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A 37-year-old woman presented to her local district general hospital with a cough, pleuritic chest pain and intermittent cyanosis. Eight months prior, she underwent a successful pericardial window for recurrent, symptomatic pericardial effusions. On presentation she was hypoxic but haemodynamically stable. Her chest radiograph raised the suspicion of a diaphragmatic hernia, confirmed by CT imaging. This identified herniation through the diaphragm of the transverse colon and left lobe of the liver resulting in cardiac compression and right ventricular dysfunction. She continued to deteriorate and required emergency intubation to allow safe transfer to a tertiary upper gastrointestinal unit. She underwent a laparotomy and repair of the diaphragmatic hernia with an uneventful inpatient recovery. In the literature, diaphragmatic liver herniation is a recognised complication secondary to trauma or congenital defects, however, to our knowledge, there are currently no cases described following pericardial windowing., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The optimal surgical technique for drainage of pericardial effusions is frequently debated. Transpleural drainage via thoracotomy or thoracoscopy is hypothesized to provide more durable freedom from recurrent pericardial effusion than a subxiphoid pericardial window. We sought to compare operative outcomes and mid-term freedom from recurrent effusion between both approaches in patients with nontraumatic pericardial effusions., Methods: All patients at our institution who underwent a pericardial window from 2001 to 2018 were identified. After excluding those who underwent recent cardiothoracic surgery or trauma, patients (n = 46) were stratified by surgical approach and presence of malignancy. Primary outcome was freedom from recurrent moderate or greater pericardial effusion. Secondary outcomes included operative mortality and morbidity and mid-term survival. Follow-up was determined by medical record review, with a follow-up of 67 patient-years. Fisher's exact test and Wilcoxon rank-sum test were used to compare groups. Mid-term survival and freedom from effusion recurrence were determined using Kaplan-Meier method., Results: Subxiphoid windows (n = 31; 67%) were more frequently performed than transpleural windows (n = 15; 33%) and baseline characteristics were similar. Effusion etiologies included malignancy (n = 22; 48%), idiopathic (n = 12; 26%), uremia (n = 8; 17%), and collagen vascular disease (n = 4; 9%). Perioperative outcomes were comparable between the two surgical approaches, except for longer drain duration (7 versus 4 d, P = 0.029) in the subxiphoid group. Operative mortality was 19.6% overall and 36.4% in patients with malignancy. Mid-term survival and freedom from moderate or greater pericardial effusion recurrence was 37% (95% confidence interval [CI]: 19%-54%) and 69% (95% CI: 52%-86%) at 5 y, respectively. There was no difference in mid-term survival (P = 0.90) or freedom from pericardial effusion recurrence (P = 0.70) between surgical approaches. Although malignant etiology had worse late survival (P < 0.01), freedom from effusion recurrence was similar to nonmalignant etiology (P = 0.70)., Conclusions: Pericardial window provides effective mid-term relief of pericardial effusion. Subxiphoid and transpleural windows are equivalent in mid-term efficacy and both surgical approaches can be considered. Patients with malignancy have acceptable operative mortality with low incidence of recurrent effusion, supporting palliative indications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Cardiothoracic surgeons are frequently called upon to perform surgical pericardial drainage procedures (pericardial window) for pericardial effusions. These procedures have therapeutic value, but the diagnostic value of such procedures is debated. We set out to determine the sensitivity of pericardial drainage to detect the disease when cytology, microbiology, and pathology are evaluated., Methods: A retrospective chart review of patients who underwent pericardial windows from 1 July 2011 to 1 January 2018 at a single academic institution was conducted. All patients who had undergone a recent trauma or cardiac procedure were excluded. Cytology, microbiology, and pathology were examined. The charts were then carefully reviewed to determine if a clinical diagnosis was reached. Sensitivity was then calculated for all diseases and for those that should have been able to be detected., Results: One hundred sixty-two patients who had undergone a pericardial drainage procedure were identified; 49 patients were excluded for recent cardiac procedure or trauma. Of the 113 patients who met our inclusion criteria, 56 patients (49.6%) were female with a mean age of 59.7 ± 15.1 years. A diagnosis based on the pathology, microbiology, or cytology was obtained for 27 patients. The most common pathologies detected were adenocarcinoma (11), bacteremia (9), and small cell lung cancer (3); 56 patients had underlying pathologies that would have been possible to detect with either pathology, microbiology, or cytology. The most common detectable diagnoses were adenocarcinoma (20), bacteremia (12), and lymphoma (7). The most common undetectable diagnoses were idiopathic (17), cardiorenal fluid overload (17), and viral (11). The sensitivity of a pericardial drainage procedure for detecting disease was 0.24 for all cases, and 0.48 when restricted to cases where a detectable disease was present., Conclusion: Cytology, microbiology, and pathology for pericardial drainage procedures were unable to detect a diagnosis for 76% of all cases and greater than 50% of cases with the theoretically detectable disease. Pericardial drainage procedures have a clear therapeutic value, but they have limited diagnostic utility., (© 2019 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals, Inc.)

