How to Perform Pericardiocentesis in Cancer Patients With Thrombocytopenia

Jacob, Robin; Palaskas, Nicolas; Lopez‐Mattei, Juan; Hassan, Saamir; Kim, Peter; Donisan, Teodora; Balanescu, Dinu Valentin; Çilingiroğlu, Mehmet; Marmagkiolis, Konstantinos; Iliescu, Cezar

doi:10.1016/j.jaccao.2021.05.005

Cited by 5 publications

(7 citation statements)

References 8 publications

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“…In addition, the risk of complications related to pericardiocentesis, mainly major bleeding in the present case due to severe thrombocytopenia was minimized by platelet transfusion before the procedure, echocardiographic guidance and an experienced cardiologist who performed pericardiocentesis. In fact, it has been shown that percutaneous pericardiocentesis can be performed safely in cancer patients with severe thrombocytopenia by following a rigorous technical approach ( 17 ). In the previous case ( 9 ), interestingly, anti-inflammatory therapy (tocilizumab and high dose corticosteroids) and appropriate management of hemodynamic failure were able to resolve the tamponade within one week without pericardiocentesis.…”

Section: Discussionmentioning

confidence: 99%

“…Finally, based on the present case and that of Moriyama et al ( 9 ), CAR-T cell therapy-induced pericardial effusion with cardiac tamponade requires prompt anti-inflammatory therapy in all cases. Pericardiocentesis appears feasible, allows a rapid resolution of this severe CVAE, and should be discussed immediately before an irreversible worsening, considering the benefit-risk balance for the patient ( 17 , 18 ).…”

Section: Discussionmentioning

confidence: 99%

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Case report: CAR-T cell therapy-induced cardiac tamponade

Sarfati

Norbert

Hérault

et al. 2023

Front. Cardiovasc. Med.

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CD19-specific chimeric antigen receptor T (CAR-T) cell therapy has recently been shown to improve the prognosis of refractory diffuse large B-cell lymphoma (DLBCL). However, CAR-T cells may induce numerous adverse events, in particular cytokine release syndrome (CRS) which is frequently associated with cardiovascular manifestations. Among the latter, acute pericardial effusion represents less than 1% of cases and cardiac tamponade has only been reported once. The management and outcome of these severe complications are not well established. We report here, a case of cardiac tamponade associated with CRS in a context of CAR-T cell therapy, which required urgent pericardiocentesis.Case summaryA 65-year-old man with refractory DLBCL was treated with CAR-T cell therapy. He had a history of dilated cardiomyopathy with preserved ejection fraction and transient atrial fibrillation. A pericardial localization of the lymphoma was observed on the second relapse. One day after CAR-T cell infusion the patient was diagnosed with grade 1 CRS. Due to hypotension, he was treated with tocilizumab and dexamethasone, and then transferred to intensive care unit (ICU). Echocardiography performed at ICU admission showed acute pericardial effusion with signs of right ventricular heart failure due to cardiac tamponade. It was decided to perform pericardiocentesis despite grade IV thrombocytopenia in a context of aplasia. Analysis of pericardial fluid showed a large number of lymphoma cells and 73% of CAR-T cells amongst lymphocytes, a level that was similar in blood. Hemodynamic status improved after pericardiocentesis, and no recurrence of pericardial effusion was observed. The presence of a high count of activated CAR-T cells in the pericardial fluid as well as the short interval between CAR-T cells injection and the symptoms appear as potential arguments for a direct action of CAR-T cells in the mechanism of this adverse event. The patient was discharged from ICU after two days and initially exhibited a good response to DLBCL treatment. Unfortunately, he died fifty days after starting CAR-T cell therapy due to a new DLBCL relapse.ConclusionPatients with a pericardial localization of DLBCL should be assessed for a risk of cardiac tamponade if receiving CAR-T cell therapy and presenting CRS. In this case, cardiac tamponade seems directly related to CAR-T cell expansion. Pericardiocentesis should be considered as a feasible and effective treatment if the risk of bleeding is well controlled, in association with anti-IL6 and corticosteroids.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Case report: CAR-T cell therapy-induced cardiac tamponade

Sarfati

Norbert

Hérault

et al. 2023

Front. Cardiovasc. Med.

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“…Second, it is distinctively used amongst different cancer types, with the highest utilisation in the lung, haematological and breast cancer, followed by heart/mediastinum, gastroesophageal and female genital cancer. Third, this cohort has an increased prevalence of comorbidities that are considered to be higher risk in pericardiocentesis, such as anaemias, atrial fibrillation (due to anticoagulation), coagulopathy and thrombocytopenia 5,10,11 . Fourth, cancer patients undergoing pericardiocentesis have increased mortality compared to other cancer patients admitted to hospitals and that overall mortality rates are dependent on the underlying cancer type.…”

