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Figure.
Subxyphoid (A) and transthoracic (B) incisions used for performing pericardial windows.

Subxyphoid (A) and transthoracic (B) incisions used for performing pericardial windows.

Table 1. 
Number of Procedures Performed per Surgeon
Number of Procedures Performed per Surgeon
Table 2. 
Underlying Cause and Location of the 191 Primary Tumors
Underlying Cause and Location of the 191 Primary Tumors
Table 3. 
Preoperative Characteristics*
Preoperative Characteristics*
Table 4. 
Operative Characteristics*
Operative Characteristics*
Table 5. 
Postoperative Outcomes*
Postoperative Outcomes*
Table 6. 
Pericardial Effusion Recurrence Rates in the Literature
Pericardial Effusion Recurrence Rates in the Literature
1.
Anderson  TMNwogu  CEBottiggi  AJLenox  JMDriscoll  DLUrschel  JD Pericardial catheter sclerosis versus surgical procedures for pericardial effusions in cancer patients. J Cardiovasc Surg (Torino) 2001;42415- 419
PubMedArticle
2.
Mueller  XMTevaearai  HTHurni  M  et al.  Long-term results of surgical subxiphoid pericardial drainage. Thorac Cardiovasc Surg 1997;4565- 69
PubMedArticle
3.
Campione  ACacchiarelli  MGhiribelli  CCaloni  VD’Agata  AGotti  G Which treatment in pericardial effusion? J Cardiovasc Surg (Torino) 2002;43735- 739
PubMed
4.
Watarida  SShiraishi  SMatsubayashi  KImura  MNishi  T Pericardial-peritoneal window for chronic exudative pericarditis using a subxiphoid approach: report of three cases. Surg Today 2002;32410- 413
PubMedArticle
5.
Dosios  TTheakos  NAngouras  DAsimacopoulos  P Risk factors affecting the survival of patients with pericardial effusion submitted to subxyphoid pericardiostomy. Chest 2003;124242- 246
PubMedArticle
6.
Gregory  JRMcMurtrey  MJMountain  CF A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985;8319- 323
PubMedArticle
7.
Little  AGKremser  PCWade  JLLevett  JMDeMeester  TRSkinner  DB Operation for diagnosis and treatment of pericardial effusions. Surgery 1984;96738- 744
PubMed
8.
Health Division, Statistics Canada, Canadian Classification of Diagnostic, Therapeutic, and Surgical Procedures.  Ottawa, Ontario Statistics Canada1986;
9.
 Miller RD. Anesthesia 5th ed. New York, NY Churchill Livingstone Inc2003;
10.
Laham  RJCohen  DJKuntz  REBaim  DSLorell  BHSimmons  M Pericardial effusion in patients with cancer: outcome with contemporary management strategies. Heart 1996;7567- 71
PubMedArticle
11.
Fiocco  MKrasna  MJ The management of malignant pleural and pericardial effusions. Hematol Oncol Clin North Am 1997;11253- 265
PubMedArticle
12.
Robles  RPinero  ALujan  JA  et al.  Thoracoscopic partial pericardiectomy in the diagnosis and management of pericardial effusion. Surg Endosc 1997;11253- 256
PubMedArticle
13.
Ohtsuka  TWolf  RKWurnig  PPark  SE Thoracoscopic limited pericardial resection with an ultrasonic scalpel. Ann Thorac Surg 1998;65855- 856
PubMedArticle
14.
Totté  Evan Hee  Rvan Brabant  P  et al.  Laparoscopic transabdominal pericardial window: new standard in the treatment of recurrent pericardial effusion complicated by cardiac tamponade. Surg Endosc 2002;16859- 863
PubMedArticle
15.
Rodriguez  MIAsh  KFoley  RWListon  W Pericardio peritoneal window: laparoscopic approach. Surg Endosc 1999;13409- 411
PubMedArticle
16.
Santos  GHFrater  RW The subxiphoid approach in the treatment of pericardial effusion. Ann Thorac Surg 1977;23467- 470
PubMedArticle
17.
Hankins  JRSatterfield  JRAisner  JWiernik  PHMcLaughlin  JS Pericardial window for malignant pericardial effusion. Ann Thorac Surg 1980;30465- 471
PubMedArticle
18.
Alcan  KEZabetakis  PMMarino  NDFrazone  AJMichelis  MFBruno  MS Management of acute cardiac tamponade by subxiphoid pericardiotomy. JAMA 1982;2471143- 1148
PubMedArticle
19.
Prager  RLWilson  CHBender  HW  Jr The subxiphoid approach to pericardial disease. Ann Thorac Surg 1982;346- 9