Objective: In this retrospective study, we aimed to observe the efficacy of pericardial effusion (PE) treatments by a survey conducted at the Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University., Methods: In order to get comparable results, the patients with PE were divided into three groups - group A, 480 patients who underwent subxiphoid pericardiostomy; group B, 28 patients who underwent computerized tomography (CT)-guided percutaneous catheter drainage; and group C, 45 patients who underwent echocardiography (ECHO)-guided percutaneous catheter drainage., Results: In the three groups of patients, the most important symptom and physical sign were dyspnea and tachycardia, respectively. The most common causes of PE were uremic pericarditis in patients who underwent tube pericardiostomy, postoperative PE in patients who underwent CT-guided percutaneous catheter drainage, and cancer-related PE in patients who underwent ECHO-guided percutaneous catheter drainage. In all the patients, relief of symptoms was achieved after surgical intervention. There was no treatment-related mortality in any group of patients. In patients with tuberculous pericarditis, the rates of recurrent PE and/or constrictive pericarditis progress were 2,9% and 2,2% after tube pericardiostomy and ECHO-guided percutaneous catheter drainage, respectively., Conclusion: Currently, there are many methods to treat PE. The correct treatment method for each patient should be selected according to a very careful analysis of the patient's clinical condition as well as the prospective benefit of surgical intervention.

Background: Pericardial effusion (PE) is a common finding in patients who have chronic cardiac failure, who had undergone cardiac surgery, or who have certain other benign and malignant diseases. Pericardial drainage procedures are often requested for both diagnostic and therapeutic purposes. The perceived benefit is that it allows for diagnosis of malignancy or infection for patients with PEs of unclear etiology. The purpose of the study is to determine the diagnostic yield of surgical drainage procedures., Methods: We conducted a retrospective chart review of patients who underwent surgical drainage procedures of PEs from July 1st, 2011 to January 1st, 2017 at a single institution. The variables included data on preoperative, intraoperative, and postoperative findings; morbidity; and survival., Results: A total of 145 patients with an average age of 61 ± 5 and primarily men (53%) were evaluated. All of the surgical drainage procedures were performed through the sub-xiphoid approach. Twenty-five of the 145 patients (17.2%) had diagnostic findings in either the pericardial tissue or fluid. The cytology alone was diagnostic in 4.8% (N = 7) of patients with mixed findings including adenocarcinoma of the lung and breast. The pathology was diagnostic for cancer in 1.4% (N = 2) of patients with Melanoma and Lung cancer identified. The cytology and pathology were concordant in 4.0% (N = 6) identifying cancers that included mesothelioma and adenocarcinoma. Infection was identified in the pericardial fluid in 6.9% (N = 10) of the patients., Conclusion: Surgical pericardial drainage procedures allow for removal of PE that may lead to tamponade physiology and potential mortality. Although there is therapeutic benefit from these procedures there is only a small diagnostic benefit.

There are numerous surgical approaches for the treatment of pericardial effusions but no clear consensus of best management. We present a 44-year-old woman with metastatic breast cancer presenting with a new 2-cm pericardial effusion on ultrasound. In light of the patient's palliative condition and the urgent need for chemotherapy, careful consideration was made for her surgical drainage of the pericardial effusion. Because of the patient's medical comorbidities, a general anesthetic was deemed not to be in the patient's best interest. Furthermore, the invasive subxiphoid or thoracotomy approach for a pericardial window would have risked delaying her much needed chemotherapy. A single-port thoracoscopic pericardial window was performed under light sedation, ventilating spontaneously on supplementary oxygen through nasal cannula only. The patient was positioned in a supine position, and a single 8-mm port was inserted into the left hemithorax at the 5th intercostal space, midaxillary line under local anesthetic, and a pericardial window made. This minimally invasive approach, without the need for intubation or ventilation, allowed for rapid relief of symptoms and discharge for the patient to begin her chemotherapy in a timely manner. By undergoing the procedure awake and through a single port, the patient was discharged after a short inpatient stay. This novel approach can be advocated for patients where a general anesthetic or invasive surgical procedure is not suitable in the treatment of their pericardial effusion.

An 80-year-old woman initially presented with an episode of pleuritic chest pain 10 days after implantation of a dual chamber permanent pacemaker. She returned to hospital a day later with vomiting and fever. She was found to have new atrial fibrillation in addition to right-sided weakness and dysarthria. An infarct in the left anterior inferior cerebellar artery territory was later confirmed on CT. She continued to have recurrent febrile episodes associated with vomiting and dyspnoea. Extensive investigations for infection were negative, and her symptoms were initially attributed to aspiration pneumonia. The patient gradually deteriorated despite antibiotics and became progressively short of breath, with development of large pleural and pericardial effusions. A diagnosis of postcardiac injury syndrome was made after exclusion of other differentials. The patient recovered well after pleurocentesis, pericardiocentesis and a pericardial window, with resolution of symptoms without further medical therapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To report the efficacy of chronic pericardial effusion treatment with pericardial window creation through video-assisted thoracoscopic surgery and pericardial drainage through a small subxiphoid incision., Material and Methods: Retrospective analysis of 31 patients after pericardial window creation through video-assisted thoracoscopic surgery (PW group) and 77 patients where pericardial drainage through small subxiphoid incision (PD group) was performed. Echocardiography examinations were performed to document pericardial tamponade and pericardial effusion recurrence., Results: Length of surgery was 20.5±5.4 minutes in the PD group and 25.8±6.4 minutes in the PW group, p<0.001. Amount of fluid evacuated from pericardium during surgery was 483±191 ml and 521±253 ml in PD and PW groups respectively, p=0.654. Postoperative drainage was maintained longer (4.3±1.4 days vs. 3.2±1.0, p<0.001) and the amount of fluid drained after surgery was higher (497±351 ml vs. 309±231 ml, p=0.031) in the PW group. The amount of pericardial fluid at the end of hospitalization was statistically significantly higher in the PD group compared with the PW group (8.9±4.9 mm vs. 4.9±3.2 mm, p<0.001). Hospital stay was 5.7±2.7 days in the PD group and 6.1±3.4 in the PW group, p=0.112. No patient died during hospitalization period in either group. Mortality within 30 days after surgery was 2.6% in the PD and 3.2% in the PW group (p=0.642). In the PW group there were 4 conversions to right minithoracotomy due to dense pleural adhesions. Pericardial effusion recurrence occurred in 9 patients (12.0%) in the PD group and none was observed (0.0%) in the PW group (p=0.042) within 30 days after surgery., Conclusion: Pericardial window creation through video-assisted thoracoscopic surgery should be considered the preferred method over pericardial drainage through a small subxiphoid incision for chronic pericardial effusion and pericardial tamponade treatment to reduce the frequency of pericardial effusion reoccurrence.

