Document Type : Original Article


Department of General and Thoracic Surgery, University Hospital of Chieti, Chieti, Italy


Objective: Cardiac tamponade is a life-threatening clinical entity that requires an emergency treatment. Cardiac tamponade can be caused both by benign and malignant diseases. A variety of methods have been described for the treatment of these cases from needle-guided pericardiocentesis, balloon-based techniques to surgical pericardiotomy. The Authors report their experience in surgical management of cardiac tamponade and an exhaustive review of literature.
Methods: This study involved 61 patients (37 males and 24 females) with an average age of 61.80 ± 16.32 years. All patients underwent emergency surgery due to the presence of cardiac tamponade.
Results: Cardiac tamponade was caused by a benign disease in 57.40% of patients. In cancer patients group, lung cancer, breast cancer and malignant pleural mesothelioma were the most common neoplasms (17-27, 87%). The average preoperative size of pericardial effusion at M-2D echocardiography was 30.15 ± 5.87 mm. Postoperative complications were observed in 11 patients (18%). The reoperation rate was 3.3% (2 patients) due to relapsed cardiac tamponade. 30-day mortality rate was 3.3%. Overall cumulative survival was 29.9 ± 20.1 months. Twenty-nine patients (47.5%) died during the follow up period. By dividing the population into two groups, group B (benign) and group M (malignant), there was a statistically significant difference (P < 0.001) in terms of survival.
Conclusion: In conclusions, anterior minithoracotomy for surgical treatment of cardiac tamponade has to be held into account in patients both with benign diseases and malignancies.


Main Subjects


    1. Sagristà-Sauleda J, Mercé AS, Soler-Soler J. Diagnosis and management of pericardial effusion. World J Cardiol 2011; 3(5): 135-43. doi: 10.4330/wjc.v3.i5.135.
    2. Seferović PM, Ristić AD, Imazio M, Maksimović R, Simeunović D, Trinchero R, et al. Management strategies in pericardial emergencies. Herz 2006; 31(9): 891-900. doi: 10.1007/s00059-006-2937-0.
    3. LeWinter MM, Tischler MD. Pericardial diseases. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadlephia, PA: Saunders Elsevier; 2011.
    4. Beck CS. Two cardiac compression triads. JAMA 1935; 104 (9): 714-6. doi: 10.1001/jama.1935.02760090018005.
    5. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002; 77(5): 429-36. doi: 10.4065/77.5.429.
    6. Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion. JAMA 1994; 272(1): 59-64. doi: 10.4065/77.5.429.
    7. Swanson N, Mirza I, Wijesinghe N, Devlin G. Primary percutaneous balloon pericardiotomy for malignant pericardial effusion. Catheter Cardiovasc Interv 2008; 71(4): 504-7. doi: 10.1002/ccd.21431.
    8. Mercé J, Sagristà-Sauleda J, Permanyer-Miralda G, Soler- Soler J. Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade? Am J Med 1998; 105(2): 106-9. doi: 10.1016/ s0002-9343(98)00192-2.
    9. Georghiou GP, Stamler A, Sharoni E, Fichman-Horn S, Berman M, Vidne BA, et al. Video-assisted thoracoscopic pericardial window for diagnosis and management of pericardial effusions. Ann Thorac Surg 2005; 80(2): 607-10. doi: 10.1016/j.athoracsur.2005.02.068.
    10. Fortuño Andrés JR, Alguersuari Cabiscol A, Falcó Fages J, Castañer González E, Bermudez Bencerrey P. Radiological approach to cardiac tamponade. Radiologia 2010; 52(5): 414-24. doi: 10.1016/j.rx.2010.05.011. [In Spanish].
    11. Liberman M, Labos C, Sampalis JS, Sheiner NM, Mulder DS. Ten-year surgical experience with nontraumatic pericardial effusions: a comparison between the subxyphoid and transthoracic approaches to pericardial window. Arch Surg 2005; 140(2): 191-5. doi: 10.1001/archsurg.140.2.191.
    12.  Eisenberg MJ, de Romeral LM, Heidenreich PA, Schiller NB, Evans GT Jr. The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG. A technology assessment. Chest 1996; 110(2): 318-24. doi: 10.1378/ chest.110.2.318.
    13.  Karatay CM, Fruehan CT, Lighty GW Jr, Spear RM, Smulyan H. Acute pericardial distension in pigs: effect of fluid conductance on body surface electrocardiogram QRS size. Cardiovasc Res 1993; 27(6): 1033-8. doi: 10.1093/ cvr/27.6.1033.