Section: Discussionmentioning

confidence: 99%

“…Pericardiocentesis is indicated for different diagnostic and therapeutic indications in the cancer population. Due to a strong association between cancer and pericardial effusion, it is more often undertaken than the general population and requires strict protocols to minimise the risk associated with the procedure 11 . Previous studies have shown that cancer is an underlying cause of pericardial effusion in up to 46% of patients undergoing pericardiocentesis 1–3 .…”

Section: Discussionmentioning

confidence: 99%

Prevalence, characteristics and mortality of cancer patients undergoing pericardiocentesis in the United States between 2004 and 2017

Matetić

Yang

et al. 2022

Cancer Medicine

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Background: Pericardiocentesis is undertaken in patients with cancer for diagnostic and therapeutic purposes. However, there are limited data on the frequency, characteristics and mortality of patients with different cancers undergoing pericardiocentesis.Methods: All hospitalisations of adult cancer patients (≥18 years) in the US National Inpatient Sample between January 2004 and December 2017 were included. The cohort was stratified by discharge code of pericardiocentesis and cancer, using the International Classification of Diseases. The prevalence of pericardiocentesis, patient characteristics, cancer types and in-hospital all-cause mortality were analysed between cancer patients undergoing pericardiocentesis versus not.Results: A total of 19,773,597 weighted cancer discharges were analysed, out of which 18,847 (0.1%) underwent pericardiocentesis. The most common cancer types amongst the patients receiving pericardiocentesis were lung (51.3%), haematological (15.9%), breast (5.4%), mediastinum/heart (3.2%), gastroesophageal (2.2%) and female genital cancer (1.8%), whilst 'other' cancer types were present in 20.2% patients. Patients undergoing pericardiocentesis had significantly higher mortality (15.6% vs. 4.2%, p < 0.001) compared to their counterparts. The presence of metastatic disease (aOR 2.67 95% CI 1.79-3.97), weight loss (aOR 1.48 95% CI 1.33-1.65) and coagulopathy (aOR 3.22 95% CI 1.63-6.37) were each independently associated with higher mortality in patients who underwent pericardiocentesis. Conclusion:Pericardiocentesis is an infrequent procedure in cancer patients and is most commonly performed in patients with lung, haematological and breast cancer. Cancer patients undergoing pericardiocentesis have increased mortality, irrespective of the underlying cancer type.

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“…However, there are not enough clinical data regarding the safety of pericardiocentesis in patients under antiplatelet or anticoagulant drugs. Several cases have reported its feasibility in patients with uncorrected coagulopathy, such as thrombocytopenia or elevated INR due to cancer, chemotherapy, and cirrhosis ( 18 – 20 ). Iliescu et al ( 21 ) analyzed cancer patients presenting with cardiac tamponade in the setting of thrombocytopenia and identified 2 major bleeding events out of 60 procedures.…”

Section: Discussionmentioning

confidence: 99%

The safety of pericardiocentesis in patients under antithrombotic therapy: A single-center experience

Zhu

Zhang

Xie

et al. 2022

Front. Cardiovasc. Med.

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ObjectiveThis study aimed to analyze the characteristics of patients with pericardial effusion requiring pericardiocentesis and to evaluate the safety of pericardiocentesis without discontinuation of anticoagulant or antiplatelet drugs.MethodsWe performed a retrospective study of patients undergoing pericardiocentesis in our hospital between 2012 and 2022. Patients were categorized into the Antithrombotic Group if they had used any antiplatelet or anticoagulant drugs on the day of pericardiocentesis; otherwise they were categorized into the Non-antithrombotic Group. All procedures were performed by experienced cardiologists with echocardiographic guidance. Bleeding events were defined using the National Institutes of Health scale of adverse events.ResultsA total of 501 consecutive patients were identified and 70 cases were under antithrombotic drugs (Antithrombotic Group). Patients in Antithrombotic Group were older, had more comorbidities, presented with lower platelet counts and prolonged activated partial thromboplastin time (all p < 0.05). Malignancy was the most common etiology for pericardial effusion in both groups (28.6% in Antithrombotic Group and 54.7% in Non-antithrombotic Group) and tuberculosis was the second etiology in the Non-antithrombotic Group (21.9%), while procedure-related effusion (17.1%) accounted for the second cause in the Antithrombotic Group. Two patients in the Antithrombotic Group had mild oozing at the puncture site that resolved without interventions (2.9 vs. 0%, p = 0.019), and no bleeding events higher than Grade 1 occurred in either group.ConclusionAlthough antiplatelet or anticoagulant drugs may put patients undergoing pericardiocentesis at theoretically higher risk of bleeding, our study demonstrated that they are not associated with increased major bleeding complications.

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How to Perform Pericardiocentesis in Cancer Patients With Thrombocytopenia

Cited by 5 publications

References 8 publications

Case report: CAR-T cell therapy-induced cardiac tamponade

Case report: CAR-T cell therapy-induced cardiac tamponade

Prevalence, characteristics and mortality of cancer patients undergoing pericardiocentesis in the United States between 2004 and 2017

The safety of pericardiocentesis in patients under antithrombotic therapy: A single-center experience

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