Idiopathic chylopericardium in pregnancy is extremely rare and poses difficulties in both decision-making and timing of surgery. A young lady who was 24-weeks pregnant presented with chylopericardium and increasing shortness of breath. Repeated nonsurgical interventions failed to resolve her pathology. She underwent thoracoscopic pericardial window formation and thoracic duct ligation, and made a satisfactory recovery., (© The Author(s) 2016.)

Background: Pericardial effusion (PE) is a common finding in patients who had chronic cardiac failure, who had undergone cardiac surgery, or who had certain other benign and malignant diseases. PE ranges in severity from mild, asymptomatic effusions to cardiac tamponade. Although a thoracoscopic pericardial window (TPW) is a minimally invasive surgical option for patients with PE, there are few published data regarding the outcomes of TPW for PE. We investigated the contribution of the TPW to the treatment of PEs that are recurrent or difficult to drain percutaneously., Methods: We conducted a retrospective chart review of the indications for TPW that included data on preoperative, intraoperative, and postoperative variables; morbidity; recurrence; and survival. Fourteen consecutive patients with PE that was recurrent or difficult to drain percutaneously and who underwent treatment with a TPW were enrolled in this study. Trocars for passage of the thoracoscope and surgical instruments were introduced through two or three incisions. Mini-thoracotomy was also performed in patients with hemopericardium and loculated fibrinous effusions. All patients were evaluated by face-to-face interviews, transthoracic echocardiography (TTE), and chest radiography 3-6 months after the TPW was obtained., Results: The mean age of the patients was 70 years (range 28-83 years). The operative time was 72.1 ± 29.5 min. Six patients had undergone open heart surgery during the month prior to their presentation with PE. No intraoperative or postoperative complications occurred, although PE had recurred in one patient. Two patients died of malignant disease several months after the TPW. The cardiothoracic ratio (determined on chest radiographs) and the ejection fraction ratio (determined using TTE) had improved at the 3- and 6-month follow-up evaluations (p < 0.0001 and p = 0.012, respectively). Some patients could discontinue diuretics after the procedure, as assessed by the cardiologist based on symptom alleviation, chest radiography, and TTE findings., Conclusions: For patients with PEs that are recurrent or difficult to drain percutaneously, TPW is an effective, safe surgical approach in terms of cardiac function and radiological findings.

Background: The optimal window procedure for drainage of a large pericardial effusion has yet to be established. The purpose of this study was to compare the outcomes associated with the subxiphoid and thoracotomy pericardial window techniques, with a focus on perioperative pain and effusion recurrence rates., Methods: A retrospective single-center observational study of all pericardial window operations was performed, with the incision based on surgeon preference. Perioperative data was recorded including time to extubation, narcotic requirements, and the development of a recurrent pericardial effusion., Results: From 2002 to 2015, 179 patients with a large pericardial effusion underwent either a subxiphoid (n = 127) or left anterior mini-thoracotomy (n = 52) pericardial window procedure. Patients (mean age 73.2 years, 56 % female) had a high incidence of previous malignancy (49 %), chronic anticoagulation (34 %), recent infection (26 %), or renal failure (18 %). Cardiac tamponade was present in 50 %, and 12 % had undergone previous pericardiocentesis. Comparing the two techniques, there was no difference in the amount of fluid drained or in the perioperative mortality rate. Postoperatively, patients who had the subxiphoid approach required less time before extubation (P = 0.002) and needed less narcotics within 48 h after surgery (P = 0.0001) compared to thoracotomy patients. However, patients treated with the subxiphoid technique more often developed recurrent moderate or large pericardial effusions (P = 0.02), and there was a trend towards more repeat operations needed (P = 0.15)., Conclusion: Pericardial window surgery via a subxiphoid incision is associated with less postoperative pain and faster time to extubation. However, the thoracotomy approach may be more effective at preventing effusion recurrence and the need for repeat surgery.

