Author + information
- Cezar Iliescu, MD∗ (, )
- Tarif Khair, MD,
- Konstantinos Marmagkiolis, MD,
- Gloria Iliescu, MD and
- Jean Bernard Durand, MD
- ↵∗Cardiac Catheterization Laboratory, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030
Thrombocytopenia has been considered a relative contraindication to pericardiocentesis; limited data are available regarding the safety of the procedure in thrombocytopenic patients. The incidence of refractoriness to platelet transfusion defined as failure to increase by at least 10,000/μl after transfusion of an appropriate dose of platelets or <3,000 μl increase per unit transfused, varies from 15% to 25% in patients with blood disorders and cancer. The excellent editorial by Tsang (1) on our paper “Outcomes of Cancer Patients Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion” (2) prompted us to perform an additional analysis on the safety of pericardiocentesis guided with echocardiography and/or fluoroscopy in cancer patients with cardiac tamponade with different degrees of thrombocytopenia and tested the impact of platelet transfusion on platelet count in these patients.
All cancer patients with thrombocytopenia (platelet count <100,000/μl) who underwent primary percutaneous pericardiocentesis for cardiac tamponade from May 2009 through October 2015 were identified through a search of the cardiac catheterization laboratory registry. Patient demographics, underlying malignancy, platelet count, coagulation profile, thromboelastography findings, transfusions of platelets, and entry site (subxiphoid vs. lateral) were recorded.
Combined echocardiographic and fluoroscopic guidance was used when possible to increase the safety of pericardiocentesis and to avoid challenges that can occur when only one of these imaging techniques is used; for example, with echocardiography alone, there is poor visualization of the agitated saline injected through the micropuncture needle or technical difficulties due to patient body habitus or reconstructive surgical procedures, and the fluoroscopy alone guided procedure is difficult when the pericardial space was already opened due to previous intrathoracic procedures. Platelet transfusion was performed when blood products were available. Only platelets transfused in the 24 h before the pericardiocentesis were considered. Complications (type and number) were reviewed and classified as major or minor as previously described (1).
Of 229 pericardiocentesis procedures, 60 were performed on 59 patients during the study period. Of the 60 procedures, 27 (45%) were performed in women and 33 (55%) in men. The majority of patients (n = 48; 81%) had hematologic malignancies. Pericardiocentesis was performed using only echocardiographic guidance in 18 procedures (30%), only fluoroscopic guidance in 1 (2%), and combined echocardiographic and fluoroscopic guidance in 41 (68%). A subxiphoid entry site was used in 45 procedures (75%) and a lateral entry site in 15 procedures (25%) (Figure 1). In 15 procedures (25%), the platelet count was <20,000/μl (critical thrombocytopenia); in 24 procedures (40%), the platelet count was 20,000 to 50,000/μl; and in 21 procedures (35%), the platelet count was >50,000/μl.
In the group with a subxiphoid entry site, 1 patient developed a small entry site hematoma and 1 a small pleural effusion. In the group with lateral entry site, 1 patient developed a left hemothorax requiring surgical evacuation of hematoma. Overall, the major complication rate was 2%.
In only 26 procedures (43%) were platelets transfused before pericardiocentesis. The median increase in platelet count after transfusion was 5,000/μl (IQR: 4,000/μl to 15,000/μl). The small increase in platelet count was consistent with refractoriness to platelet transfusion.
Thromboelastography was obtained before in only 7 procedures, and findings were normal in patients with platelet count >50,000/μl. One patient with platelet count of 21,000/μl had R (reaction time), angle, and MA (angle and the maximum amplitude) values within reference ranges, whereas a patient with a platelet count of 26,000/μl and the 3 patients with a platelet count of <20,000/μl had abnormalities in the R, angle, and MA values. The 2-year survival rate was 10% in patients with platelet count <20,000/μl, 20% in patients with platelet count of 20,000 to 50,000/μl, and 30% in patients with a platelet count of >50,000/μl.
Being a retrospective chart review, our findings are limited by the retrospective nature of data collection as well as the small number of patients. The choice of method for entry site depended on the patient’s anatomy and general status (in patients who could not lie flat, a lateral approach was the only possible way). Finally, differentiating between disease and procedure-related platelet transfusion can be challenging. In conclusion, despite the thrombocytopenia and relative refractoriness to platelet transfusion in this small group of patients, the rate of major complications was comparable with that reported in recent large series of echocardiography-guided pericardiocentesis in the general population. Platelet transfusion might not modify the overall risk of the procedure. Due to impaired hemostasis in thrombocytopenic patients, the use of micropuncture technique and a lateral approach to pericardiocentesis should be considered when hepatomegaly or unfavorable anatomy is present. Although timely management of pericardial effusion may decrease the short-term risk of death from the effusion, decisions regarding whether and when to treat large pericardial effusion or effusion causing cardiac tamponade should balance treatment efficacy with life expectancy.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Tsang T.S.M.
- El Haddad D.,
- Iliescu C.,
- Yusuf S.W.,
- et al.