 103/82 mmHg and respiratory rate 28 breaths/minute. His neck veins were not visualized, his lungs had right basal rhonchi, and cardiac examination did not disclose any murmurs, gallops or pericardial rubs. His ECG showed diffuse ST-segment elevations suggestive of pericarditis. Serial cardiac markers were negative. A chest X-ray showed right lower lobe infiltrate. He was admitted to the intensive care unit and was started on intravenous antibiotics. A transthoracic echocardiogram (TTE) was performed the next morning and revealed a small pericardial effusion without evidence of tamponade. His blood cultures grew Hemophilus influenza in 4 out of 4 bottles within 24 hours of admission. He responded poorly to medical therapy, and over the next 2 days he continued to be tachycardic and tachypneic with marginal blood pressure and oxygenation, though he did not require intubation and mechanical ventilation. On the fourth day of admission, he was noted to have pulsus paradoxus. A repeat TTE revealed a large pericardial effusion with systolic right atrial and diastolic right ventricular collapse suggestive of cardiac tamponade (Figure 1A). The pericardium was thickened and the pericardial space contained echo-dense fibrinous-like material. He was evaluated by cardiovascular surgery for consideration for a pericardial window, and was considered a high-risk surgical candidate. At that time, he was septic, tachycardic, hypotensive and in respiratory distress, with marginal oxygenation from a right lobar pneumonia and tamponade. He also had altered mental status and acute renal failure. The patient was taken emergently to the catheterization laboratory. Right heart catheterization revealed elevated filling pressures with equalization of diastolic pressures in the right atrium (RA), right ventricle, pulmonary artery and the pulmonary wedge pressure (Figure 2A). Pericardiocentesis was performed under echocardiographic and fluoroscopic guidance. Local anesthesia was administered to the skin and subcutaneous tissue, and the pericardiocentesis needle was gradually advanced from the subxiphoid area in a crano-anterior direction into the pericardial space. The correct localization of the needle in the pericardial space was confirmed by injecting bubble contrast under direct visualization with TTE. A J-tip wire was then advanced into the pericardial space, and the pericardiocentesis needle was removed. An 8 Fr pericardial draining catheter was then advanced over the wire into the pericardial space and showed equalization of the pericardial and RA pressures (Figure 2B). Approximately 600 ml of yellow, thick and turbid fluid was aspirated with difficulty under negative pressure from the pericardial cavity after which the pericardial filling pressure decreased and separated from the RA pressure, along with a decrease in the end-diastolic pressures (Figure 2B). Repeat TTE examination revealed a decreased size of the pericardial effusion, however, with persistence of the thickened pericardium and dense fibrinous material, with clogging of the draining catheter (Figure 1B). In view of the ongoing pericardial inflammatory process, the thick and tenacious nature of the pericardial fluid that was difficult to aspirate under negative pressure, and in order to reduce the risk of reaccumulation and tamponade, a balloon pericardiotomy was performed. Ten ml of radio contrast was injected into the pericardial space to aid in visualization of the pericardial border (Figure 3A). A J-tipped guidewire was then advanced into the pericardium so that it looped within the pericardial space. A 20 mm-wide x 18 mm-long balloon was advanced over the guidewire and was inflated across the pericardium. Inflation of the balloon was repeated until the waist of the pericardium over the balloon was lost (Figures 3 B–D). After dilatation, the balloon was removed and replaced by a draining catheter. Immediately after the procedure, the patient’s tachycardia, tachypnea and marginal blood pressure improved. The pericardial fluid gram stain showed 4+ white blood cells, with no bacteria. Studies for fungi and tuberculosis were negative. The pericardial fluid culture grew Ochrobacterium anthropi. He subsequently had a smooth hospital course, with good response to intravenous antibiotics. He defervesced 1 day after drainage of the pericardial effusion, and remained afebrile throughout the remainder of his hospital stay and during outpatient follow up. Repeat blood cultures were negative for any growth. Repeat TTE studies over the next few days revealed some reaccumulation of the pericardial fluid, but with no evidence of tamponade. The patient was discharged from the hospital in stable condition. He was subsequently seen in the cardiology clinic 2 weeks later, where he continued to do well. A