Introduction: The optimal method for creation of a pericardial window (PW) is still controversial and it remains a surgical challenge, mainly in obese patients. The aim of this study was to evaluate the efficacy and safety of a novel approach that has not been described previously, for creation of a PW in patients with symptomatic, chronic, large pericardial effusion., Methods: We retrospectively analysed the records of 30 patients (14 men, 16 women) who underwent a PW procedure between 2001 and 2011. The mean age was 63 years (standard deviation [SD]: 17 years, median: 60 years, range: 27-90 years) and the mean body mass index was 34 kg/m(2) (SD: 2 kg/m(2)). The operation was performed through a curvilinear parasternal approach, 6-8 cm in length, followed by a mini-thoracotomy between ribs 4 and 5. Discharged patients were followed up clinically., Results: The mean operative time was 73 minutes (SD: 21 minutes) and a median of 658 ml (range: 300-1,500 ml) of fluid was evacuated. The main aetiologies were idiopathic in 17 patients (57%) and malignant in 9 (30%). Seven patients (23%) died in hospital owing to underlying malignancy. Postoperative complications included mild renal failure (20%), respiratory failure (20%), pneumonia (13%), atrial fibrillation (10%) and atelectasis (6%). There were no wound infections. The median length of stay following the procedure was 8 days. In a median follow-up period of 3.8 years, 16 patients with non-malignant effusion were free of recurrence of pericardial effusion., Conclusions: The anterior parasternal approach for creation of a PW is simple, safe and efficacious, and results in long-term symptomatic improvement, specifically in patients with non-malignant effusions. This approach may be more appealing in obese patients.

Background: Pericardial decompression syndrome (PDS) is a rare and potentially fatal complication of pericardial drainage, either by needle pericardiocentesis or surgical pericardiostomy. It manifests with paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. We sought to elucidate factors associated with mortality in PDS., Methods: MEDLINE was systematically searched for PDS case reports and case series published between 1983 and 2013. For this analysis, clinical variables, echocardiographic and hemodynamic variables, details of drainage procedure and clinical outcomes were collected for each case., Results: A total of 35 cases (12 male, 23 female) were identified. PDS developed after pericardiocentesis, pericardiostomy, or both, in 18, 16, and one patients, respectively. Cardiac tamponade was the indication in 33 cases (94%). The mean age was 47 ± 17 years. The mean amount of effusion drained was 888 mL. The minimum amount of effusion drained was 450 mL. The onset of PDS after the procedure varied widely, ranging from 'immediate' to 48 hours. Presentations included 10 (29%) with cardiogenic pulmonary edema without shock, 14 (40%) with left ventricular failure, three (9%) with right ventricular failure, seven (20%) with biventricular failure, and one (3%) with non-cardiogenic pulmonary edema. Ten patients (29%) died of PDS. Mortality was associated only with surgical drainage (p<0.001). Severe LV dysfunction normalized in PDS survivors., Conclusions: PDS is a rare complication of pericardial drainage with a high mortality rate. Surgical pericardiostomy was associated with mortality in PDS., (© The European Society of Cardiology 2014.)

Pericardial tamponade resulting in hemodynamic compromise requiring either pericardiocentesis [Vandyke 1983] or subxiphoid pericardial window has been reported in literature [Armstrong 1984]. There are no large case series, only scattered case reports. Cardiac tamponade is known to affect the diastolic function of the heart but rare reports have documented systolic impairment of the left and right ventricle in the setting of tamponade [Vandyke 1983; Armstrong 1984]. We report a case of a transient biventricular systolic dysfunction in a patient with early cardiac tamponade after surgical drainage of pericardia1 effusion.

Objective: Our aim was to compare systemic chemotherapy (CT) with drainage and with pericardial window in the treatment of neoplastic pericarditis in patients with various malignancies included in the International Neoplastic Pericarditis Treatment study., Methods: Patients treated with systemic CT alone (Group A), CT plus drainage (Group B), or CT plus pericardial window (Group C) were included. Treatment response was defined as complete response (ie, no more pericardial effusion or masses), partial response (ie, reduced total score, without requiring further treatments), stable disease (ie, unchanged total score), or progressive disease (ie, increased total score). Patients with partial or complete response were considered responders., Results: This preliminary report included 175 patients (56.6% male) with a mean age of 54.21±14.26 years. Gender distribution, age, and follow-up duration was similar for all groups (P>.05). Prevalent cancer types were lung cancer (50.9%), breast cancer (14.9%), and lymphoma/leukemia (14.9%). Overall, 22.3%, 42.9%, and 34.9% of patients were in treatment group A, B, and C, respectively. There were 132 responders (75.3%). The rate of responders significantly differed between groups (P<.001); it was significantly higher in Group B than in Group A (P<.05) and in Group C than in Group B (P=.006). The significant factors affecting response were therapy (P=.002) and extent of effusion (P=.037). Kaplan-Meier analysis showed that patients in Group C had a significantly better survival rate than patients in the other groups (P=.001)., Conclusions: Systemic CT plus pericardial window is a more effective treatment option compared with systemic CT alone and systemic CT plus drainage in patients with malignant effusions., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: We present a rare case of a liver volvulus, stomach and transverse colon herniating through the diaphragm. This scenario has not been reported previously. We discuss the presentation and management of this interesting case., Case History: A 65-year-old woman with a history of sarcoidosis and recurrent pericardial effusions, treated previously with a subxiphoid pericardial oval window fenestration, presented with acute upper abdominal pain radiating to the chest. High contrast computed tomography showed a volvulus of the liver with consequent venous congestion, and herniation of the liver, stomach and transverse colon through an anterior diaphragmatic defect. With liver perfusion threatened, an urgent laparoscopic repair was performed. The stomach and transverse colon were reduced, and the twisted left lobe of the liver was unrotated and reduced into the abdominal cavity. A double-sided synthetic mesh was used to repair the defect. The patient made an uneventful recovery., Conclusions: This is a novel complication of a patient presenting with abdominal pain with a previous history of pericardial window fenestration. A laparoscopic reduction and repair can be performed safely with excellent postoperative results.