    14.  Bruch C, Schmermund A, Dagres N, Bartel T, Caspari G, Sack S, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol 2001; 38(1): 219-26. doi: 10.1016/s0735-1097(01)01313-4.
    15.  Gumrukcuoglu HA, Odabasi D, Akdag S, Ekim H. Management of cardiac tamponade: a comperative study between echo-guided pericardiocentesis and surgery-a report of 100 patients. Cardiol Res Pract 2011; 2011: 197838. doi: 10.4061/2011/197838.
    16.  Barbetakis N, Asteriou C, Konstantinou D, Giannoglou D, Tsilikas C, Giannoglou G. Spontaneous chylous cardiac tamponade: a case report. J Cardiothorac Surg 2010; 5: 11. doi: 10.1186/1749-8090-5-11.
    17.  Maharaj SS, Chang SM. Cardiac tamponade as the initial presentation of systemic lupus erythematosus: a case report and review of the literature. Pediatr Rheumatol Online J 2015; 13: 9. doi: 10.1186/s12969-015-0005-0.
    18.  Hellmann AR, Kostro J, Dziedzic R, Hellmann M, Dudziak M. Cardiac tamponade as the first manifestation of primary hypothyroidism. Kardiol Pol 2015; 73(9): 786. doi: 10.5603/ kp.2015.0168.
    19. Sinha A, Yeruva SL, Kumar R, Curry BH. Early cardiac tamponade in a patient with postsurgical hypothyroidism. Case Rep Cardiol 2015; 2015: 310350. doi: 10.1155/2015/310350.
    20.  Goh AC, Lundstrom RJ. Spontaneous coronary artery dissection with cardiac tamponade. Tex Heart Inst J 2015; 42(5): 479-82. doi: 10.14503/THIJ-14-4260.
    21.  Allen KB, Faber LP, Warren WH, Shaar CJ. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg 1999; 67(2): 437-40. doi: 10.1016/s0003-4975(98)01192-8.
    22.  Gassman HS, Meadows R, Baker LA. Metastatic tumors of the heart. Am J Med 1955; 19(3): 357-65. doi:10.1016/0002- 9343(55)90124-8.
    23. Tsang TS, El-Najdawi EK, Seward JB, Hagler DJ, Freeman WK, O’Leary PW. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy. J Am Soc Echocardiogr 1998; 11(11): 1072-7. doi: 10.1016/s0894-7317(98)70159-2.
    24.  Fitch MT, Nicks BA, Pariyadath M, McGinnis HD, Manthey DE. Videos in clinical medicine. Emergency pericardiocentesis. N Engl J Med 2012; 366(12): e17. doi: 10.1056/nejmvcm0907841.
    25.  Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004; 25(7): 587-610. doi: 10.1016/j.ehj.2004.02.002.
    26. Wong B, Murphy J, Chang CJ, Hassenein K, Dunn M. The risk of pericardiocentesis. Am J Cardiol 1979; 44(6): 1110– 4.
    27. Ainsworth CD, Salehian O. Echo-guided pericardiocentesis: Let the bubbles show the way. Circulation 2011; 123(4): e210–1. doi: 10.1161/circulationaha.110.005512.
    28. Fejka M, Dixon SR, Safian RD, O’Neill WW, Grines CL, Finta B, et al. Diagnosis, management, and clinical outcome of cardiac tamponade complicating percutaneous coronary intervention. Am J Cardiol 2002; 90(11): 1183-6. doi: 10.1016/s0002-9149(02)02831-x.
    29. Kopecky SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardial catheter drainage: report of 42 consecutive cases. Am J Cardiol 1986; 58(7): 633-5. doi: 10.1016/0002- 9149(86)90290-0.
    30. Celermajer DS, Boyer MJ, Bailey BP, Tattersall MH. Pericardiocentesis for symptomatic malignant pericardial effusion: a study of 36 patients. Med J Aust 1991; 154(1): 19-22.
    31. Tanaka Y, Tsuboi K, Yamamoto A, Tsuda S, Tsujii S, Yagi K, et al. Long-term survival of a breast cancer patient with carcinomatous pleuritis and carcinomatous cardiac tamponade successfully treated by multimodality therapy. Gan To Kagaku Ryoho 2015; 42(4): 489-92. [In Japanese].
