Pericardial effusion: Approach to management

INTRODUCTION — The pericardium is a fibroelastic sac surrounding the heart that contains a thin layer of fluid. A pericardial effusion is considered to be present when accumulated fluid within the sac exceeds the small physiologic amount (15 to 50 mL).

An approach to management of pericardial effusion will be presented here. Related issues are discussed separately:

●(See "Pericardial effusion: Approach to diagnosis".)

●(See "Management of pericardial effusion and acute pericarditis during pregnancy".)

●(See "Pericardial disease associated with cancer: Clinical presentation and diagnosis" and "Pericardial disease associated with cancer: Management".)

●(See "Acute pericarditis: Clinical presentation and diagnosis" and "Acute pericarditis: Treatment and prognosis" and "Recurrent pericarditis".)

●(See "Etiology of pericardial disease".)

●(See "Constrictive pericarditis: Clinical features and causes" and "Constrictive pericarditis: Diagnostic evaluation" and "Constrictive pericarditis: Management and prognosis".)

INDICATIONS FOR PERICARDIAL FLUID REMOVAL — Pericardial fluid drainage is indicated in the following clinical settings (algorithm 1) [1]:

●Urgent pericardial fluid removal

•Cardiac tamponade – Patients with a pericardial effusion causing hemodynamic compromise (cardiac tamponade) should undergo urgent drainage of the pericardial effusion for therapeutic (and in some cases, diagnostic) purposes, as discussed separately. (See "Cardiac tamponade".)

•Purulent pericarditis – This condition typically presents with high fever and tachycardia, with or without chest pain. A high index of suspicion is required, particularly in patients with a known infection which may spread to the pericardium or with prior injury of the pericardium. Urgent diagnosis and management including pericardial drainage is required, as discussed separately. (See "Purulent pericarditis".)

●Other indications for pericardial fluid drainage – A patient with a pericardial effusion who does not have cardiac tamponade or suspected purulent pericarditis does not require immediate drainage of the effusion for therapeutic purposes and is monitored for development of cardiac tamponade. (See "Cardiac tamponade", section on 'Monitoring'.)

•For diagnosis – The role of sampling of the pericardial effusion for diagnostic purposes is discussed separately. (See "Pericardial effusion: Approach to diagnosis", section on 'Pericardial fluid analysis and biopsy' and "Pericardial disease associated with cancer: Clinical presentation and diagnosis", section on 'Diagnosis of malignant pericardial disease'.)

•To reduce the risk of tamponade – Asymptomatic chronic moderate or large pericardial effusions are monitored for the development of cardiac tamponade. In some cases, an enlarging chronic pericardial effusion may be drained to reduce the risk of cardiac tamponade. (See 'Large effusions' below.)

PREPROCEDURAL EVALUATION — Preparatory assessment to optimize procedural success and minimize the potential for complications includes echocardiography to define the effusion and review of concurrent conditions that may increase the risk of pericardial fluid removal.

Echocardiography — An echocardiogram is performed to document the presence of effusion, confirm its location and size, determine if the effusion is loculated, and identify signs of cardiac tamponade. (See "Pericardial effusion: Approach to diagnosis", section on 'Echocardiography' and "Cardiac tamponade".)

Echocardiography also provides direct visualization of cardiac structures and adjacent organs, which allows for better determination of the optimal access site and approach. (See 'Technique' below.)

Management of concurrent conditions — In patients with an indication for pericardial fluid drainage, concurrent conditions (such as pulmonary hypertension [PH] and bleeding disorders) and medications (such as anticoagulants) that may increase the risk of procedural complications are reviewed so that associated risk can be managed.

Pulmonary hypertension — Hemodynamic monitoring is particularly important for patients with PH undergoing pericardial fluid drainage by pericardiocentesis or surgical drainage, as these patients in this setting are at risk for acute hemodynamic collapse with risk of death. The frequency of these complications was evaluated by a National Inpatient Sample database study of 95,665 adults who underwent pericardiocentesis, of which 7770 were identified as having PH [2]. Unadjusted rates of in-hospital mortality (13.2 versus 9.5 percent) and postprocedural shock (2.8 versus 1.3 percent) were higher in patients with PH than in those without PH. In adjusted analysis, patients with PH had higher rates of mortality (adjusted odds ratio [aOR] 1.40, 95% CI 1.30-1.51) and postprocedure shock compared with patients without PH (aOR 1.53, 95% CI 1.30-1.81). Patients with pulmonary arterial hypertension (PAH) had higher mortality rates compared with other non-PAH groups (aOR 2.35, 95% CI 1.46-3.80).