Background: Although pericardial effusion (PE) is not uncommon in patients with cancer, it may lead to cardiac tamponade, a life-threatening condition. Prompt life-saving treatment is essential, and also allows the continuation of the cancer treatment. The aim of this study was to determine the prognostic factors for survival in patients with cancer who were treated surgically for PE., Methods: We retrospectively reviewed the medical records of 55 patients with cancer with PE between January 2003 and October 2012, who were treated with a pericardial window operation. Overall survival (OS) was estimated from the date of surgery, and patients were followed until the time of the final visit or time of death. Clinical outcomes and candidate prognostic factors were analyzed., Results: The median age of patients was 57 years (range 29 to 82 years), and 31 patients (56.4%) were male. The most common primary malignancy was lung cancer (65.5%), followed by breast cancer (10.9%). Fifteen patients (27.3%) developed recurrence of PE after surgery. The median OS duration was 4 months (range 0 to 39 months). Multivariate analysis found that evidence of pericardial metastasis on preoperative imaging (P = 0.029) and confirmation of malignant cells in the PE and/or pericardial tissue (P = 0.034) were associated with reduced OS., Conclusion: Evidence of pericardial metastasis on preoperative imaging and cytopathologic confirmation that the PE and/or pericardial tissue are positive for malignant cells can be used to predict poor clinical outcomes in patients with cancer-related PE.

Objectives: The optimal management and treatment of pericardial effusion are still controversial. There is limited data related to the risk factors affecting survival in these patients. The aim of this study was to determine the risk factors affecting the survival rate of patients with symptomatic pericardial effusion who underwent surgical interventions., Methods: From 2004 to 2011, we retrospectively analysed 153 patients who underwent subxiphoid pericardial window as their surgical intervention to drain pericardial effusions at the National Research Institute of Tuberculosis and Lung diseases (NRITLD). To determine the effects of risk factors on survival rate, demographic data, clinical records, echocardiographic data, computed tomographic and cytopathological findings and also operative information of patients were recorded. Patients were followed annually until the last clinical follow-up (August 2011). To determine the prognostic factors affecting survival, both univariate analysis and multivariate Cox proportional hazards model were utilized., Results: There were 89 men and 64 women with a mean age of 50.3 ± 15.5 years. The most prevalent symptom was dyspnoea. Concurrent malignancies were present in 66 patients. Lungs were the most prevalent primary site for malignancy. The median duration of follow-up was 15 (range 1-85 months). Six-month, 1-year and 18-month survival rates were 85.6, 61.4 and 36.6%, respectively. In a multivariate analysis, positive history of lung cancer (hazard ratio [HR] 2.894, 95% confidence interval [CI] 1.362-6.147, P = 0.006) or other organ cancers (HR 2.315, 95% CI 1.009-50311, P = 0.048), presence of a mass in the computed tomography (HR 1.985, 95% CI 1.100-3.581, P = 0.023), and echocardiographic findings compatible with tamponade (HR 1.745, 95% CI 1.048-2.90 P = 0.032) were the three independent predictors of postoperative death., Conclusions: In the surgical management of pericardial effusion, patients with underlying malignant disease, especially with lung cancer, patients with a detectable invasion of thorax in computed tomography and those with positive echocardiographic findings compatible with tamponade have a poor survival. Therefore, minimally invasive therapies could be considered as a more acceptable alternative for these high-risk patients.

Chylopericardium usually occurs secondary to trauma, cardiothoracic surgery, radiation therapy, or neoplasm of the mediastinum. Idiopathic chylopericardium is extremely rare. We report a case of primary chylopericardium in a 79-year-old male patient. Although pericardial window and thoracic duct ligation are the treatment of choice, the patient has been doing well for six months since video-assisted thoracoscopic pericardial window.

Background: Surgical drainage is a rapid and effective treatment for pericardial tamponade in cancer patients. We aimed to investigate the effectiveness of pericardial window formation via mini-thoracotomy for treating pericardial tamponade in cancer patients, and to evaluate clinical factors affecting long-term survival., Methods: Records of 53 cancer patients with pericardial tamponade treated by pericardial window formation between 2002 and 2008 were examined. Five patients were excluded due to insufficient data. Kaplan-Meier and Cox regression analysis were used for analysis., Results: Forty-eight patients (64.7% male), with a mean age of 55.20 ± 12.97 years were included. Patients were followed up until the last control visit or death. There was no surgery-related mortality and the 30-day mortality rate was 8.33%; all died during postoperative hospitalization. Morbidity rate was 18.75%. Symptomatic recurrence rate was 2.08%. Cancer type and nature of the pericardial effusion were the major factors determining long-term survival (P <0.001 and P <0.004, respectively).Overall median survival was 10.41 ± 1.79 months. One- and 2-year survival rates were 45 ± 7% and 18 ± 5%, respectively., Conclusion: Pericardial window creation via minithoracotomy was proven to be a safe and effective approach in surgical treatment of pericardial tamponade in cancer patients. Cancer type and nature of pericardial effusion were the main factors affecting long-term survival.

