title: Pericardial effusions in the cancer population: prognostic factors after pericardial window and the impact of paradoxical hemodynamic instability.
abstract: OBJECTIVE
  In the cancer population, pericardial effusions are a common and potentially life-threatening occurrence. Although decompression benefits most patients, paradoxical hemodynamic instability (PHI) develops in some, with hypotension and shock in the immediate postoperative period. This study examines paradoxical hemodynamic instability after pericardial window and identifies prognostic factors in patients with cancer who are treated for pericardial effusion.
  
  
  METHODS
  Retrospective review of 179 consecutive pericardial windows performed for pericardial effusion in a tertiary cancer center over a 5-year period (January 2004 through March 2009). Demographic, surgical, pathologic, and echocardiographic data were analyzed for the end points of paradoxical hemodynamic instability (pressor-dependent hypotension requiring intensive care unit admission) and overall survival.
  
  
  RESULTS
  The most common malignancies were lung (44%), breast (20%), hematologic (10%), and gastrointestinal (7%). Overall survival for the group was poor (median, 5 months); patients with hematologic malignant disease fared significantly better than the others (median survival 36 months; P = .008). Paradoxical hemodynamic instability occurred in 19 (11%) patients. These patients were more likely to have evidence of tamponade on echocardiogram (89% vs 56%; P = .005), positive cytology/pathology (68% vs 41%; P = .03), and higher volume drained (674 mL vs 495 mL; P = .003). Overall survival was significantly shorter in those in whom paradoxical hemodynamic instability developed (median survival 35 vs 189 days; hazard ratio = 3; P < .001), and the majority of them (11/19, 58%) did not survive their hospitalization.
  
  
  CONCLUSIONS
  Postoperative hemodynamic instability after pericardial window portends a grave prognosis. Evidence of tamponade, larger effusion volumes, and positive cytologic findings may predict a higher risk of paradoxical hemodynamic instability and anticipate a need for invasive monitoring and intensive care postoperatively.
authors.affiliation: Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
authors.forename: Patrick L
authors.initials: PL
authors.lastname: Wagner
authors.forename: Eileen
authors.initials: E
authors.lastname: McAleer
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Stillwell
authors.forename: Matthew
authors.initials: M
authors.lastname: Bott
authors.forename: Valerie W
authors.initials: VW
authors.lastname: Rusch
authors.forename: Wendy
authors.initials: W
authors.lastname: Schaffer
authors.forename: James
authors.initials: J
authors.lastname: Huang
mesh_terms: D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D005260:Female; D006439:Hemodynamics; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000209:etiology / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D009519:New York City; D010490:Pericardial Effusion / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D010491:Pericardial Window Techniques / Q000009:adverse effects / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012769:Shock / Q000209:etiology / Q000503:physiopathology; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome