Should a Large Pericardial Effusion Be Drained? To Drain or Not to Drain is the Question
A 57-year-old woman with a past medical history relevant for hypertension, obesity (BMI 32 kg/m2), tobacco abuse (20 pack years) and left hip osteoarthritis was admitted for a large asymptomatic pericardial effusion.
The patient was scheduled to have a hip replacement for osteoarthritis and pre-operative testing revealed she had low voltage on the preoperative electrocardiogram (EKG) (Figure 1) and a "water bottle sign" on chest X ray (Figure 2). An echocardiogram was also performed which showed a posterior pericardial effusion adjacent to the left ventricle measuring 1.3 cm and anterior pericardial effusion adjacent to the right ventricle measuring 2.5 cm (Figures 3 and 4). The inferior vena cava was dilated at 2.7 cm, but compressibility could not be assessed due to suboptimal subcostal images. However, there were no other signs of tamponade. Specifically, there was no overt chamber collapse, and respiratory inflow variation across the mitral valve was 17.6% and across the tricuspid valve was 54%.
Based on these findings, she was sent to the emergency department for further evaluation and management. The patient denied any chest pain, shortness of breath, palpitations, recent trauma, thoracic radiation, recent cardiac intervention, personal history of cancer or autoimmune diseases but reported 60-pound weight gain in the preceding 5 months. She was not very active recently due to her left hip pain and she spent most of the day in a wheelchair. Her temperature was 37 degrees Celsius, pulse was 78 beats per minute, respiratory rate was 18 breaths per minute and blood pressure was 136/85 mmHg. Her physical exam showed obesity, point of maximal impulse could not be palpated, regular heart rate and rhythm, normal S1 and S2 without a pericardial rub and no jugular venous distention, pulsus paradoxus, lower limb edema, thyromegaly or thyroid mass.
She had normal kidney function, negative cardiac enzymes, hemoglobin of 15.1 g/dL (normal range: 11.5 - 15.5 g/dL), platelets of 405 k/uL (normal range: 150 - 400 k/uL), international normalized ratio of 1.0 (normal range: 0.8 - 1.2), erythrocyte sedimentation rate of 27 mm/hour (normal range: 0 - 20 mm/hour), thyroid stimulating hormone (TSH) of 104 uU/mL (normal range: 0.400 - 5.500 uU/mL) and a free thyroxine (T4) of 0.2 ng/dL (normal range: 0.9 - 1.7 ng/dL).
Which of the following is the best approach to the management of the patient's large pericardial effusion?