PubMedArticle
20.
Snow  NLucas  AE A safe, accurate, diagnostic and therapeutic approach to pericardial and intrapericardial disease. Am Surg 1983;49249- 253
PubMed
21.
Ghosh  SCLarrieu  AJAblaza  SGGrana  VP Clinical experience with subxyphoid pericardial decompression. Int Surg 1985;705- 7
22.
Piehler  JMPluth  JRSchaff  HVDanielson  GKOrszulak  TAWaller  DA Surgical management of effusive pericardial disease: influence of extent of pericardial resection on clinical course. J Thorac Cardiovasc Surg 1985;90506- 516
PubMed
23.
Reitknecht  FRegal  AMAntkowiak  JGTakita  H Management of cardiac tamponade in patients with malignancy. J Surg Oncol 1985;3019- 22Article
24.
Mills  SAJulian  SHolliday  RH  et al.  Subxiphoid pericardial window for pericardial effusive disease. J Cardiovasc Surg (Torino) 1989;30768- 773
PubMed
25.
Palatianos  GMThurer  RJPompeo  MQKaiser  GA Clinical experience with subxiphoid drainage of pericardial effusions. Ann Thorac Surg 1989;48381- 385
PubMedArticle
26.
Sugimoto  JTLittle  AGFerguson  MK  et al.  Pericardial window: mechanisms of efficacy. Ann Thorac Surg 1990;50442- 445
PubMedArticle
27.
Chan  ARischin  DClarke  CPWoodruff  RK Subxiphoid partial pericardiectomy with or without sclerosant instillation in the treatment of symptomatic pericardial effusions in patients with malignancy. Cancer 1991;681021- 1025
PubMedArticle
28.
Naunheim  KSKesler  KAFiore  AC  et al.  Pericardial drainage: subxiphoid vs transthoracic approach. Eur J Cardiothorac Surg 1991;599- 103
PubMedArticle
29.
Park  JSRentschler  RWilbur  D Surgical management of pericardial effusion in patients with malignancies: comparison of subxiphoid window versus pericardiectomy. Cancer 1991;6776- 80
PubMedArticle
30.
Campbell  PTVan Trigt  PWall  TC  et al.  Subxiphoid pericardiotomy in the diagnosis and management of large pericardial effusions associated with malignancy. Chest 1992;101938- 943
PubMedArticle
31.
Okamoto  HShinkai  TYamakido  MSaijo  N Cardiac tamponade caused by primary lung cancer and the management of pericardial effusion. Cancer 1993;7193- 98
PubMedArticle
32.
Van Trigt  PDouglas  JSmith  PK  et al.  A prospective trial of subxiphoid pericardiotomy in the diagnosis and treatment of large pericardial effusion: a follow-up report. Ann Surg 1993;218777- 782
PubMedArticle
33.
Moores  DWAllen  KBFarber  LP  et al.  Subxiphoid pericardial drainage for pericardial tamponade. J Thorac Cardiovasc Surg 1995;109546- 551
PubMedArticle
34.
Wilkes  JDFidias  PVaickus  LPerez  RP Malignancy-related pericardial effusion: 127 cases from the Roswell Park Cancer Institute. Cancer 1995;761377- 1387
PubMedArticle
35.
Allen  KBFarber  LPWarren  WHShaar  CJ Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg 1999;67437- 440
PubMedArticle
36.
Porte  HLJanecki-Delebecq  TJFinzi  LMétois  DGMillaire  AWurtz  AJ Pericardoscopy for primary management of pericardial effusion in cancer patients. Eur J Cardiothorac Surg 1999;16287- 291
PubMedArticle
37.
Lin  JCHazelrigg  SRLandreneau  RJ Video-assisted thoracic surgery for diseases within the mediastinum. Surg Clin North Am 2000;801511- 1533
PubMedArticle
38.
Mack  MJLandreneau  RJHazelrigg  SRAcuff  TE Video thoracoscopic management of benign and malignant pericardial effusions. Chest 1993;103 ((suppl)) 390S- 393SArticle
39.
Romano  EJGlass  SP Laparoscopic pericardial window: anesthetic implications. J Cardiothorac Vasc Anesth 2002;16623- 625
PubMedArticle
40.
del Barrio  LGMorales  JHDelgado  C  et al.  Percutaneous balloon pericardial window for patients with symptomatic pericardial effusion. Cardiovasc Intervent Radiol 2002;25360- 364Article
41.
Wang  HHsu  KChiang  FTseng  CLiau  C Technical and prognostic outcomes of double-balloon pericardiotomy for large malignancy-related pericardial effusions. Chest 2002;122893- 899
PubMedArticle
Original Article
February 01, 2005