repeat TTE then revealed a small residual pericardial effusion, with no evidence of tamponade. A follow-up TTE 3 months later showed no pericardial effusion. At a follow-up visit 10 months after PBP, he continued to do well, with no chest pain, heart failure or infectious symptoms. Discussion. Our patient presented with a Hemophilus influenza pneumonia complicated by sepsis, with development of a complex and purulent pericardial effusion and pericarditis. The Ochrobacterium anthropi that grew from the pericardial fluid is most likely a contaminant, and not a primary pathogen. This case illustrates the feasibility and usefulness of PBP in specific situations where a surgical procedure such as a pericardial window might be necessary. Our patient was too critically ill to undergo a surgical pericardial window. We believe that the PBP helped prevent reaccumulation of the pericardial fluid, prevented another tamponade and helped his recovery. There were no adverse events related to the PBP. The patient was already on empiric antibiotics with ciprofloxacin and zosyn for 3 days prior to the pericardial drainage. We believe that systemic antibiotics helped minimize the risk of infection spread, which is always a concern and a reason for not performing PBP routinely in infected pericardial effusions. Palacios et al. first described the procedure of PBP in 1991.15 He recommended this technique as an alternative to surgical pericardial window in patients with malignant pericardial effusion and tamponade. Chow et al. studied the mechanism of pericardial window creation during autopsy in 12 adults with normal pericardium.21 The histological assessment revealed breakage of the collagen and elastic fibers and disruption of their alignment at the edge of the pericardiotomy site. The balloon inflation resulted in a localized tearing in the parietal pericardium creating a communication between the pericardial and pleural, or rarely, the abdominal cavities. Ziskind et al. reported on the safety and effectiveness of this procedure in 50 patients with large pericardial effusion and tamponade.19 Forty-four of these patients had malignancy-related effusions. The procedure was successful in 46 patients during a 3-month follow-up period, giving an efficacy of 90%. One patient in their series required surgical intervention due to pericardial bleeding. Thanopoulos et al. reported the outcomes of 10 children with malignant recurrent effusions treated with PBP.17 They also reported a success rate of 90% over a 14-month follow-up period, with no complications requiring surgical intervention. Other authors have described a modified double-balloon technique with one short and one long balloon for pericardiotomy.18 In this modification, two balloons, one large and one small, are inflated simultaneously across the pericardium. The smaller balloon is then pushed and pulled across the pericardial border in an attempt to create a larger window in the parietal pericardium. Wang et al. reported the results of this modified technique in 50 patients.18 The procedure was successful in 44 patients. Five patients had recurrence of their effusion that required further percutaneous or surgical pericardiotomy. In the multicenter PBP registry that involved 130 patients, 85% of PBP were performed in patients with malignant pericardial effusions, and the rest were performed in patients with idiopathic effusions, HIV disease, postoperative/traumatic effusions, uremia, renal transplantation, hypothyroidism, congestive heart failure, autoimmune disease and viral infection.20 To the best of our knowledge, the use of PBP in bacterial pericardial effusions has not been previously reported. In the PBP registry, PBP was successful in 85% of cases, with no recurrence of the pericardial effusion at 5 ± 5.8 months of follow up. The most common complication was fever that occurred in 11 patients, though no patient showed evidence of bacteremia or infected pericardial fluid. Prophylactic antibiotic therapy is thought to decrease these febrile episodes. Large pleural effusions have been reported within 12 to 24 hours of PBP, and have required thoracenteseis or chest tube placement in 9% of patients without preexisting pleural effusions in the PBP registry.20 In summary, percutaneous balloon pericardiotomy technique can be safely performed in the management of purulent pericardial effusions with tamponade in patients who are at a high operative risk for precicardial window. It is an effective, less invasive alternative to a surgical pericardial window, and circumvents the need for general anesthesia in these patients, although the risk of infection spread remains a concern. Pretreatment with intravenous antibiotics might decrease this risk.
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