Bleeding disorders — Unless emergency pericardial drainage is required for life-threatening cardiac tamponade, coagulation tests (prothrombin time [PT], activated partial thromboplastin time [aPTT], and platelet count) are obtained prior to pericardial drainage. Patients with bleeding disorders may be at increased risk for hemorrhagic complications with pericardiocentesis or surgical pericardial fluid drainage. Periprocedural management of these disorders is discussed separately. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Management of thrombocytopenia or platelet dysfunction' and "Perioperative blood management: Strategies to minimize transfusions", section on 'Management of medications affecting hemostasis' and "Perioperative blood management: Strategies to minimize transfusions", section on 'Management of specific hemostatic disorders'.)

Patients receiving anticoagulants — The approach to periprocedural management of anticoagulants in patients undergoing pericardial drainage varies depending upon the indication for pericardial fluid drainage, the cause of the pericardial effusion, the planned drainage procedure (percutaneous versus surgical), other factors impacting the risk of bleeding, and the indication for anticoagulation (eg, atrial fibrillation versus a mechanical heart valve).

If cardiac tamponade is present and felt to be life-threatening, emergency pericardial fluid removal is required. For pericardial effusion without tamponade that is managed with elective pericardiocentesis, it is generally preferred to delay the procedure to allow time to hold a direct oral anticoagulant or hold a vitamin K antagonist and allow the international normalized ratio to fall. Periprocedural management of anticoagulant therapy for percutaneous and surgical procedures is discussed separately. (See "Perioperative management of patients receiving anticoagulants" and "Anticoagulation for prosthetic heart valves: Management of bleeding and invasive procedures".)

CHOICE OF PERICARDIAL DRAINAGE PROCEDURE — Pericardial fluid removal can be accomplished by percutaneous pericardiocentesis or by a surgical procedure (open surgical drainage with or without a pericardial window or video-assisted thoracoscopic pericardial window), which are generally highly effective for removal of fluid and relief of symptoms associated with hemodynamic compromise [3,4]. The choice of procedure for pericardial fluid drainage is based largely upon whether the pericardial effusion is accessible to percutaneous drainage and whether there is a critical cardiac or aortic bleeding site that requires surgical management (algorithm 1) [1].

In patients with cardiac tamponade, invasive hemodynamic monitoring during the pericardial drainage procedure enables definitive confirmation of cardiac tamponade and recovery with pericardial fluid removal.

Percutaneous pericardiocentesis — Percutaneous pericardiocentesis is the treatment of choice for most patients with an indication for pericardial fluid drainage (algorithm 1) [1]. Catheter pericardiocentesis, with echocardiographic guidance, permits the operator to select the best location and angle for puncture, permits precise measurement of hemodynamics, facilitates the diagnosis of effusive-constrictive pericarditis, and requires fewer resources than surgical intervention. (See "Constrictive pericarditis: Diagnostic evaluation", section on 'Effusive-constrictive pericarditis'.)

Although the pericardial fluid volume is often relatively small in the setting of acute cardiac tamponade complicating invasive cardiac procedure (eg, percutaneous coronary intervention or invasive electrophysiology procedure), patients with this condition can often be safely managed with pericardiocentesis under echocardiographic guidance by experienced interventional cardiologists or electrophysiologists, although surgical backup is required, particularly for high-risk cases. In the setting of acute bleeding, pericardial pressure rises very quickly with small increases in pericardial fluid, resulting in hemodynamic compromise and the need for urgent fluid removal. Pericardiocentesis has a higher associated risk if there is less than 1 cm of effusion. (See "Periprocedural complications of percutaneous coronary intervention", section on 'Perforation' and "Invasive diagnostic cardiac electrophysiology studies", section on 'Complications of invasive cardiac electrophysiology studies'.)

Team and location for pericardiocentesis — Pericardiocentesis should be performed by an experienced team including a cardiac interventionalist, a catheterization laboratory nurse, a monitor technician, and a sonographer.

When feasible, hemodynamic assessment via cardiac catheterization is performed during the pericardial fluid drainage procedure. If cardiac tamponade is present, the diagnosis is confirmed by identifying typical hemodynamic findings prior to pericardial fluid removal and resolution of hemodynamic abnormalities after drainage. Effusive-constrictive pericarditis is suspected if the right atrial pressure remains elevated after removal of the pericardial effusion. (See "Constrictive pericarditis: Diagnostic evaluation", section on 'Effusive-constrictive pericarditis'.)