Ten-Year Surgical Experience With Nontraumatic Pericardial EffusionsA Comparison Between the Subxyphoid and Transthoracic Approaches to Pericardial Window

Author Affiliations

Author Affiliations: Departments of Surgery (Drs Liberman, Sampalis, and Mulder and Mr Labos) and Clinical Epidemiology (Drs Liberman and Sampalis), Montreal General Hospital, McGill University Health Center; and Department of Surgery, Sir Mortimer B. Davis Jewish General Hospital, McGill University (Dr Sheiner), Montreal, Quebec.

Arch Surg. 2005;140(2):191-195. doi:10.1001/archsurg.140.2.191
Abstract

Hypothesis  The approach to pericardial window in patients with nontraumatic pericardial effusion impacts outcome.

Design  Retrospective review and comparison of all cases of pericardial window performed over 10 years. Follow-up was to patient death.

Setting  Three hospitals performing cardiothoracic surgery at a single university.

Patients  All patients in whom pericardial window was performed for nontraumatic pericardial effusion.

Main Outcome Measures  Outcomes associated with the subxyphoid approach to pericardial window were compared with those associated with the transthoracic approach. The primary outcome was postsurgical recurrence of pericardial effusion. Secondary outcomes included operative time, intraoperative and postoperative complications, in-hospital mortality, hospital and intensive care unit lengths of stay, and days between surgery and death.

Results  Over 10 years, there were 342 patients with procedural codes for pericardial window in the medical record databases of 3 hospitals performing cardiothoracic surgery at 1 university center. One hundred fifty-one patients were excluded because the operation was performed for trauma, postoperative tamponade, or pericardial biopsy without effusion. The results are, therefore, based on the remaining 191 procedures. The subxyphoid approach was used in 78 patients, and the transthoracic approach in 113 patients. Patients were well matched for age (P = .31), sex (P = .05), preoperative tamponade (P = .08), and comorbidities (> .05). No differences were observed between the 2 approaches in terms of recurrence of effusion, operative time, overall intraoperative or postoperative complications, and hospital or intensive care unit lengths of stay. In-hospital mortality was significantly greater in the subxyphoid group (27 of 78 vs 18 of 113 patients; P = .003).

Conclusions  Over 10 years, there were 191 pericardial windows performed for nontraumatic pericardial effusions. The subxyphoid and transthoracic approaches were well tolerated by patients, required short operative times, and resulted in similar rates of overall postoperative complications and intensive care unit and hospital lengths of stay. Recurrence rates were low with both procedures.

Surgical management of nontraumatic pericardial effusion differs between and within centers. There is some controversy regarding the most effective operation for the treatment of pericardial effusion in terms of recurrence and complication rates.

Pericardial effusions can occur secondary to multiple causes. Only a few patients with pericardial effusions will eventually develop symptoms or complications secondary to the effusion. For those who do become symptomatic, definitive surgical therapy is necessary to drain the effusion and prevent recurrence.

