Original Article

Poor Outcomes Associated with Drainage of Pericardial Effusions in Patients with Pulmonary Arterial Hypertension

Authors: Anna R. Hemnes, MD, Sean P. Gaine, MD, PhD, Charles M. Wiener, MD

Abstract

Objectives: Pulmonary arterial hypertension (PAH) in its advanced stages is complicated by right heart failure and often pericardial effusion. The optimal treatment of large or hemodynamically significant pericardial effusions in this group has not been defined.


Methods: All patients followed at the Johns Hopkins Hospital for PAH during a 1-year period that underwent pericardiocentesis or pericardial window placement were identified. Charts were analyzed for patient characteristics, echocardiographic data, and type/outcome of procedure.


Results: Six patients were identified; five underwent therapeutic drainage. Pericardiocentesis was performed in four cases; two had surgical pericardial windows. Two patients died after pericardiocentesis and one patient died after surgery. All patients died within 13 hours of the procedure.


Conclusion: We found a high mortality related to pericardial fluid drainage in patients with PAH. The pathophysiologic explanation for these deaths remains unclear, but clinicians should consider conservative management in this situation if possible.


Key Points


* The presence of pericardial effusion in pulmonary arterial hypertension usually represents advanced right heart failure and is associated with a poor prognosis.


* We report on six patients with large or hemodynamically significant pericardial effusions seen in one year at a referral center for pulmonary hypertension.


* Pericardial drainage is associated with a high mortality in patients with pulmonary arterial hypertension, and consideration should be given to alternative management strategies such as vasoactive therapy and/or diuresis.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Simonneau G, Galie N, Rubin LJ, et al. Clinical classification of pulmonary hypertension. J Am Coll Cardiol 2004;43(suppl S):5S–12S.
 
2. Humbert M, Sitbon O, Simonneau G. Treatment of pulmonary arterial hypertension. New Engl J Med 2004;351:1425–1436.
 
3. Hinderliter Al, Willis PW IV, Long W, et al. Frequency and prognostic significance of pericardial effusion in primary pulmonary hypertension. Am J Cardiol 1999;84:481–484.
 
4. Eysmann SB, Palevsky HI, Reichek N, et al. Two-dimensional and Doppler-echocardiographic and cardiac catheterization correlates of survival in primary pulmonary hypertension. Circulation 1989;80:353–360.
 
5. Raymond RJ, Hinderliter AL, Willis PW, et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol 2002;39:1214–1219.
 
6. Krowka MJ, Plevak DJ, Findlay JY, et al. Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. Liver Transpl 2000;6:443–450.
 
7. Mellins R, Levine O, Fishman A. Effect of systemic and pulmonary venous hypertension on pleural and pericardial fluid accumulation. J Appl Physiol 1970;29:564–569.
 
8. Miller AJ. Some observations concerning pericardial effusions and their relationships to the venous and lymphatic circulation of the heart. Lymphology 1970;2:76–78.
 
9. Gilliam LD, Guyer De, Gibson TC, et al. Hydrodynamic compression of the right atrium; a new echocardiographic sign of cardiac tamponade. Circulation 1983;68:294–301.
10. Singh S, Wann LS, Schuchard GH, et al. Right ventricular and right atrial collapse in patients with cardiac tamponade-a combined echocardiographic and hemodynamic study. Circulation 1984;70:966–971.
11. Appleton CP, Hatle LK, Popp RL. Cardiac tamponade and pericardial effusion: respiratory variation in transvalvular flow velocities studied by Doppler echocardiography. J Am Coll Cardiol 1988;11:1020–1030.
12. Himmelman RB, Kircher B, Rockey DC, et al. Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol 1988;12:1470–1477.
13. Plotnick G, Rubin D, Zenaida F, et al. Pulmonary hypertension decreases the predictive accuracy of echocardiographic clues for cardiac tamponade. Chest 1995;107:919–924.
14. Kaplan LM, Epstein SK, Schwartz SL. Clinical, echocardiographic and hemodynamic evidence of cardiac tamponade caused by large pleural effusions. Am J Respir Crit Care Med 1995;151:904–908.
15. Brodyn N, Rose M, Prior F, et al. Left atrial diastolic compression in a patient with a large pericardial effusion and pulmonary hypertension. Am J Med 1990;88:64N–66N.
16. Schwartz Sl, Pandian NG, Cao QL, et al. Left ventricular diastolic collapse in regional left heart cardiac tamponade. An experimental echocardiographic and hemodynamic study. J Am Coll Cardiol 1993;22:907–913.
17. Frey M, Berko B, Palevsky H, et al. Recognition of cardiac tamponade in the presence of severe pulmonary hypertension. Ann Intern Med 1989;111:615–617.
18. Krikorian JG, Hancock WE. Pericardiocentesis. Am J Med 1978;65:808–814.
19. Spodick DH. Pericardial disease, in Heart Disease: A Textbook of Cardiovascular Medicine. New York, NY, WB Saunders, 2001, ed 6, pp 1823–1876.