The procedure should be performed in the cardiac catheterization laboratory or a procedure room with catheterization laboratory capabilities, even if fluoroscopy is not used. This enables invasive hemodynamics to be more readily and accurately monitored and recorded along with continuous standard electrocardiographic (ECG) monitoring. Right heart and pericardial pressures are recorded simultaneously; the catheter is then pulled back to the right atrium, where pressure is monitored during and immediately after the procedure. The appropriate team and setting with continuous hemodynamic monitoring aids in early detection and immediate management should a life-threatening complication arise.

Technique

●Imaging – For patients undergoing percutaneous pericardiocentesis, we suggest echocardiographic guidance rather than no imaging guidance or only fluoroscopic guidance. Echocardiography offers several advantages over fluoroscopy:

•Echocardiography permits identification of the configuration of the effusion, particularly where it is closest to the skin with no intervening vital organs. This allows the operator to select the shortest safe route to the effusion [5-8].

•Monitoring the position of the needle during the initial puncture is easier and more convenient than with fluoroscopy.

•Patients and staff are not exposed to radiation.

•Agitated saline with microbubbles, rather than radiopaque contrast, is used to verify that the needle is in the pericardial effusion.

●Patient position and puncture location – The patient is commonly positioned in a semirecumbent position of about 30 degrees head-up and slightly rotated leftward to enhance fluid collection along the inferior-anterior aspect of the chest [9]. The puncture site may be apical, parasternal, subxiphoid, or subcostal. In a series of 1127 therapeutic echocardiographically-guided pericardiocentesis cases, the para-apical location was the most frequently utilized location (68 percent), while the subcostal or subxiphoid was utilized as the ideal location in only 15 percent of cases [6].

When the apical route is chosen, the needle is directed parallel with the long axis of the left ventricle towards the aortic valve. For parasternal insertion, the puncture is made 1 cm lateral to the sternal edge to avoid both inadvertent puncture of the internal mammary artery when too medial as well as pneumothorax when too lateral.

●Drainage – Once the pericardial space has been accessed, a thin-walled pigtail catheter should be inserted for ongoing drainage. This catheter, with a three-way stopcock attached, may also be used for pericardial pressure measurement. Following catheter insertion and initial pericardial pressure measurement, fluid is then aspirated, and pressures are often remeasured every several minutes to ascertain the hemodynamic result.

Pericardial fluid is drained in <1000 mL sequential steps to reduce the risk of pericardial decompression syndrome, as recommended in the 2015 European Society of Cardiology guidelines, although this is a rare complication [1,10]. (See 'Complications of pericardial fluid removal' below.)

The procedure is generally continued until pericardial pressure is <5 mmHg, at least during inspiration.

Additional discussion regarding the technical aspects of pericardiocentesis is presented separately. (See "Emergency pericardiocentesis", section on 'Technique overview'.)

Postprocedure care — Following the initial pericardiocentesis, the patient should be observed in a unit equipped to monitor the ECG, the patency of the pericardial catheter, and the rate of drainage into a sealed container under slight negative pressure. In most cases, pericardiocentesis does not completely evacuate the effusion, and active secretion of fluid or bleeding may result in reaccumulation of an effusion. For these reasons, an indwelling catheter is left in the pericardial space for up to five days after pericardiocentesis until fluid return is <25 to 50 mL/day [1]. For patients with persistent pericardial fluid drainage greater than 50 mL/day after three to five days of drainage, we evaluate for a surgical pericardial window. (See 'Management of recurrent pericardial effusion' below.)

Extended pericardial catheter drainage of pericardial effusions requiring intervention is associated with lower recurrence rates [11,12]. In a study of 157 consecutive patients with pericardial effusion treated with pericardiocentesis, the rate of recurrent pericardial effusions was significantly lower in patients treated with extended (mean 38 hours) catheter drainage (12 versus 52 percent among those without extended catheter drainage) [12]. (See 'Management of recurrent pericardial effusion' below.)