A pericardial window involves the excision of a portion of pericardium, thus allowing the effusion to continuously drain. The 2 main surgical approaches to pericardial window have been through the subxyphoid space or the thorax.Many surgeons primarily use one technique or the other, and the choice of procedure is usually based on surgeon preference, training, and/or experience. To our knowledge, there has been no evidence-based evaluation comparing these 2 approaches to pericardial window.

The present study was undertaken with the goal of comparing the outcomes between 2 approaches to pericardial window in the management of nontraumatic pericardial effusion. Although others have reported their experience with pericardial window,17 to our knowledge, this series is the largest looking at the surgical management of nontraumatic pericardial effusion and the only to compare outcomes between the 2 most common approaches.

METHODS

This study consisted of a retrospective review of all cases of pericardial window performed for the treatment of nontraumatic pericardial effusion at a single university (McGill University). Three hospitals that perform cardiothoracic surgery (Montreal General Hospital, Royal Victoria Hospital, and Sir Mortimer B. Davis Jewish General Hospital) were used for patient identification. The study was approved by the institutional review board at all 3 hospitals. All patients who had undergone a pericardial window for any cause (surgical procedure code8 49.13 [pericardiotomy]) between April 1, 1992, and November 16, 2002 (Montreal General Hospital and Royal Victoria Hospital), and January 31, 2003 (Sir Mortimer B. Davis Jewish General Hospital), had their medical records pulled from archives at all 3 centers.

All medical records were manually reviewed. Any patient who had the procedure performed for postcardiac surgery tamponade, pericardial biopsy without window, or trauma was excluded. Two cohorts were defined based on the surgical approach to pericardial window (subxyphoid or transthoracic approach), as described in the surgeon’s operative note. Choice of procedure was based on surgeon preference.

Patients were compared by baseline characteristics (age, sex, prior pericardiocentesis, tamponade, comorbidities, American Society of Anesthesiologists classification,9 and time between diagnosis and procedure). Outcomes associated with the subxyphoid approach to pericardial window were compared with those associated with the transthoracic approach. The primary outcome was postsurgical recurrence of pericardial effusion. Secondary outcomes included operative time, intraoperative and postoperative complications, intraoperative mortality, in-hospital mortality, hospital and intensive care unit lengths of stay, and days between surgery and death. Operative time was defined as the time from incision until the time the patient left the operative room. Follow-up was to death or last follow-up clinic visit with any physician at the treating hospital, and was based on physician in-hospital and clinic notes.

SUBXYPHOID PERICARDIAL WINDOW

A short incision (about 5 cm long) is made over the xyphoid extending onto the midline of the abdomen (Figure, incision A). The linea is incised, and the xyphoid completely removed. The retrosternal space is entered by finger dissection. With upward retraction, the diaphragmatic aspect of the pericardium is visualized. The pericardium can be grasped with the hook or a pointed long clamp or can be incised directly. The opening in the pericardium is enlarged by finger dissection, and a protected sucker is inserted into the pericardial space and the fluid aspirated. A biopsy specimen is also taken from the pericardium. After all the fluid has been aspirated, the epicardium is inspected. A finger is introduced into the pericardial space to determine if there are any adhesions and if there are any nodules in the pericardium. Finally, through a separate stab wound, a tube is inserted into the pericardial space and connected to water seal drainage; the incision is closed in layers.

TRANSTHORACIC PERICARDIAL WINDOW

The operative exposure is achieved by a small anterior thoracotomy in the fourth or fifth intercostal space (Figure, incision B). An inframammary skin incision (6-8 cm long) allows division of the pectoralis muscle to expose the chosen intercostal space. The intercostal space is opened over the superior margin of the rib entering the pleural cavity. A retractor is placed, and samples of pleural effusion are obtained. The adjacent lung is palpated and a biopsy is easily performed if indicated.

The pericardium is visualized, and careful attention is paid to the phrenic nerve. The pericardium is usually bulging and can be incised anterior to the phrenic nerve with a scalpel or scissors. A generous window (2 × 3 cm) is created, and the pericardium is sent for pathological inspection. A small Silastic sump drain is placed into the pericardium and brought out through the sixth intercostal space and connected to low suction. A pleural tube is placed and connected to an underwater seal.

