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Malignant Pericardial Effusion: Prognostic Factors after Pericardial Window and the Significance of Paradoxical Hemodynamic Instability

Patrick L Wagner1, James Huang2, Robert J Downey2, Nabil Rizk2, *Bernard Park2, Raja M Flores2, Valerie W Rusch2
1New York-Presbyterian Hospital, New York, NY;2Memorial Sloan-Kettering Cancer Center, New York, NY

Objective: In the oncologic population, pericardial effusions are a frequent and potentially life-threatening occurrence. Despite decompression, some patients develop paradoxical hemodynamic instability, with hypotension and shock. The purpose of this study was to identify characteristics associated with this poorly understood phenomenon, and prognostic factors in oncologic patients 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 (1/04-3/09). Demographic, surgical, pathologic, and echocardiographic data were analyzed for the endpoints of postoperative hemodynamic instability (pressor-dependent hypotension requiring ICU admission) and overall survival.
Results: The most common malignancies were lung (44%), breast (20%), hematologic (10%), GI (7%). Overall survival for the group was poor (median survival 5 mo); however, patients with hematologic malignancies fared significantly better than the others (median survival 36 mo, p=0.008). Postop instability (PHI) occurred in 19 patients (11%). These patients were more likely to have evidence of tamponade on echocardiogram (89% vs. 56%, p=0.005), positive cytology/pathology (68% vs. 41%, p=0.03), and higher volume drained (674mL vs. 495mL, p=0.003). Overall survival was significantly shorter (median survival 35 vs. 189 days) in those who developed PHI (HR=3, p<0.001), and the majority of them (11/19, 58%) did not survive their hospitalization.
Conclusion: Postoperative hemodynamic instability after pericardial window portends a grave prognosis. Evidence of tamponade, larger effusion volumes, and positive cytology may predict those patients at higher risk of developing this phenomenon and anticipate a need for invasive monitoring and ICU admission postoperatively. Patients with hematologic malignancies fare significantly better when presenting with pericardial effusions.
Multivariate Analysis of Predictors of Postoperative Hemodynamic Instability
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