Surgical drainage — Surgical drainage with direct or video visualization is preferred if the effusion is inaccessible to percutaneous drainage (eg, loculated, thick, and/or coagulated) or if there is a crucial cardiac or aortic bleeding site that requires surgical management (eg, penetrating chest trauma, aortic dissection, myocardial rupture) (algorithm 1). (See "Management of acute type A aortic dissection" and "Acute myocardial infarction: Mechanical complications", section on 'Rupture of the left ventricular free wall'.)

An advantage of surgical drainage is that a pericardial window can be created (to reduce the risk of recurrent pericardial effusion) and/or pericardial biopsies can be obtained during the procedure. The pericardial window specimen and any additional pericardial biopsies can be examined to determine the cause of effusion if such diagnostic testing is indicated. (See "Pericardial effusion: Approach to diagnosis", section on 'Pericardial fluid analysis and biopsy'.)

In selected patients with cardiac tamponade preparing to undergo surgical drainage who have accessible pericardial fluid and no contraindication to pericardiocentesis (such as aortic dissection or myocardial rupture), percutaneous pericardiocentesis may be performed as a temporizing measure. Surgical drainage usually requires general anesthesia, which may worsen hemodynamic compromise if percutaneous drainage is not performed first to reduce the severity of the cardiac tamponade. (See "Cardiac tamponade", section on 'Management'.)

Complications of pericardial fluid removal — Pericardial fluid removal by pericardiocentesis or surgical drainage is generally well tolerated and effective.

A retrospective single-center cohort included 1281 patients undergoing either pericardiocentesis or surgical pericardial window from 2000 through 2012 [13].

●In-hospital mortality was similar for pericardiocentesis and surgical drainage in propensity matched groups (4.9 versus 6.1 percent). Hemodynamic instability after the procedure was more common in the pericardial window group in matched cohorts (6.1 versus 2.0 percent).

●Reaccumulation was more common after pericardiocentesis in matched cohorts (23 versus 9 percent).

●Among 656 patients who underwent an intervention for a pericardial effusion secondary to cardiac surgery, there was similar mortality with pericardiocentesis and surgical drainage in matched cohorts (2.6 versus 4.5 percent).

For pericardiocentesis, the incidence of major complications in experienced hands is 1.2 to 1.6 percent [5,6,14,15]. In the above-cited series of 1127 echocardiographically guided procedures, major complications occurred in only 1.2 percent of cases [6].

Bleeding during pericardiocentesis may be silent, induce typical pericardial pain, or be the cause of acute cardiac tamponade. When pressure measurement, fluid analysis, or contrast injection (using saline bubbles or radiopaque media) demonstrate that a cardiac chamber has been entered and this event is followed by pain or hemodynamic deterioration, the central venous pressure should be reassessed. A value higher than that measured before the puncture indicates acute bleeding causing cardiac tamponade until proven otherwise.

Pericardial fluid removal by pericardiocentesis or surgical drainage of a large pericardial effusion (generally with cardiac tamponade) is rarely complicated by acute hemodynamic instability, cardiogenic shock, and pulmonary edema, which has been termed pericardial decompression syndrome [16,17]. The time of onset ranges from immediately after the procedure to 48 hours later. Echocardiographic signs may include acute development of hypokinesis of left, right, or both ventricles [16]. The cause of this complication is unknown. Hemodynamic monitoring during and following the procedure enables rapid identification and supportive care for patients at risk for this rare complication.

GENERAL MANAGEMENT

Monitoring — Patients in whom the initial approach is observation (or who have undergone therapeutic pericardiocentesis) should undergo serial clinical and echocardiographic evaluation (eg, every five to seven days or sooner if clinically indicated), avoid volume depletion, and receive therapy aimed at the underlying cause (if known) of the pericardial effusion.

Clinical and echocardiographic follow-up in patients with pericardial effusion is aimed at identifying risk of cardiac tamponade and need for pericardial drainage. Follow-up is particularly important for patients at highest risk for cardiac tamponade, including those in the following clinical settings: those who have undergone pericardial drainage for tamponade, have early signs of cardiac tamponade and have not undergone pericardial fluid drainage, have a large pericardial effusion, or have a disease process with high risk of recurrent pericardial effusion (eg, cancer involving the pericardium). (See 'Large effusions' below.)

Treatment of cause — Treatment of pericardial effusion includes management of the etiology when that can be determined. The management of specific underlying disease states associated with pericardial effusion, including acute pericarditis, post-cardiac injury syndromes, uremia, infection, and malignancy, are discussed separately. (See "Acute pericarditis: Treatment and prognosis" and "Post-cardiac injury syndromes", section on 'Prevention and treatment' and "Overview of the management of chronic kidney disease in adults", section on 'Pericarditis' and "Purulent pericarditis", section on 'Treatment' and "Tuberculous pericarditis" and "Pericardial disease associated with cancer: Management".)