An alternative approach is to enter the pleural space via a subperiosteal resection of the fifth rib and adjacent costal cartilage.

STATISTICAL ANALYSIS

Outcomes associated with the subxyphoid approach to pericardial window were compared with those associated with the transthoracic approach. The primary outcome was clinically significant postsurgical recurrence of pericardial effusion, defined as the recurrence of pericardial effusion following pericardial window, requiring a second procedure, causing symptoms, or causing death. Secondary outcomes included operative time, intraoperative and postoperative complications, in-hospital mortality, hospital and intensive care unit lengths of stay, and days between surgery and death. Logistic regression was used to control for baseline characteristics in the analysis of the primary outcome.

RESULTS

Over 10 years, there were 342 patients with procedural codes for pericardial window in the medical record databases of 3 hospitals performing cardiothoracic surgery at 1 university center. One hundred fifty-one patients were excluded because the operation was performed for trauma, postoperative tamponade, or pericardial biopsy without effusion. The results are, therefore, based on the remaining 191 procedures performed by 22 different surgeons.

Table 1 describes the distribution of procedures by surgeon. Most procedures were performed by 3 surgeons, 1 of whom preferentially used the subxyphoid approach ( 32/49 [65.3% of this surgeon’s cases]) and the other 2 who preferentially used thoracotomy ( 23/25 [92.0% of one surgeon’s cases] and 34/37 [91.9% of the other surgeon’s cases]). All procedures were performed by cardiothoracic surgeons. The mean ± SD age of the sample was 56.3 ± 14.1 years. There were 99 women (51.8%) and 92 men (48.2%). Table 2 outlines the underlying cause of the effusion and the distribution of the location of the primary tumor responsible for the pericardial effusion.

The subxyphoid approach was used in 78 patients (40.8%) and the transthoracic approach in 113 patients (59.2%). Patients were well matched for age, sex, preoperative tamponade, and comorbidities (Table 3). Operative and postoperative outcomes for the 2 groups are described in Table 4 and Table 5, respectively. Video-assisted thoracoscopy was used in 3 patients in the transthoracic group. Pericardial fluid cytological specimens were sent in 57 and 70 cases and were positive for malignancy in 22 and 19 patients (38.6% and 27.1%) in the subxyphoid and thoracotomy groups, respectively (P = .12).

There was one operative mortality (in the transthoracic group). The single operative death occurred secondary to a right ventricular injury in a patient who was undergoing a second pericardial window procedure and was unstable before anesthesia induction. The pericardium was adherent to the right ventricle, and the ventricle was entered during dissection. However, the injury was repaired; the patient was in critical condition and had requested preoperatively to not be resuscitated should he require it. He was not a candidate for cardiopulmonary bypass, and his pressure could not be maintained using vasopressors.

Following adjustment for preoperative confounders, risk of recurrence of pericardial effusion was not associated with either procedure (odds of recurrence, 0.38 [95% confidence interval, 0.05-2.64] for the subxyphoid vs the transthoracic approach).

COMMENT

We reviewed our experience with the surgical treatment of symptomatic pericardial effusion to ascertain whether there was a difference between the 2 most prevalent surgical approaches. Over 10 years, there were 191 pericardial windows performed for nontraumatic pericardial effusions at our university. The subxyphoid and transthoracic approaches were well tolerated, required short operative times, and resulted in similar rates of overall postoperative complications and intensive care unit and hospital lengths of stay. Recurrence rates were low and similar with both procedures. The lengthy duration of stay, high mortality rate, and severity of illness reflect the underlying disease process.

Postoperative care was similar for all patients; however, postoperative cardiac complications occurred with significantly greater frequency in the subxyphoid cohort. Possible explanations for this include decreased visualization of the heart through the subxyphoid compared with the transthoracic approach, with inadvertent minor injury to the myocardium. The presence of a pericardial sump remaining in the pericardium postoperatively may also be a factor in the increased incidence of postoperative complications with the subxyphoid approach. The differences in cardiac complications and in-hospital deaths in the subxyphoid group could also be attributed to their preoperative status at anesthesia induction (American Society of Anesthesiologists class 4 or 5, 18.1% higher in the subxyphoid vs the transthoracic group; P = .02).

