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Tex Heart Inst J. 2003; 30(2): 130–133.
PMCID: PMC161899

Diagnosis of Pericardial Disease Using Percutaneous Biopsy

Case Report and Literature Review

Abstract

We describe the case of a 75-year-old man who presented with a large pericardial effusion and an intrapericardial mass. Malignant thymoma with pericardial involvement was diagnosed by percutaneous pericardial tumor biopsy. The pleural effusion was not malignant. The patient underwent further oncologic evaluation followed by adjunctive chemotherapy and radical extirpation of the tumor. He remains asymptomatic and free of disease 24 months after the procedure. We also discuss the role of percutaneous biopsy in the diagnosis of pericardial diseases. (Tex Heart Inst J 2003;30:130–3)

Key words: Biopsy/instrumentation/methods, percutaneous pericardial biopsy, pericardial effusion, pericardium/pathology, thymoma

A multitude of diseases can present as large pericardial effusions. The traditional management approach has been to perform diagnostic/therapeutic pericardiocentesis followed by open pericardial biopsy, if needed. We report the case of a patient who had a malignant thymoma with pericardial involvement, which presented as a large pericardial effusion with an intrapericardial mass. The diagnosis by percutaneous pericardial tumor biopsy is described, as is the role of percutaneous biopsy in the diagnosis of pericardial diseases.

Case Report

In March 2001, a 75-year-old man presented to his internist for evaluation of progressive fatigue, low-grade fever, a 13-lb weight loss, and dyspnea on exertion of 4 months' duration. There was no orthopnea, paroxysmal nocturnal dyspnea, or chest pain. The heart sounds were muffled, but no adventitious sounds were heard. The neck veins were not distended, and blood pressure was normal with no pulsus paradoxus. The rest of the physical exam was also unremarkable. A chest radiograph showed an enlarged cardiac silhouette without any pulmonary congestion or other parenchymal abnormality except for some left-sided pleural effusion. A computed tomographic (CT) scan of the chest confirmed the presence of a moderate-sized left pleural effusion and a large pericardial effusion with a 5- × 8-cm mass in the anterior pericardial space adjacent to the right ventricular outflow tract. The patient was referred to our center for further treatment. An echocardiogram confirmed the presence of a large circumferential pericardial effusion with a mass in the anterior pericardial space anterior to the right ventricular outflow tract (Fig. 1). There was no sign of tamponade. Percutaneous pericardiocentesis and pericardial tumor biopsy were performed.

figure 10FF1
Fig. 1 Two-dimensional transthoracic echocardiograms: A) a parasternal short-axis view shows a large pericardial mass with multiple lobulations anterior to the RVOT, and B) a modified apical 4-chamber view shows a lobulated pericardial mass extending ...

Technique

The procedure was performed in the cardiac catheterization laboratory using the subxiphoid approach. Local anesthesia and light intravenous sedation were administered. Using the Seldinger technique, we placed a 7F, 45-cm sheath (Arro® International, Inc.; Reading, Penn) in the pericardial cavity under fluoroscopic and echocardiographic guidance. Serosanguineous fluid (750 mL) was removed, and a small amount of radiographic contrast material was injected into the pericardial cavity to better delineate the mass (Fig. 2).

figure 10FF2
Fig. 2 Cine angiographic image (anter-posterior view) of contrast material injected into the pericardial space silhouettes the pericardial tumor.

A T-Rex® endomyocardial biopsy forceps (pre-curved, 50-cm, 2.2-mm jaw size, by Boston Scientific Corporation; Maple Grove, Minn) was advanced through the sheath and directed toward the mass. Echocardiographic localization was also used. Three tissue samples were obtained and the sheath was removed. There were no complications.

Results

Table I presents the detailed chemical and microbiologic characteristics of the pericardial fluid. The cytologic exam was negative for malignant cells and showed lymphocytes and mesothelial cells. The biopsy, however, revealed the presence of mixed lymphocytic and epithelial cell malignant thymoma. The pleural effusion was not malignant. The patient underwent further oncologic evaluation followed by adjunctive chemotherapy and radical surgical extirpation of the tumor. He remains asymptomatic and free of disease 24 months after the procedure.

