Ann Thorac Surg 2004;78:1084-1085
© 2004 The Society of Thoracic Surgeons
Case report
AIDS-related cardiac tamponade: Is surgical drainage justified?
Theodosios J. Dosios, MDa,
Nikolaos P. Theakos, MDb,*,
Dimitrios C. Angouras, MDb,
Olga I. Katsarou, MDc,
Panayiotis J. Asimacopoulos, MDb,d
a Athens University Medical School, Athens, Greece
b Henry Dunant Hospital, Athens, Greece
c Second Regional Blood Transfusion and Hemophilia Center, Laikon Hospital, Athens, Greece
d Baylor College of Medicine, Houston, Texas, USA
Accepted for publication June 23, 2003.
* Address reprint requests to Dr Theakos, Kosma Etolou 3, Marousi, 15125, Athens, Greece
ntheakos{at}hotmail.com
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Abstract
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In order to evaluate the usefulness of surgical drainage in the treatment of patients with acquired immunodeficiency syndrome (AIDS)–related cardiac tamponade, we reviewed our experience with subxiphoid pericardiostomy on 5 consequent such patients. One patient died in the immediate postoperative period and the remaining 4 died within 21 weeks after the operation. Similar results have been reported by other authors who found that surgical drainage has no diagnostic or therapeutic benefit over pericardiocentesis in this particular group of patients. Based on our limited experience and the data of the literature, we feel that surgical drainage cannot be justified as the primary method of treatment of AIDS-related cardiac tamponade.
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Introduction
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The reported incidence of pericardial effusion in acquired immunodeficiency syndrome (AIDS) patients is 11% per year [1]. Nine percent of these effusions lead to cardiac tamponade annually [1]. Urgent drainage is obviously a lifesaving treatment for these patients but the method of drainage is debatable. In general, pericardiocentesis is considered readily available, easy to perform, and effective in the acute management of symptomatic pericardial effusion, irrespective of the underlying cause [2]. On the other hand, surgical drainage has numerous advantages: the risk of heart injury associated with pericardiocentesis is avoided, the effusion is effectively drained even if it is located posteriorly or loculated, a pericardial biopsy is performed that increases the diagnostic efficacy of the procedure, and the possibility of recurrent effusion is dramatically decreased.
In order to evaluate the usefulness of surgical drainage in the treatment of AIDS-related cardiac tamponade, we herein present our 11 years experience with surgical drainage on 5 consequent such patients along with a brief review of the literature. All patients underwent subxiphoid pericardiostomy, also known as pericardial window.
From January 1, 1991 through December 31, 2001, 5 consecutive AIDS patients with evident or impending cardiac tamponade underwent subxiphoid pericardiostomy by one surgeon. All patients were men. Cardiac tamponade was diagnosed on the basis of clinical and echocardiographic findings. One patient, with AIDS-related cardiomyopathy, developed low cardiac output syndrome immediately after surgery and died three days later in spite of vigorous inotropic support. There were no other major postoperative complications in the remaining 4 patients who manifested dramatic improvement of their clinical condition after the operation. All patients died within 21 weeks after the operation with no recurrence of the pericardial effusion. Their mean survival time was 10.3 (± 7.7) weeks. The patients' age, concomitant disease(s), preoperative Karnofsky score, human immunodeficiency virus (HIV) stage (according to Centers for Disease Control [CDC]), CD4 cell count, histologic examination of the pericardium, cytologic examination of pericardial fluid, postoperative hospital stay, and survival time are presented in Table 1.
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Comment
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The findings of this retrospective study highlight that the prognosis of patients with AIDS-related cardiac tamponade submitted to surgical drainage is ominous. Our results are compared to those reported in literature. We utilized the Medline database to perform an English language literature search from 1984 up to date using the terms: HIV, AIDS, cardiac tamponade, pericardiocentesis, and pericardial drainage. We were able to isolate a total of 45 patients presented in 4 series[3–6] with at least 5 patients each. Twenty-nine of these patients underwent pericardiocentesis and the remainder surgical drainage. In-hospital mortality ranged between 0% and 46%. Flum and colleagues [3], who reported on 9 such patients, had almost identical results to ours. All their patients were treated with surgical drainage and all were followed up. No patient survived more than 22 weeks after the operation. Reynolds and colleagues [4] treated 10 patients with pericardiocentesis and found that, in most cases, fluid analysis alone is not useful in determining the cause of pericardial effusion. There was no follow-up of their patients. Kwan and colleagues [5] treated 11 patients. Six of them underwent pericardiocentesis and 5 were submitted to surgical drainage. Five patients died in-hospital within 7 weeks after the operation. There was no follow-up of the 6 patients who left the hospital alive. Chen and colleagues [6] reported on 15 patients, 13 of whom were submitted to pericardiocentesis and 2 to surgical drainage. They had no in-hospital deaths. Ten patients were followed up for 12 months and 3 of them were survivors at the end of that period. The authors concluded that pericardial effusion in AIDS patients is a sign of shortened survival.
On the other hand, the diagnostic usefulness of subxiphoid pericardiostomy in our patients was negligible. Cytologic and histologic examination of the surgical specimens provided evidence of malignant pericardial invasion in one patient who had already been diagnosed with non-Hodgkin lymphoma. In the remaining 4 patients, the histologic diagnosis was "nonspecific pericarditis" and the cytologic examination was negative for malignancy. Bacteriological examinations were all negative. Others have reported similar results [4, 5, 7]. Interestingly, unlike non-AIDS-related pericardial effusions, surgical drainage does not appear to have a better diagnostic yield over pericardiocentesis, as the diagnosis in AIDS patients seems to be mainly dependent on examination of the pericardial fluid and not on histology of the pericardium. Based on our limited experience and the data of the literature, we feel that surgical drainage cannot be justified as the primary treatment of patients with AIDS-related cardiac tamponade. The prognosis of these patients is grave regardless of the method of treatment. Therefore, the utilization of a more invasive and expensive approach apparently offers no benefit. For this reason, we suggest that pericardiocentesis, preferably under ultrasound guidance, should be the procedure of choice for AIDS patients with cardiac tamponade. In case of recurrence, a percutaneous balloon pericardiostomy seems a reasonable option, as it combines permanent drainage with minimal invasiveness [8]. Surgical drainage can be justified only in the unusual case of recurrent cardiac tamponade following percutaneous balloon pericardiostomy.
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References
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- Heidenreich PA, Eisenberg MJ, Kee LL, et al. Pericardial effusion in AIDS: incidence and survival. Circulation. 1995;92:3229–3234[Abstract/Free Full Text]
- Bastian A, Meissner A, Lins M, Siegel EG, Moller F, Simon R. Pericardiocentesis: differential aspects of a common procedure. Intensive Care Med. 2000;26:572–576[Medline]
- Flum DR, McGinn JT Jr, Tyras DH. The role of the ‘pericardial window’ in AIDS. Chest. 1995;107:1522–1525[Abstract/Free Full Text]
- Reynolds MM, Hecht SR, Berger M, Kolokathis A, Horowitz SF. Large pericardial effusions in the acquired immunodeficiency syndrome. Chest. 1992;102:1746–1747[Abstract/Free Full Text]
- Kwan T, Karve MM, Emerole O. Cardiac tamponade in patients infected with HIV. A report from an inner-city hospital. Chest. 1993;104:1059–1062[Abstract/Free Full Text]
- Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M. Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature. Am Heart J. 1999;137:516–521[Medline]
- Zakowski MF, Ianuale-Shanerman A. Cytology of pericardial effusions in AIDS patients. Diagn Cytopathol. 1993;9:266–269[Medline]
- Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovasc Diagn. 1991;22:224–244
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Abstract
Introduction