Major limitations of the study include the retrospective nature of data acquisition and missing patients. Pure comparisons are difficult to interpret in a retrospective review of a center’s experience. This is because of the fact that choice of procedure was by surgeon preference and the reality that not all surgeons had the same experience with the procedure. The lack of a standardized protocol for the operative technique also biases the results. This deficiency is somewhat decreased because of the fact that most procedures were performed by 3 surgeons, 1 of whom preferentially used the subxyphoid approach and the other 2 who preferentially used thoracotomy. The second major limitation of the study is that many patients were missed during the initial identification of eligible patients from the medical record databases. This is because of inaccuracies in surgical coding and the fact that if another procedure was performed during the same operation, coding typically was based on the major procedure.

Pericardial effusions can be managed using either percutaneous pericardiocentesis or surgery. Pericardiocentesis is associated with high rates of early recurrence10 and, therefore, has been abandoned by most because it is not considered a definitive treatment for pericardial effusions.11 Mueller et al2 assessed the long-term results in 64 consecutive patients who underwent subxyphoid pericardial window over 11 years, and found that 18% of patients had a recurrence, with 50% of these requiring reoperation. We observed a 3.7% overall rate of recurrence of pericardial effusion following pericardial window. Table 6 outlines the recurrence rates for pericardial effusion after pericardial window (using subxyphoid and transthoracic approaches) in the literature. Recurrence rates range between 0% and 33%.

Although minimally invasive surgery (video-assisted thoracoscopy) was only used in 3 patients in this series, it seems to have a role in the surgical management of pericardial effusions12,13,37,38 and its use will probably increase in the future. Other minimally invasive techniques include laparoscopic transabdominal pericardial window14,15,39 and percutaneous balloon pericardial window.40,41

In conclusion, to our knowledge, this is the largest series to report on the surgical creation of pericardial window and the first to compare the subxyphoid with the transthoracic approach. Pericardial window in the definitive management of nontraumatic pericardial effusions is well tolerated, is associated with low complication rates and postoperative morbidities, and is not significantly affected by the route chosen to approach the pericardium.

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Article Information

Correspondence: Moishe Liberman, MD, Department of Clinical Epidemiology, Montreal General Hospital, 1650 Cedar Ave, Room L10-520, Montreal, Quebec, Canada H3G 1A4 (moishe.liberman@mail.mcgill.ca).

Accepted for Publication: August 11, 2004.

Reprints: David S. Mulder, MD, Department of Cardiothoracic Surgery, Montreal General Hospital, 1650 Cedar Ave, Room L9-512, Montreal, Quebec, Canada H3G 1A4 (david.mulder@muhc.mcgill.ca).

Acknowledgment: We thank Anne Hubert for providing the figure for this article.