Background: The tumorous infiltration or carcinosis of the pericardium could cause pericardial effusion in up to one-third of cases of malignancy, thus potentially interfere with the otherwise desirable oncological treatment. The existing surgical methods for the management of pericardial fluid are well-established but are not without limitations in the symptomatic relief of malignant pericardial effusion (MPE). The recurrence rate ranges between 43 and 69% after pericardiocentesis and 9 to 16% after pericardial drainage. The desire to overcome relative limitations of the existing methods led us to explore an alternative approach., Methods: The standard armamentarium of the Carlens collar mediastinoscopy procedure was utilized in a Chamberlain parasternal approach of the pericardial sac. The laterality of approach was decided based upon the pleural involvement, as tumor-free pericardiopleural reflection is required. A pericardio-pleural window at least 3 cm in diameter was created. From January 2000 to December 2009, 22 cases were operated on with mediastinoscope-controlled parasternal fenestration (MCPF). Considering the type of the primary tumor, there were 11 lung cancer, 6 breast cancers, 2 haematologic malignancies and in 3 patients the origin of malignancy could not be verified., Results: There were no operative deaths. We lost one patient (4.5%) in the postoperative hospital period. All of the surviving patients had a minimum of 2 months of symptom-free survival. We detected transient recurrence of MPE in one patient (4.5%) 14 days after the MCPF, which disappeared spontaneously after 24 hours., Conclusion: The MCPF offers a real alternative in certain cases of pericardial effusion. We recommend this method especially for the definitive surgical palliation of MPE.

Pericardial effusion and cardiac tamponade are often refractory and difficult to manage. The transthoracic pericardial fenestration which create a window is the conventional procedure for releasing pericardial effusion to the thoracic cavity. We experienced two cases of pericardial fenestration. The first case was a patient with hypertrophic cardiomyopathy with pericardial effusion. She had a thoracic compression fracture, which indicated pericardial fenestration before an orthopedic surgery. The second case was a patient with recurrent cardiac tamponade caused by postpericardiotomy syndrome after off-pump coronary artery bypass grafting. In both cases, the patients underwent left anterior thoracotomy of about 10 cm at the level of the 5th intercostal space. The pericardium was incised within a radius of about 20 mm; furthermore, the fenestrated window was opened to the left thoracic cavity. In this paper, we present our experience of pericardial fenestration and discuss a review of the literature.

Pericardial effusion in a patient with a history of cancer should always prompt a hypothesis of malignant involvement. We report the case of a 66-year-old white woman presenting with pericardial effusion 25 years after a mastectomy for ductal breast carcinoma. This is one of the cases with the latest recurrence ever reported.

Introduction: Pericardial effusion is a clinical condition requiring multidisciplinary management. There are several surgical techniques for its diagnosis and treatment. In the present study we report our experience in performing a pericardial window (PW) by videothorascopy., Material and Methods: We performed surgery on 56 patients (20 females and 36 males), with a mean age of 56±1.22 years, and diagnosed with moderate to severe chronic pericardial effusion. The side chosen for the approach depended on whether there was an associated pleural effusion or lung lesion, and if not the left side was chosen., Results: The mean duration of the surgery was 37.6±16 minutes. The definitive diagnoses were malignant processes in 23% of cases, including bronchogenic carcinoma and breast cancer. The intra-operative mortality was 0%., Conclusions: Videothorascopic pericardial window is an effective and safe technique for the diagnosis and treatment of chronic pericardial effusion, and which enables it to be drained and perform a pleuro-pulmonary and/or mediastinal biopsy during the same surgical act., (Copyright © 2010 AEC. Published by Elsevier Espana. All rights reserved.)

Behçet's syndrome is a chronic multisystem inflammatory disease characterised classically by recurrent oral and genital ulcers with ocular lesions. It can affect blood vessels of all sizes, but involves veins more commonly than arterie. The presence of chylothorax in Behçet's syndrome is rare, with only a few cases cited in the literature. The most likely pathogenesis is SVC thrombosis with obstruction of the orifice of the thoracic duct resulting in leakage of chyle from the pleural lymphatics into the pleural space. The majority of the previously reported cases were managed medically without surgical intervention. We believe that this report describes the first use of surgery to ligate the thoracic duct and create a pericardial window in a Behçet's syndrome with chylothorax and chylopericardium.

Numerous methods exist for the treatment of pericardial effusions. These methods, however, can be applied with limitations only for long-term eradication of malignant pericardial effusion. Lately, several new methods, including minimally invasive procedures, have been published, and the VATS technique has become fairly popular. This technique needs special instruments and single lung ventilation, which is relatively risky in case of contralateral malignancy. We apply a new and simple minimally invasive fenestration method using the well-known approach of the parasternal mediastinoscopy by Stemmer. No recurrence of pericardial effusions was noted in long-term follow-up. In the past 10 years 73 patients were treated for pericardial effusion in our department and 22 pericardium fenestrations have been performed with parasternal approach. This method is recommended for the definitive treatment of pericardial effusion with malignant origin.

