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Posts Tagged ‘percutaneous baloon pericardiocentesis’

Answer  : I guess all mechanisms  contribute.Though E appears unlikely,  its backed by evidence (Ref 5)

Balloon pericardiotomy is done as a drainage procedure in recurrent pericardial effusion. It is actually a replication of surgical pericardial window by Interventional cardiologist.The window not only drains the effusion , it also act as a continuous drain. Though the  benefits are real (Pericardial fluid is shunted away from the pericardial space)  the exact mechanism of its benefit is not clear .

By concept , the catheter and  balloon should not cross the pleural space , (As pneumothorax may ensue) but still pleural effusion is a common consequence of this procedure .How is this possible ? One probable explanation is, the pleural space has some hidden communication with pericardial space .The other possibility is that, balloon creates virtual tissue channels  in the para-cardiac spaces of mediastinum .The extra-cardiac lymphatics does the drainage job without true shunting  pericardial space into the pleural space..

There is an article  from Annals of thoracic surgery which specifically   looked  into the  mechanism of benefit of  surgical pericardial window and came to a surprise conclusion, ie, it is not the continuous  drainage that keeps the space dry , rather it is likely the window  somehow obliterates the pericardial space permanently.(Sugimoto 1990,Annals of thoracic surgery )

Future  Innovation  : A technical add-on to  balloon pericarditomy  could be , delivering a covered stent across the pericardial space  into  peritoneal space like a VP shunt done by  Neurosurgeons.(If no body has done this , Can I claim the patency  for this  !)

The procedure

 

percutaneous balloon pericarditomy

Image used from Daniel A. Jones & Ajay K. Jain, Journal of thoracic Oncology , 2011

Risk of procedure

The procedure carries a definite risk especially  if done in an  emergency fashion. The aim of  procedure is two fold one to drain pericardial effusion second to prevent recurrence of effusion  .Since procedure carries  considerable risk  its to be performed  only in malignant effusion that are documented to be recurrent.

Surgical vs Balloon window  and other alternatives

Surgical window  creation is well known procedure , ever since Palacios (Ref 1) in 1991 described this per cutaneous approach as an alternative to surgery has become less popular. The risk of anesthesia and co-morbidity makes balloon pericardiotomy attractive. But surgical window creation still may have a role. A video  assisted pericardiotomy by thoracoscopy is also possible .Another option is injecting sclerosing agents into pericardial space .This time tested simple modality probably requires  more attention.

Need for subsequent pleural tapping

It should be realised this procedure may just  shift the  fluid from pericardium to pleural space. Some of them become significant effusion that requires pleural space drainage.

Concern of risk of dissemination of malignancy

Its a real issue , there has been instances of accelerated death after the procedure. Hence this procedure is a trade-of  between patient comfort and quality of life with a  potential risk of dissemination impacting  the longevity of life .

1.Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percoutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovasc Diagn 1991: 22;244-249.

5.

 

 

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