Management of Pericardial Effusion in Patients With Solid Tumor: An Algorithmic, Multidisciplinary Approach Results in Reduced Mortality After Paradoxical Hemodynamic Instability.

OBJECTIVE: This study compared outcomes in patients with solid tumor treated for pericardial effusion with surgical drainage versus interventional radiology (IR) percutaneous drainage and compared incidence of paradoxical hemodynamic instability (PHI) between cohorts. BACKGROUND: Patients with advanced-stage solid malignancies may develop large pericardial effusions requiring intervention. PHI is a fatal and underreported complication that occurs following pericardial effusion drainage. METHODS: Clinical characteristics and outcomes were compared between patients with solid tumors who underwent s urgical drainage or IR percutaneous drainage for pericardial effusion from 2010 to 2020. RESULTS: Among 447 patients, 243 were treated with surgical drainage, of which 27 (11%) developed PHI, compared with 7 of 204 patients (3%) who were treated with IR percutaneous drainage ( P =0.002); overall incidence of PHI decreased during the study period. Rates of reintervention (30-day: 1% vs 4%; 90-day: 4% vs 6%, P =0.7) and mortality (30-day: 21% vs 17%, P =0.3; 90-day: 39% vs 37%, P =0.7) were not different between patients treated with surgical drainage and IR percutaneous drainage. For both interventions, OS was shorter among patients with PHI than among patients without PHI (surgical drainage, median [95% confidence interval] OS, 0.89 mo [0.33-2.1] vs 6.5 mo [5.0-8.9], P <0.001; IR percutaneous drainage, 3.7 mo [0.23-6.8] vs 5.0 mo [4.0-8.1], P =0.044). CONCLUSIONS: With a coordinated multidisciplinary approach focusing on prompt clinical and echocardiographic evaluation, triage with bias toward IR percutaneous drainage than surgical drainage and postintervention intensive care resulted in lower incidence of PHI and improved outcomes.

Pericardial effusions in the cancer population: prognostic factors after pericardial window and the impact of paradoxical hemodynamic instability.

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.

Brugada electrocardiographic pattern in a postoperative patient.

OBJECTIVE: To report the development of the Brugada electrocardiographic (ECG) pattern in the immediate postoperative setting. DESIGN: Case report. SETTING: Postanesthesia care unit at Memorial Sloan-Kettering Cancer Center. PATIENT: A 51-yr-old white male who developed new ST-segment elevation in leads V(1)-V(3) typical of the ECG changes of the Brugada syndrome immediately after undergoing head and neck surgery for cancer. The patient was asymptomatic, and the cardiac enzymes and echocardiogram were normal; therefore, electrophysiologic study was not performed. CONCLUSIONS: We postulated that the Brugada ECG abnormalities were induced primarily by an increase in parasympathetic tone resulting from vagal nerve manipulation during deep neck dissection and partially by the fever he developed during the postoperative period. In addition to the more common causes of ST-segment elevation, the Brugada ECG pattern or syndrome should be considered in patients undergoing deep neck dissection who develop characteristic ECG changes in association with normal cardiac enzymes and echocardiogram.

Semirigid partial annuloplasty band allows dynamic mitral annular motion and minimizes valvular gradients: an echocardiographic study.

BACKGROUND: Traditional mitral annuloplasty devices include both rigid rings, which restrict annular motion, and soft rings and bands, which can locally deform. Conflicting data exist regarding their impact on annular dynamics. We studied mitral annuloplasty with a semirigid partial band and with a nearly complete rigid ring. METHODS: Intraoperative three-dimensional transesophageal echocardiograms (n = 14) and predischarge transthoracic echocardiograms were retrospectively analyzed in patients undergoing mitral valve repair for degenerative disease with either a rigid ring (n = 77) or a semirigid partial band (n = 38). Each transesophageal echocardiogram was analyzed with TomTec three-dimensional software to produce cardiac cycle frame planimetry and to measure device geometry. Actual device sizes provided reference dimensions. Blinded analysis of Doppler data from transthoracic echocardiograms was performed. RESULTS: Validation of the quantitative transesophageal echocardiogram methodology revealed a 1.3% +/- 0.3% (mean +/- standard error of the mean) underestimation of actual linear dimension. With the semirigid partial band, systolic valve orifice area and intertrigonal distance decreased from 6.14 +/- 0.37 to 5.55 +/- 0.24 cm(2) (-9.6%; p = 0.01) and from 2.69 +/- 0.08 to 2.55 +/- 0.13 cm (-5.2%; p = 0.03), respectively. Systolic anterior-posterior distance decreased from 2.1 +/- 0.10 to 1.95 +/- 0.06 cm (-7.1%; p = 0.01) compared with diastole. In contrast, rigid ring orifice area was unchanged (4.12 +/- 0.15 to 4.10 +/- 0.16 cm(2); -0.5%; p = 0.48) during the cardiac cycle. Transthoracic echocardiography revealed significantly lower mitral inflow gradients with semirigid partial band (mean gradients compared with rigid ring, 4.0 +/- 0.3 versus 5.0 +/- 0.3 mm Hg; p = 0.02; peak gradients, 8.9 +/- 0.5 versus 11.1 +/- 0.5 mm Hg; p = 0.01). CONCLUSIONS: Three-dimensional transesophageal echocardiographic measurements of annular dynamics are valid and reliable when discrete annuloplasty devices are present. In contrast to the rigid ring, the semirigid partial band permits more physiologic geometric changes and is associated with lower postoperative mitral valve gradients.

Substernal epicardial echocardiography: review of a new technique.

BACKGROUND: Patients after cardiac operation pose a challenge to the treating physician-these patients may become critically ill and are among the most difficult to image using transthoracic echocardiography. Several factors contribute to this, including difficulties in positioning the patient, inability of the patient to cooperate with instructions, surgical dressings, and hyperinflated lungs. Transesophageal echocardiography may be performed when transthoracic echocardiography is not diagnostic; however, transesophageal echocardiography is semi-invasive and does not lend itself to prolonged or repeated monitoring. METHODS: Recently, a new approach to echocardiography for use in the patient after operation has been introduced with the modification of the standard mediastinal drainage tube to allow for substernal epicardial echocardiography (SEE). The SEE tube has 2 lumens. The first allows for routine mediastinal drainage and the second has a blind end that permits the insertion of a standard transesophageal echocardiographic probe for high-resolution imaging as often as is desired over the period during which the mediastinal tube is in place. CONCLUSION: This article reviews the technique of SEE including a description of the method of performance of SEE (with representative images), a review of the published literature on this new modality, examples of clinical use, and a discussion of the advantages, indications, and limitations of SEE with an eye toward future directions for research.