One in five patients with malignancy develop malignant pericardial effusion (MPE). Traditional pericardiocentesis (PC) can relieve life-threatening cardiac tamponade; however, the recurrence rate can be as high as 60%. A study conducted by The Chinese University of Hong Kong (CUHK)’s Faculty of Medicine (CU Medicine) has revealed that the recurrence rate of MPE drops to 12% in patients with malignancy after undergoing percutaneous balloon pericardiotomy (PBP) —an 80% reduction compared to PC. This not only spares patients from repeated needle drainage and reduces the need for hospitalisation but also lowers the risk of cardiac tamponade to just 4%. The findings have been published in the internationally renowned European Heart Journal.

 

Pericardial effusion is commonly seen in patients with advanced malignant tumours and occurs when cancer cells metastasise to the pericardium. This condition can restrict the normal blood filling of the heart and decrease heart function, leading to life-threatening cardiac tamponade. Cancer patients who develop pericardial effusion typically require PC to drain the excess fluid. However, the high recurrence rate means repeated drainage procedures are often necessary, which can affect quality of life and increase the risk of infection.

 

A multidisciplinary team at CU Medicine has used percutaneous balloon pericardiotomy (PBP) to treat pericardial effusion in cancer patients. After the procedure, the recurrence rate of pericardial effusion was reduced by 80% compared to traditional pericardiocentesis (PC), decreasing the need for repeated needle drainage and hospital admissions due to recurrence, and thereby improving patients’ quality of life.

(From left) Professor Randolph Wong Hung-leung, Chief of the Division of Cardiothoracic Surgery from Department of Surgery at CU Medicine; Dr Tan Guangming,Assistant Professor of Department of Medicine and Therapeutics at CU Medicine; Professor Bryan Yan Ping-yen,Ip’s Family Trust Professor of Cardiology and Professor from the Department of Medicine and Therapeutics at CU Medicine; and Professor Stephen Chan Lam,Ip’s Family Trust Professor of Clinical Oncology and Professor from the Department of Clinical Oncology at CU Medicine.

PBP significantly reduces MPE recurrence, lowering the incidence of cardiac tamponade

A total of 50 patients aged over 18, with histologically confirmed active malignancy and a pericardial effusion measuring over 10 mm, were recruited from four tertiary hospitals between 2020 and 2024 by the Department of Medicine and Therapeutics at CU Medicine. All enrolled patients were randomised in a 1:1 ratio to receive either PBP or, as a control group, PC with extended pericardial drainage.

In the PBP group, pericardial access was obtained via the subxiphoid route under fluoroscopy, followed by balloon pericardiotomy using a 20 mm balloon. This procedure creates a channel between the pericardial and pleural cavities, allowing pericardial effusion to drain into the pleural space for absorption, and alleviating the risk of cardiac compression due to fluid accumulation. Both groups of patients were scheduled for six months of follow-up after the procedure.

The study revealed that six months after the procedure, the PBP group had a MPE recurrence rate of just 12%, much lower than the control group. The risk of cardiac tamponade was also only a tenth that of the control group, with only one patient in the PBP group developing the condition. (Please refer to Table 1 for details.)

Table 1. Comparison of the outcomes of PBP and PC

Additionally, the study showed no significant differences between the two groups in terms of three- and six-month survival rates, or six-month tamponade-free survival after the procedure. Postoperative quality of life assessments also revealed no notable differences between the groups. Two severe adverse events occurred – one in each group – with no deaths attributed to the procedures; both patients passed away from malignancy, 19 days and 12 days after the procedure, respectively.

Ms. Lai (left), who was diagnosed with stage IV lung cancer, developed malignant pericardial effusion causing severe shortness of breath during treatment in 2020. She underwent PBP and has not experienced any recurrence of pericardial effusion since the procedure. Ms. Lai says, “After the surgery, my life has returned to normal—I can work and do housework without any problems. I even feel that my voice has improved when I sing.

First randomised trial to demonstrate the superiority of PBP over PC

Dr Tan Guangming, Assistant Professor of the Department of Medicine and Therapeutics at CU Medicine, said: “Although previous registries have highlighted the feasibility of PBP, this is the first randomised trial to demonstrate the superiority of PBP over PC in reducing MPE recurrence, associated with a significantly lower incidence of cardiac tamponade.”

Professor Stephen Chan Lam, Ip’s Family Trust Professor in Clinical Oncology of the Department of Clinical Oncology at CU Medicine, said: “It is estimated that there are about 100 to 150 patients with advanced cancer who require PC due to MPE every year in Hong Kong. However, because of the high recurrence rate of pericardial effusion after the procedure, patients often need to be hospitalised multiple times for PC, with each admission lasting at least several days, in addition to increasing the risk of infection and significantly impacting their quality of life. In contrast, PBP can effectively prevent recurrence of pericardial effusion, reducing the number of hospitalisations and lowering overall healthcare costs.”

Professor Randolph Wong Hung-leung, Chief of the Division of Cardiothoracic Surgery in the Department of Surgery at CU Medicine, said: “In the past, pericardial effusion in patients with advanced cancer was mainly treated with cardiothoracic surgical procedures, such as subxiphoid incision or thoracoscopic pericardial window surgery, to reduce recurrence. However, these procedures require general anaesthesia, several days of hospitalisation and chest drainage after the operation. In contrast, the new PBP can shorten hospital stays and, as a result, improve patients’ quality of life.”

Professor Bryan Yan Ping-yen, first author of the trial report and Ip’s Family Trust Professor of Cardiology and Professor from the Department of Medicine and Therapeutics at CU Medicine, said: “The use of PBP to treat MPE is not yet widely adopted in public hospitals in Hong Kong, as the technique is still under trial. Our team hopes to expand the study to more hospitals in the future and to train more medical practitioners in the use of this technique, so that more patients can benefit.” 

Professor Bryan Yan (right) explains that, in PBP, after the traditional PC procedure, a 20-mm balloon is inserted to create a channel, allowing pericardial effusion to drain into the pleural space for absorption. This helps relieve the risk of cardiac compression caused by fluid accumulation.