Balloon pericardiotomy for recurrent pericardial effusion

Cardiology · Interventional Cardiology

Pericardial effusion, defined as the accumulation of fluid within the pericardial cavity, may arise from various causes, including trauma, infection, autoimmune disease, malignancy and complications following interventional cardiac procedures such as left atrial appendage closure, pacemaker or implantable cardioverter-defibrillator implantation, electrophysiological procedures and structural heart interventions. Recurrent pericardial effusion can result in persistent symptoms, repeated hospitalisations and, in some cases, haemodynamic compromise. Although pericardiocentesis with catheter drainage is often used for initial management, fluid reaccumulation may occur, particularly in patients with malignant pericardial effusions. Balloon pericardiotomy is a minimally invasive, percutaneous procedure that creates a communication between the pericardial cavity and an adjacent space, usually the pleural cavity, allowing continuous drainage and reducing the likelihood of recurrent fluid accumulation. It offers an alternative to surgical pericardial window creation in selected patients, particularly those who are at high surgical risk or require palliative management.[1]Principle and mechanism of balloon pericardiotomyBalloon pericardiotomy involves creating an opening in the pericardial sac using an inflatable balloon catheterThe procedure establishes communication between the pericardial cavity and the adjacent pleural cavity, allowing accumulated fluid to drain into the pleural spaceThe drained fluid is subsequently absorbed through the pleural surface, thereby reducing fluid accumulation within the pericardial cavityUnlike conventional pericardiocentesis, which removes accumulated fluid without establishing a drainage pathway, balloon pericardiotomy facilitates ongoing drainageThe procedure is performed through percutaneous pericardial access, generally under imaging guidance to facilitate appropriate catheter positioningClinical indications and patient selectionBalloon pericardiotomy may be considered in patients with recurrent symptomatic pericardial effusion despite previous pericardiocentesis or catheter drainageRecurrent malignant pericardial effusion represents an important clinical setting in which the procedure may provide palliative symptom reliefPatients with advanced malignancy, limited life expectancy, or substantial surgical risk may be considered when conventional surgical drainage is unsuitablePatient selection should account for the underlying etiology, recurrence pattern, hemodynamic status, previous interventions, and overall clinical prognosisThe 2025 European Society of Cardiology (ESC) guidelines do not recommend balloon pericardiotomy as a routine first- or second-line intervention. Its use should be restricted to selected circumstances, including recurrent neoplastic effusions, contraindications to surgery, or terminal illness associated with severely impaired quality of life[2]Procedural approach and considerationsPercutaneous access to the pericardial cavity is established before introducing the balloon catheterThe balloon catheter is positioned appropriately and inflated to create an opening in the pericardial sacThe resulting communication permits drainage of pericardial fluid into the adjacent pleural cavityImaging guidance and assessment of pericardial anatomy are important for procedural planning and safe accessFollowing intervention, clinical monitoring and echocardiographic assessment help evaluate residual effusion, drainage effectiveness, and potential complicationsPreprocedural assessmentThe following parameters should be evaluated before selecting balloon pericardiotomy.AssessmentClinical relevanceEchocardiographyEvaluates effusion size, distribution, cardiac chamber compression, and hemodynamic consequences.Pericardial fluid analysisHelps establish malignant, infectious, or inflammatory etiology.Thoracic imagingAssesses pleural anatomy and associated thoracic abnormalities.Surgical fitnessDetermines the suitability of surgical pericardial window creation as an alternative.Overall prognosisHelps establish the expected benefit of a palliative intervention.Stepwise approach[3]Anaesthesia and access: The procedure is performed under local anaesthesia. The pericardial cavity is accessed using a percutaneous subxiphoid approachGuidewire insertion: An angiographic guidewire is introduced through the access site and advanced into the pericardial cavityGuidewire exchange: If the initial guidewire does not provide adequate support for balloon catheter advancement, it is exchanged for a stiff, coiled-tip guidewire to facilitate catheter manipulationDilatation of the access site: The entry site is sequentially dilated using an appropriately sized dilator to facilitate catheter passageBalloon catheter advancement: The balloon catheter is advanced over the coiled-tip guidewire into the pericardial cavityBalloon positioning: The balloon is partially inflated and gradually withdrawn until a visible waist develops, indicating contact with the parietal pericardium and confirming the balloon positionBalloon inflation: Once optimally positioned, the balloon is inflated using contrast medium and maintained for the required duration until the balloon waist disappearsConfirmation of dilatation: A second inflation is performed to confirm the complete disappearance of the waist and adequate dilatationDevice removal: Following confirmation, the balloon catheter and guidewire are carefully withdrawnLimitations and potential complicationsBalloon pericardiotomy does not treat the underlying cause of pericardial effusion and should be accompanied by appropriate etiology-directed managementThe created communication may close over time, resulting in recurrent pericardial fluid accumulationPotential complications include bleeding, pneumothorax, pleural effusion, infection, and injury to adjacent structuresInadequate drainage may occur in patients with loculated or compartmentalized pericardial effusionsPurulent pericardial effusion requires appropriate drainage and antimicrobial therapy rather than balloon pericardiotomy as a substitute for infection controlSurgical pericardial window creation remains an important alternative when more durable drainage is required and the patient can tolerate surgeryConclusionBalloon pericardiotomy is a minimally invasive, predominantly palliative option for carefully selected patients with recurrent pericardial effusion, particularly those with malignant effusions or a high risk associated with conventional surgery. By establishing communication between the pericardial cavity and an adjacent space, it facilitates ongoing drainage and may reduce fluid reaccumulation. However, potential communication closure, recurrent effusion and procedural complications should be considered when assessing its suitability. Individualised patient selection, taking into account the underlying aetiology, recurrence pattern, haemodynamic status and surgical fitness, is essential to guide treatment and optimise clinical outcomes.[4]Reference(s):1. Katz JB, Kalluri A, Leya M, et al. Balloon Pericardiotomy: A Comprehensive Review and Case Series. J Soc Cardiovasc Angiogr Interv. 2025;4(8):103800. Published 2025 Jul 23. doi:10.1016/j.jscai.2025.103800. https://pmc.ncbi.nlm.nih.gov/articles/PMC12462121/2. Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025;46(40):3952-4041. doi:10.1093/eurheartj/ehaf192. https://pubmed.ncbi.nlm.nih.gov/40878297/3. Puri A, Agarwal N, Dwivedi SK, Narain VS. Percutaneous balloon pericardiotomy for the treatment of recurrent malignant pericardial effusion. Indian Heart J. 2012;64(1):88-89. doi:10.1016/S0019-4832(12)60018-2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3860904/4. Chang LK, Kuo YW, Wu SG, Chung KP, Shih JY. Recurrence of pericardial effusion after different procedure modalities in patients with non-small-cell lung cancer. ESMO Open. 2022;7(1):100354. doi:10.1016/j.esmoop.2021.100354. https://pmc.ncbi.nlm.nih.gov/articles/PMC8717440/