Objectives: The approach to the pericardial window in patients with pericardial effusion (PE) remains undefined as to whether a surgical (transthoracic or subxiphoid) or a thoracoscopic pericardial window is the optimal operative approach to PE. We hypothesized that the window into the pleural space created by the thoracoscopy might improve the outcome., Methods: We conducted a prospective study between September 2007 and October 2009. All patients with PE diagnosed by echocardiography who attended the Cardiothoracic Department in King Fahd Hospital are included in this study. They were 30 patients (18 males, 12 females aged 44±1.22 years). Patients were subdivided into two groups. Group A, 15 patients underwent the surgical (transthoracic or subxiphoid) procedure and Group B, 15 patients underwent the video-assisted thoracoscopy procedure. Preoperative, intraoperative and postoperative variables, morbidity, recurrence, and survival were compared in both groups., Results: Preoperative variables were well-matched for age, sex, preoperative tamponade, echocardiographical characteristics and co-morbidities between both groups. No recurrence of effusion was observed in the two groups. Operative time was statistically highly significant (P<0.001); it was longer in Group B. There was no intraoperative complication in both groups. There was no postoperative complication in both groups except one case of superficial wound infection in Group A. There was no significance difference between both groups as regard duration of chest tube drainage and length of hospital stay. There was no in-hospital mortality in both groups., Conclusions: Pericardial window by video-assisted thoracoscopy is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures.

Objective: In the cancer population, pericardial effusions are a common and potentially life-threatening occurrence. Although decompression benefits most patients, paradoxical hemodynamic instability (PHI) develops in some, with hypotension and shock in the immediate postoperative period. This study examines paradoxical hemodynamic instability after pericardial window and identifies prognostic factors in patients with cancer who are treated for pericardial effusion., Methods: Retrospective review of 179 consecutive pericardial windows performed for pericardial effusion in a tertiary cancer center over a 5-year period (January 2004 through March 2009). Demographic, surgical, pathologic, and echocardiographic data were analyzed for the end points of paradoxical hemodynamic instability (pressor-dependent hypotension requiring intensive care unit admission) and overall survival., Results: The most common malignancies were lung (44%), breast (20%), hematologic (10%), and gastrointestinal (7%). Overall survival for the group was poor (median, 5 months); patients with hematologic malignant disease fared significantly better than the others (median survival 36 months; P = .008). Paradoxical hemodynamic instability occurred in 19 (11%) patients. These patients were more likely to have evidence of tamponade on echocardiogram (89% vs 56%; P = .005), positive cytology/pathology (68% vs 41%; P = .03), and higher volume drained (674 mL vs 495 mL; P = .003). Overall survival was significantly shorter in those in whom paradoxical hemodynamic instability developed (median survival 35 vs 189 days; hazard ratio = 3; P < .001), and the majority of them (11/19, 58%) did not survive their hospitalization., Conclusions: Postoperative hemodynamic instability after pericardial window portends a grave prognosis. Evidence of tamponade, larger effusion volumes, and positive cytologic findings may predict a higher risk of paradoxical hemodynamic instability and anticipate a need for invasive monitoring and intensive care postoperatively., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A 46-yr-old female Sumatran orangutan (Pongo abelli) was first diagnosed with pericardial effusion in July 2006. Pericardiocentesis performed in January 2007 only provided short-term relief. In May 2007, a pericardial-peritoneal window was created using a transabdominal subxiphoid pericardiostomy technique, providing immediate and long-term relief. Seven months later, the orangutan was euthanized due to worsening heart failure, and no pericardial effusion was present. Transabdominal subxiphoid pericardiostomy offers a straightforward surgical approach that can provide significant relief in cases of chronic pericardial effusion in great apes.

Background: Pericardial pathology still has challenging diagnostic and treating issues. To reduce surgical trauma and pain for the patient, the authors developed a totally endoscopic echo-guided approach for both diagnostic and operative pericardioscopy., Methods: Three steps moved from animal model (8 pigs) through concomitant open-chest interventions (7 patients) to closed-chest interventions for 10 patients with a diagnosis of severe pericardial effusion., Results: A lesion of the right ventricle in one patient (10%) due to imperfect preoperative pericardial visualization needed sternotomy for repair. All the patients, except the aforementioned one, underwent surgery with local anesthesia or mild sedation. No method-related mortality was reported., Conclusion: The closed-chest nonintrapleural approach to the pericardium may represent an evolution, with a positive impact on the treatment of this pathology. Therapeutic maneuvers with rigid instruments in nonintubated patients are possible. Accurate patient selection and technical refinement should increase the safety and effectiveness of the method.

A window in the pericardial sac was created by thoracoscopy in two dogs with diagnosed idiopathic haemorrhagic pericardial effusion (IHPE). Thoracoscopic access to the pericardial sac facilitated surgery and minimised the risk of complications associated with conventional thoracotomy.

Introduction: Malignancies are the most common causes of pericardial effusion (PE) or tamponade (PT). Lung and breast carcinoma are the most frequent. The treatment of PE consists in the performance of drainage and/or pericardial window (PW) usually subxiphoid. In the present study we describe our experience with the PW by videothoracoscopic (VATS) approach, a procedure scarcely referred to in the literature., Objective: To evaluate the efficacy of the PW by videothoracoscopic (VATS) approach in the treatment of PE and/or PT., Patients and Method: Retrospective study of 12 patients with PE submitted to PW by VATS in a period of 10 years, since February 1994 to October 2004. The surgical procedure employed was VATS, under general anesthesia, selective intubation and lateral decubitus. We systematically performed a PW anterior to phrenic nerve and studied pleural and pericardial fluids. Talc pleurodesis was added if neoplastic pleural effusion was objectived by a previous needle thoracocentesis and cytological analysis of pleural fluid. A single chest drain (24 F) was inserted after surgery, and removed when daily debit was under 100 ml., Results: 12 patients were operated on, 4 men and 8 women, mean age of 58.6 years (range, 32-78). There was no surgical mortality. There were 8 cases of PT. The causes of PE were: breast carcinoma in 8 cases, lung carcinoma in 3 cases and infectious origin in one case. Mean duration of surgical procedure was 30 minutes. All the patients had concomitant pleural effusion. Surgical approach was by the left side in all the cases. Talc pleurodesis was added in 8 cases of the 12 that had pleural effusion, in the 8 cases cytological analysis had shown paraneoplastic origin. Chest drain was removed after a mean period of 3.5 days. There was no mortality associated with the procedure. Mean stay was 3.8 days. Mean survival was 12 months for breast cancer patients and 4 months for lung cancer., Conclusions: PW by VATS is a suitable procedure for the management of massive PE or PT. In our experience this procedure showed no mortality and minimal morbidity, providing symptomatic improvement (in PE and pleural efusión) in all the patients. This approach also makes possible the study of pleural cavity, the obtaining of parietal pleura samples and, if necessary, the performance of talc pleurodesis.

A successful placement of a transabdominal pericardial window is associated with diaphragmatic hernia. In this paper, we present the case of a 5-month-old ex-31-weeks-premature baby who developed a symptomatic diaphragmatic hernia following a chronic pericardial effusion who was treated successfully with a laparoscopic transabdominal pericardial window. Laparoscopy and a pericardial window were used to manage the symptomatic effusion that developed following a bilateral thoracotomy and median sternotomy for the patient's massive hygroma. The patient was followed before and after pericardial drainage with a serial examination, chest radiography, and echocardiography. In addition, computerized tomography was also used for long-term follow-up following the repair of the hernia. An acellular dermal matrix was utilized for patching the hernia with a laparotomy. The abdominal approach in both operations offered direct access to the pericardial space and hernia, thereby avoiding previously operated thoraces. A subsequent follow-up at 9 months following the creation of the window suggested a recurrent tamponade physiology. Plain radiographs and an echocardiogram showed herniation into the pericardial sac. The hernia was operatively reduced and repaired with an acellular dermal matrix. Recovery and subsequent followup at 1 year revealed no hernia, full symptom resolution, and no recurrence of the pericardial effusion. A pericardial window is an effective approach for the management of chronic pericardial effusion. Diaphragmatic herniation through a pericardial window can be successfully repaired with an acellular dermal matrix.

Purpose: Malignant pericardial effusion is a frequent complication of advanced incurable malignancies and requires treatment. The purpose of this study was to identify prognostic factors for cytology-positive malignant pericardial effusion in patients treated by pericardial drainage., Methods: We retrospectively analyzed a series of consecutive patients diagnosed with cytologically positive malignant pericardial effusion who were treated by pericardial drainage at the National Cancer Center Hospital, Tokyo., Results: A total of 88 patients with pericardial effusion were treated by pericardial drainage, 60 patients were diagnosed with cytological positive malignant pericardial effusion including 32 with non-small cell lung cancer, 13 with breast cancer, 8 with gastrointestinal cancer, and 7 with miscellaneous cancers. Subxiphoid pericardiostomy was performed in 50 of the patients and percutaneous tube pericardiostomy in the other 10 patients. Malignant pericardial effusion recurred in 14 patients, and pericardial drainage was performed again in 9 of them. The median overall survival time was 6.1 months, and the 1-year survival rate was 28%. A multivariate analysis revealed the following significant negative prognostic factors: performance status, development of malignant pericardial effusion during chemotherapy, mediastinal lymph node enlargement, and cytologic type. (P = 0.03, 0.02, 0.01, 0.001, respectively)., Conclusion: Patients with poor prognostic factors may be better to consider as indication of palliative therapy, even if oncologic emergency had been resolved rapidly by drainage.

We report a case of malignant pericardial effusion after lung cancer surgery treated with thoracoscopic pericardial fenestration. The patient was admitted to our hospital because of dyspnea. Computed tomography (CT) and ultrasound cardiography (UCG) revealed cardiac tamponade which was diagnosed as carcinomatous pericarditis by cytology. We attempted to inject 25 mg of cisplatin (CDDP) into the pericardial space twice. The response of the treatment was unexpectedly poor for the patient. The thoracoscopic pericardial fenestration was performed and the patient was discharged without a drainage tube on the 17th postoperative day. Malignant pericardial effusion is a common complication of advanced cancers and is often associated with significant morbidity. Thoracoscopic pericardial fenestration appears to be a safe, effective and minimally invasive treatment for patients with malignant pericardial effusion. This surgery might also have a favorable effect on the improvement of the quality of life for patients with malignant pericardial effusion resistant to chemotherapy.

A 77-year-old woman with a previous history of median sternotomy and collagen disease, presented with chief complaints of resting dyspnea as a result of recurrent pericardial effusions or restrictive ventilatory impairment. She experienced significant symptom amelioration after undergoing pericardioperitoneal fenestration. We weighed the positive against the negative of various pericardial effusion drainage methods in this study. This operative procedure is not innovative, but favorable because it can be carried out conveniently and safely, enabling early rehabilitation without appreciable postoperative complications.