Herron C, Forbes TJ, Kobayashi D.Cardiol Young. 2020 Nov 3:1-4. doi: 10.1017/S1047951120003686. Online ahead of print.PMID: 33140718
Take Home Points:
- Percutaneous balloon pericardiotomy is a feasible alternative to surgical pericardial window creation in the pediatric population.
- Although technical success was excellent in this manuscript, re-interventions were common and some patients did require subsequent surgical pericardial window creation.
Commentary from Dr. Arash Salavitabar (Ann Arbor MI, USA), catheterization section editor of Pediatric Cardiology Journal Watch: The authors report on a retrospective single-center experience with percutaneous balloon pericardiotomy (PBP) in children with the goal of creating a non-surgical pericardial window, a relatively unique procedure in the pediatric population. Technical success was defined as achievement of a pericardial window by this technique, judged by identification of the balloon waist at the parietal pericardium and following disappearance of this balloon waist. Procedural success was defined as resolution of the pericardial effusion without need of subsequent surgical pericardial window.
The technique described by the authors was performed in 11 patients with a median age of 12 years (range 1.8-19) and median weight of 50kg (12-.3-122). The approach involves a standard pericardiocentesis with subsequent placement of a 0.035” Rosen wire (Cook Medical, Bloomington, IN) into the pericardial space. The skin tract is dilated with an 8-10Fr dilator, and then serial dilation is performed with balloons situated across the pericardium. A mid-balloon waist is observed via gentle inflation and by fluoroscopy to confirm position and the ultimate balloon diameter is chosen based on the goal diameter. Some patients required two simultaneous balloon catheter inflations to achieve that goal diameter. Contrast injections were used to visualize the pericardial space and margin of the parietal pericardium. A pericardial drain was left in most patients.
Four of the 11 patients were post-pericardiotomy syndrome patients at a median 58 days (39-88) post-cardiac surgery and 4 required percutaneous re-interventions (4 pericardiocentesis in 3 patients and 2 PBPs in 2 patients) due to re-accumulation of the pericardial effusion. Three of those patients who required percutaneous re-interventions also required subsequent surgical pericardial window creation. The majority of PBPs were performed with compliant balloons (e.g., Tyshak II, Z-Med), however two received PBP using relatively non-compliant balloons (e.g., Atlas, Powerflex). The largest balloon diameter used ranged from 8 to 20mm; 20mm was the final dilation diameter in most older children. Echocardiography was used to confirm improvement in pericardial effusion.
Based on these results, the authors reported a technical success of 100% with no acute complications, an overall procedural success of 73%, and 45% re-intervention rate. Of note, 4/11 patients showed development of a left pleural effusion post-PBP, but did not require chest tube placement. The authors describe that this procedural success rate and re-intervention rate may be explained by the fact that a “torn” pericardium by PBP is not a permanent anatomic solution. The other possible contributing factors described were final balloon size, inability to completely expand the balloon based on position against chest wall, residual waist, or the etiology of the underlying effusion.
The approach of percutaneous balloon pericardiotomy is certainly an enticing alternative to surgical pericardial window creation and the authors describe a technique that is certainly plausible in many patients with pericardial effusions. Based on these results, the care team and proceduralist must understand that re-interventions are relatively common with this procedure, but may preclude the need for more invasive surgical interventions in some patients. Given the heterogeneity in their reported patient population and the potential for variable results, larger studies will be of benefit to better understand its utility, as well as risk factors for procedural failure and complications.