When operation is indicated for the management of pericardial effusion, options include subxiphoid drainage (SXD) and thoracoscopic pericardial window (TPW), but it remains undefined which of these approaches is optimal. TPW creates a true “window” into the pleural space (unlike SXD) and permits the performance of simultaneous intra-pleural procedures, but it requires intercostal incisions, double-lumen intubation, and unilateral pulmonary collapse. We retrospectively reviewed our experience with TPW and SXW at the University of Pennsylvania Health System from 1992 to 2003 to compare indications, hospital course, and outcomes.
Records were reviewed for pertinent clinical information, including pre-operative and intra-operative variables, procedural morbidity, and recurrence of effusion. Echocardiographic evidence of tamponade was defined as right chamber collapse. Recurrence was defined as an effusion on follow-up echo that was moderate or greater, or hemodynamically significant.
Fifteen patients underwent TPW, 56 underwent SXW. Prior percutaneous drainage was performed in 19 (27%). Echocardiographic evidence of tamponade present in 8 of 11 TPW patients (73%) and 43 of 56 SXD patients (81%). Concomitant procedures were performed in 10 (67%) and 18 (32%) patients, respectively (p=0.020). Anesthesia time was longer for TPW [117.1 ± 32.4 vs. 81.1 ± 25.5 minutes (p<0.001)]. Procedural morbidity was higher among TPW patients [4 (27%) vs. 1 (2%) (p=0.006)]. Hospital mortality related primarily to co-morbid illness and tended to be higher in SXD patients [7 (13%) vs. 0 (0%) (p=0.332)]“. (i.e. 7 patients, not 8, and the percentage now 13%). Follow up was complete for 67 patients (94%). Recurrences occurred in 1 TPW patient (8%) and 5 SXW patients (10%) (p=1.000).
TPW and SXD appear to be equally effective in controlling pericardial effusions. TPW was more likely to be used when concomitant intra-pleural procedures were required. Operative time and procedural morbidity were higher following TPW.
Since it simpler, faster, and less morbid, SXD is the more appropriate approach in the management of pericardial effusion except possibly in cases where a concomitant intra-pleural process needs to be addressed.
P.K. O’Brien, None.