Table thumbnail
TABLE I. Pericardial Fluid Characteristics

Discussion

Large pericardial effusions are a fairly common clinical presentation of many diseases, and the 1st step toward a definitive diagnosis is percutaneous pericardiocentesis.

Although helpful in the therapeutic removal of large amounts of pericardial fluid, pericardiocentesis provides a definite diagnosis in only about 25% of cases. 1 Tuberculosis is the most commonly missed diagnosis. 2,3 Mycobacterium tuberculosis can only rarely be cultured from the pericardial fluid, and a positive acid-fast stain is even less frequent. In malignant pericarditis, on the other hand, fluid cytology is positive for malignancy in about 50% to 80% of cases, although cell typing is poor. 2–4 To increase diagnostic yield, a pericardial biopsy is often required. 5,6 Traditionally, this has been an open surgical biopsy performed with the patient under general anesthesia.

Nonsurgical (percutaneous) techniques for obtaining multiple pericardial tissue samples have been described during the last 15 years, and substantially improved diagnostic yields have been reported, compared with pericardiocentesis alone. 2,7,8 Although it was described several years ago, 2,7 percutaneous pericardial biopsy is not a commonly performed procedure. Only a few reports of percutaneous pericardial (or pericardial mass) biopsies have been published. 2,7,9

In 1988, Endrys and colleagues 2 reported their series of pericardial biopsies in 18 consecutive patients who needed pericardiocentesis for large pericardial effusions with or without tamponade. The authors, using a subxiphoid approach, advanced a 7F Teflon catheter into the pericardial cavity under fluoroscopic guidance. Pericardial fluid was aspirated and the catheter was exchanged over the wire with an 8F Teflon 40-cm sheath with a curved tip and multiple side holes. An endomyocardial bioptome was inserted through the sheath. Air was allowed to enter the pericardial cavity freely, to delineate the visceral and parietal layers. Multiple tissue samples were obtained from both the right and the left side of the parietal pericardium (an average of 8 samples). At the end of the procedure, the air was aspirated and the sheath left in place until drainage was less than 30 mL a day.

In 9 of the 18 patients, 2 a definite diagnosis was established by biopsy; 6 of those 9 patients had tuberculosis. Cultures from the biopsy specimens were positive in all 6; on histology, acid-fast bacilli were present in 4 of 6 patients. On the other hand, pericardial fluid analysis was culture-positive for tuberculosis in only 1 patient, and no pericardial fluid smear preparation revealed acid-fast bacilli. Three patients had malignancy diagnosed by biopsy, but only 2 were positive on cytologic exam. In the remaining 9 of the 18 patients, tissue diagnosis was non-contributory, but none of these patients were found to have developed tuberculosis or malignancy on long-term follow-up.

Mehan and co-authors 8 noted that the floppy nature of the bioptome made it difficult to direct it to the appropriate site in the pericardial cavity. Therefore, they modified the technique by using the distal portion of a 9F right Judkins coronary guiding catheter cut 40 cm from the tip. They inserted this modified catheter through a 9F sheath and then inserted the bioptome through the guiding catheter. By using the guiding catheter to position the bioptome, they were able to reduce the procedure time by 15% (to an average of 45 min; average fluoroscopy time, 260 sec).

Zeskind's group 7 used a similar fluoroscopic approach but used a special pericardial bioptome with a central needle and serrated jaws. They did not instill air into the pericardial cavity but maintained visceral pericardial layer separation by not removing all the fluid at the beginning of the procedure. In their series of 15 patients, tissue adequate for pathologic analysis was obtained in all patients. The diagnostic yield for fluid cytology and percutaneous biopsy was determined individually and in combination. For patients with a history of malignancy, the addition of biopsy increased the yield of a specific diagnosis from 46% to 62%. For patients without a history of malignancy, the yield increased from 7% to 29%. Selig 9 successfully performed percutaneous pericardial biopsies with echocardiographic guidance without the use of fluoroscopy.

