Ann Thorac Surg 2005;79:386-387
© 2005 The Society of Thoracic Surgeons
Correspondence
Subxiphoid Pericardiostomy Versus Percutaneous Extended Catheter Drainage
Keith B. Allen, MD
Heart Center of Indiana, 10590 N Meridian St, Suite 105, Indianapolis, IN 46290, USA
kallen2340{at}aol.com
To the Editor:
Buchanan and colleagues [1] detail their experience in 29 patients with pericardial effusions and suggest that echocardiography-guided pericardiocentesis and extended catheter drainage is a safe and effective management. However, their definition of safe and effective challenges the imagination. They report a 10% (3 of 29) conversion rate to a thoracotomy for complications that included a left ventricular tear, a right ventricular tear, and inability to appropriately position the pericardial drain. All of these misdirected catheters occurred under the guise of accurate echocardiographic guidance. We reported a similar ventricular perforation rate of 9% (2 of 23) resulting in 1 death when cardiologists trained in echocardiography performed the same technique [2]. Furthermore, Buchanan and colleagues [1] narrowly defined the effectiveness of this technique as a clinically significant recurrence within 30 days, and they reported a 7% recurrence rate. However, in our series, average time to symptomatic recurrence was 39 days, and when patients were followed-up long enough this resulted in a 33% recurrence rate [2].
In contrast, in a large series of patients with pericardial effusions treated with subxiphoid pericardiostomy, we reported no operative deaths, a complication rate of only 1% (1 of 94), and a pericardial effusion recurrence rate of 1% (1 of 94) [2]. These results were reaffirmed in a larger series of patients formed from two centers [3]. Subxiphoid pericardiostomy is a simple and safe procedure for the treatment of malignant and nonmalignant pericardial effusions. The procedure can be performed under local anesthesia in approximately 50% of patients and allows direct visualization, biopsy, and exploration of the pericardium and pericardial cavity. Although there is no hard and fast rule regarding the duration of subxiphoid drainage, in our experience and that of others [4], suction through a large pericardial tube for 4 to 5 days places the parietal and visceral pericardium in apposition, a prerequisite for symphysis to take place. Pericardiocentesis with extended catheter drainage should be reserved for patients with hemodynamic instability who would not tolerate a safer and more definitive therapy.
References
- Buchanan CL, Sullivan VV, Lampman R, Kulkarni MG. Pericardiocentesis with extended catheter drainage: an effective therapy. Ann Thorac Surg. 2003;76:817–820[Abstract/Free Full Text]
- Allen KB, Faber LP, Warren WH, Shaar CJ. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg. 1999;67:437–440[Abstract/Free Full Text]
- Moores DWO, Allen KB, Gillman DJ, et al. Subxiphoid pericardial drainage for pericardial tamponade. J Thorac Cardiovasc Surg. 1995;109:546–552[Abstract/Free Full Text]
- Sugimoto JT, Little AG, Ferguson MK, et al. Pericardial window: mechanism of efficacy. Ann Thorac Surg. 1990;50:442–445[Abstract]