References
1.
Anderson  TMNwogu  CEBottiggi  AJLenox  JMDriscoll  DLUrschel  JD Pericardial catheter sclerosis versus surgical procedures for pericardial effusions in cancer patients. J Cardiovasc Surg (Torino) 2001;42415- 419
PubMedArticle
2.
Mueller  XMTevaearai  HTHurni  M  et al.  Long-term results of surgical subxiphoid pericardial drainage. Thorac Cardiovasc Surg 1997;4565- 69
PubMedArticle
3.
Campione  ACacchiarelli  MGhiribelli  CCaloni  VD’Agata  AGotti  G Which treatment in pericardial effusion? J Cardiovasc Surg (Torino) 2002;43735- 739
PubMed
4.
Watarida  SShiraishi  SMatsubayashi  KImura  MNishi  T Pericardial-peritoneal window for chronic exudative pericarditis using a subxiphoid approach: report of three cases. Surg Today 2002;32410- 413
PubMedArticle
5.
Dosios  TTheakos  NAngouras  DAsimacopoulos  P Risk factors affecting the survival of patients with pericardial effusion submitted to subxyphoid pericardiostomy. Chest 2003;124242- 246
PubMedArticle
6.
Gregory  JRMcMurtrey  MJMountain  CF A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985;8319- 323
PubMedArticle
7.
Little  AGKremser  PCWade  JLLevett  JMDeMeester  TRSkinner  DB Operation for diagnosis and treatment of pericardial effusions. Surgery 1984;96738- 744
PubMed
8.
Health Division, Statistics Canada, Canadian Classification of Diagnostic, Therapeutic, and Surgical Procedures.  Ottawa, Ontario Statistics Canada1986;
9.
 Miller RD. Anesthesia 5th ed. New York, NY Churchill Livingstone Inc2003;
10.
Laham  RJCohen  DJKuntz  REBaim  DSLorell  BHSimmons  M Pericardial effusion in patients with cancer: outcome with contemporary management strategies. Heart 1996;7567- 71
PubMedArticle
11.
Fiocco  MKrasna  MJ The management of malignant pleural and pericardial effusions. Hematol Oncol Clin North Am 1997;11253- 265
PubMedArticle
12.
Robles  RPinero  ALujan  JA  et al.  Thoracoscopic partial pericardiectomy in the diagnosis and management of pericardial effusion. Surg Endosc 1997;11253- 256
PubMedArticle
13.
Ohtsuka  TWolf  RKWurnig  PPark  SE Thoracoscopic limited pericardial resection with an ultrasonic scalpel. Ann Thorac Surg 1998;65855- 856
PubMedArticle
14.
Totté  Evan Hee  Rvan Brabant  P  et al.  Laparoscopic transabdominal pericardial window: new standard in the treatment of recurrent pericardial effusion complicated by cardiac tamponade. Surg Endosc 2002;16859- 863
PubMedArticle
15.
Rodriguez  MIAsh  KFoley  RWListon  W Pericardio peritoneal window: laparoscopic approach. Surg Endosc 1999;13409- 411
PubMedArticle
16.
Santos  GHFrater  RW The subxiphoid approach in the treatment of pericardial effusion. Ann Thorac Surg 1977;23467- 470
PubMedArticle
17.
Hankins  JRSatterfield  JRAisner  JWiernik  PHMcLaughlin  JS Pericardial window for malignant pericardial effusion. Ann Thorac Surg 1980;30465- 471
PubMedArticle
18.
Alcan  KEZabetakis  PMMarino  NDFrazone  AJMichelis  MFBruno  MS Management of acute cardiac tamponade by subxiphoid pericardiotomy. JAMA 1982;2471143- 1148
PubMedArticle
19.
Prager  RLWilson  CHBender  HW  Jr The subxiphoid approach to pericardial disease. Ann Thorac Surg 1982;346- 9
PubMedArticle
20.
Snow  NLucas  AE A safe, accurate, diagnostic and therapeutic approach to pericardial and intrapericardial disease. Am Surg 1983;49249- 253
PubMed
21.
Ghosh  SCLarrieu  AJAblaza  SGGrana  VP Clinical experience with subxyphoid pericardial decompression. Int Surg 1985;705- 7
22.
Piehler  JMPluth  JRSchaff  HVDanielson  GKOrszulak  TAWaller  DA Surgical management of effusive pericardial disease: influence of extent of pericardial resection on clinical course. J Thorac Cardiovasc Surg 1985;90506- 516
PubMed
23.
Reitknecht  FRegal  AMAntkowiak  JGTakita  H Management of cardiac tamponade in patients with malignancy. J Surg Oncol 1985;3019- 22Article
24.
Mills  SAJulian  SHolliday  RH  et al.  Subxiphoid pericardial window for pericardial effusive disease. J Cardiovasc Surg (Torino) 1989;30768- 773
PubMed
25.
Palatianos  GMThurer  RJPompeo  MQKaiser  GA Clinical experience with subxiphoid drainage of pericardial effusions. Ann Thorac Surg 1989;48381- 385
PubMedArticle
26.
Sugimoto  JTLittle  AGFerguson  MK  et al.  Pericardial window: mechanisms of efficacy. Ann Thorac Surg 1990;50442- 445
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