By enabling a quick etiologic diagnosis by relatively less invasive means, percutaneous pericardial biopsy avoids an open surgical procedure (with all its attendant risks and those of general anesthesia) in patients found to have benign or inoperable malignant disease (for example, metastatic lung cancer) who would otherwise not undergo surgery. Moreover, for patients who eventually require surgery, it allows better planning of the procedure by providing the correct pathologic diagnosis beforehand. For instance, malignant thymoma presenting with pericardial involvement is generally treated with radical extirpation of the tumor and adjuvant chemotherapy or radiation therapy. Chow and associates 10 reported the case of a patient with a large pericardial effusion and an intrapericardial mass who underwent open surgical biopsy. The suspected diagnosis was bronchogenic cancer with pericardial metastasis; however, biopsy showed malignant thymoma. The authors commented that if the correct diagnosis had been known before the surgery, a radical resection could have been performed in the 1st instance, thus avoiding the possible need for a 2nd surgery.

In our patient, a preoperative diagnosis of a malignant thymoma was already established; therefore, only 1 surgical procedure was needed, and appropriate adjuvant therapy could be administered before surgery.

Conclusion

Percutaneous pericardial biopsy can be performed easily with the use of conventional invasive cardiology techniques. Compared with pericardiocentesis, the percutaneous biopsy yields additional diagnostic information, is less invasive than surgical biopsy, and can easily be modified to obtain tissue samples from pericardial masses. We conclude that percutaneous pericardial biopsy is an essential part of the evaluation of patients with undiagnosed pericardial effusions and masses.

Acknowledgment

The authors thank Dr. Antonieta Hernandez for her assistance with the echocardiographic images.

Footnotes

Address for reprints: Virendra S. Mathur, MD, 6624 Fannin, Suite 2480, Houston, TX 77030

E-mail: moc.oidracgh@ragllah

References

1. Wong B, Murphy J, Chang JC, Hassenein K, Dunn M. The risk of pericardiocentesis. Am J Cardiol 1979;44:1110–4. [PubMed]
2. Endrys J, Simo M, Shafie MZ, Uthaman B, Kiwan Y, Chugh T, et al. New nonsurgical technique for multiple pericardial biopsies. Cathet Cardiovasc Diagn 1988;15:92–4. [PubMed]
3. Kralstein J, Frishman W. Malignant pericardial diseases: diagnosis and treatment. Am Heart J 1987;113:785–90. [PubMed]
4. Yazdi HM, Hajdu SI, Melamed MR. Cytopathology of pericardial effusions. Acta Cytol 1980;24:401–12. [PubMed]
5. Ortbals DW, Avioli LV. Tuberculous pericarditis. Arch Intern Med 1979;139:231–4. [PubMed]
6. Agner RC, Gallis HA. Pericarditis: differential diagnostic considerations. Arch Intern Med 1979;139:407–12. [PubMed]
7. Ziskind AA, Rodriguez S, Lemmon C, Burstein S. Percutaneous pericardial biopsy as an adjunctive technique for the diagnosis of pericardial disease. Am J Cardiol 1994;74:288–91. [PubMed]
8. Mehan VK, Dalvi BV, Lokhandwala YY, Kales PA. Use of guiding catheters to target pericardial and endomyocardial biopsy sites. Am Heart J 1991;122(3 Pt 1);882–3. [PubMed]
9. Selig MB. Percutaneous pericardial biopsy under echocardiographic guidance. Am Heart J 1991;122(3 Pt 1);879–82. [PubMed]
10. Chow WH, Chow TC, Chiu SW. Pericardial metastasis and effusion as the initial manifestation of malignant thymoma: identification by cross-sectional echocardiography. Int J Cardiol 1992;37:258–60. [PubMed]

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