    32. Lestuzzi C, Berretta M, Tomkowski W. 2015 update on the diagnosis and management of neoplastic pericardial disease. Expert Rev Cardiovasc Ther 2015; 13(4): 377-89. doi: 10.1586/14779072.2015.1025754.
    33. Sun T, Zhang Y, Shen Y, Hu K, Zuo M. A case of advanced lung cancer with malignant pericardial effusion treated by intrapericardial Cinobufacini injection instillation. Biosci Trends 2014; 8(4): 235-9. doi: 10.5582/bst.2014.01073.
    34. McDonald JM, Meyers BF, Guthrie TJ, Battafarano RJ, Cooper JD, Patterson GA. Comparison of open subxiphoid pericardial drainage with percutaneous catheter drainage for symptomatic pericardial effusion. Ann Thorac Surg 2003; 76(3): 811-5. doi: 10.1016/s0003-4975(03)00665-9.
    35. Buchanan CL, Sullivan VV, Lampman R, Kulkarni MG. Pericardiocentesis with extended catheter drainage: an effective therapy. Ann Thorac Surg 2003; 76(3): 817-20. doi: 10.1016/s0003-4975(03)00666-0
    36. Watarida S, Shiraishi S, Matsubayashi K, Imura M, Nishi T. Pericardial-peritoneal window for chronic exudative pericarditis using a subxiphoidal approach: report of three cases. Surg Today 2002; 32(5): 410-3. doi: 10.1007/ s005950200064.
    37. Kurimoto Y, Hase M, Nara S, Yama N, Kawaharada N, Morishita K, et al. Blind subxiphoid pericardiotomy for cardiac tamponade because of acute hemopericardium. J Trauma 2006; 61(3): 582-5. doi: 10.1097/01. ta.0000236060.37952.ce
    38.  Uramoto H, Hanagiri T. Video-assisted thoracoscopic pericardiectomy for malignant pericardial effusion. Anticancer Res 2010; 30(11): 4691-4.
    39.  Muhammad MI. The pericardial window: is a video-assisted thoracoscopy approach better than a surgical approach? Interact Cardiovasc Thorac Surg 2011; 12(2): 174-8. doi: 10.1510/icvts.2010.243725.
    40. Georghiou GP, Porat E, Fuks A, Vidne BA, Saute M. Video-assisted pericardial fenestration for effusions after cardiac surgery. Asian Cardiovasc Thorac Ann 2009; 17(5): 480-2. doi: 10.1177/0218492309348505.
    41. Pérez-Etchepare E, Al Makki A, Varlet F, López M. Thoracoscopic treatment in pericardial tamponade. Cir Pediatr.2012; 25(3): 166-8.
    42.  Agrawal V, Saxena A, Sethi A, Acharya H, Sharma D. Thoracoscopic pericardiotomy for management of purulent pneumococcal pericarditis in a child. Asian J Endosc Surg 2012; 5(3): 145-8. doi: 10.1111/j.1758-5910.2011.00129.x.
    43.  Monaco F, Barone M, David A, Risitano DC, Lentini S. Cardiac tamponade: a modified video-assisted thoracoscopic approach. Chir Ital 2009; 61(3): 321-6. [In Italian].
    44.  Olsen PS, Sørensen C, Andersen HO. Surgical treatment of large pericardial effusions. Etiology and long-term survival. Eur J Cardiothorac Surg 1991; 5(8): 430-2. doi: 10.1016/1010-7940(91)90189-q.
    45.   Gregory JR, McMurtrey MJ, Mountain CF. A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985; 8(4): 319-23.
    46.  Celik S, Celik M, Aydemir B, Tanrıkulu H, Okay T, Tanrikulu N. Surgical properties and survival of a pericardial window via left minithoracotomy for benign and malignant pericardial tamponade in cancer patients. World J Surg Oncol 2012; 10: 123. doi: 10.1186/1477-7819-10-123.
    47.  Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg 2002; 74(4): 1148-53. doi: 10.1016/ s0003-4975(02)03837-7.
    48.  Miller RH, Horneffer PJ, Gardner TJ, Rykiel MF, Pearson TA. The epidemiology of the postpericardiotomy syndrome: a common complication of cardiac surgery. Am Heart J 1988; 116(5 Pt 1): 1323-9. doi: 10.1016/0002-8703(88)90457-7.
    49.  Nishimura RA, Fuster V, Burgert SL, Puga FJ. Clinical features and long-term natural history of the postpericardiotomy syndrome. Int J Cardiol 1983; 4(4): 443-50. doi: 10.1016/0167-5273(83)90194-8.