Large effusions — Patients who are diagnosed with a large pericardial effusion without evidence of hemodynamic compromise do not require immediate intervention for therapeutic reasons, but pericardial fluid sampling for diagnostic purposes may be indicated. (See "Pericardial effusion: Approach to diagnosis", section on 'Identifying the etiology'.)

Such patients are generally treated conservatively, with careful monitoring as described above (see 'Monitoring' above). Effusions that progressively enlarge leading to worsening symptoms with evidence of cardiac tamponade are treated with pericardial fluid drainage. In some cases, an enlarging chronic pericardial effusion may be drained to reduce the risk of cardiac tamponade.

The incidence and significance of chronic effusions has varied somewhat in different case series:

●In a series of 1108 patients who initially presented with pericarditis between 1977 and 1992, only 28 patients (2.5 percent) had a large idiopathic effusion that persisted for a median duration of three years [18]. In this study, 58 percent developed cardiac tamponade at some point during follow-up (median three years).

●In a report of 100 consecutive patients with idiopathic chronic large pericardial effusion (none with elevated serum C-reactive protein) who presented to one of three Italian referral centers between 2000 and 2015, only eight patients developed cardiac tamponade during follow-up (mean 50 months; risk of 2.2 percent per year) [19]. While 45 patients underwent a drainage procedure at some point, there was significant regression of the effusion over follow-up in the remaining patients without a drainage procedure. The risks of recurrence and complications were higher in patients who received interventions. While this may reflect more severe disease requiring intervention, it also reflects the risk of complications of intervention, such as post-cardiac injury syndrome. (See 'Complications of pericardial fluid removal' above.)

MANAGEMENT OF RECURRENT PERICARDIAL EFFUSION — For patients deemed at high risk for recurrent pericardial effusion (including those with malignant pericardial effusion or purulent pericarditis), initial management with pericardial fluid removal may be combined with or followed by one or more measures to prevent or treat recurrent pericardial effusion, such as mechanical pericardial interventions (prolonged catheter drainage, repeated pericardiocentesis, or surgical pericardiotomy [pericardial window]) along with treatment of the underlying cause of the effusion. Selection of therapy by a multidisciplinary team is guided by the patient's overall clinical status (including symptoms, medical frailty, and comorbidities), prognosis, goals of care, care setting, and available treatment resources. Treatments should also focus on relieving symptoms, improving functional status, and minimizing repeat interventions.

As described above, pericardiocentesis is routinely followed by catheter drainage for up to five days until fluid return is <25 to 50 mL/day, with consideration of a surgical pericardial window if there is persistent pericardial fluid drainage greater than 50 mL/day. (See 'Postprocedure care' above.)

Percutaneous balloon pericardiotomy is generally avoided, as this procedure causes chest pain and has limited efficacy compared with surgical pericardiotomy, as discussed separately. Pericardial sclerosing agents are also avoided, as they cause chest pain and may cause constrictive pericarditis. (See "Pericardial disease associated with cancer: Management", section on 'Balloon pericardiotomy' and "Pericardial disease associated with cancer: Management", section on 'Avoidance of pericardial sclerosing agents'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pericardial disease".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Cardiac tamponade (The Basics)")

●Beyond the Basics topics (see "Patient education: Pericarditis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications for pericardial fluid removal

•Urgent pericardial fluid removal is required for patients with pericardial effusion causing hemodynamic compromise (cardiac tamponade). Patients with purulent pericarditis also require urgent pericardial drainage. (See "Cardiac tamponade" and "Purulent pericarditis".)

•Patients with pericardial effusion without an urgent indication for drainage are monitored for development of cardiac tamponade. The role of pericardial fluid sampling is discussed separately. (See "Pericardial effusion: Approach to diagnosis", section on 'Pericardial fluid analysis and biopsy' and "Pericardial disease associated with cancer: Clinical presentation and diagnosis", section on 'Diagnosis of malignant pericardial disease'.)

In some cases, an enlarging chronic pericardial effusion may be drained to reduce the risk of cardiac tamponade. (See 'Large effusions' above.)

●Concurrent conditions – In patients with an indication for pericardial fluid drainage, concurrent conditions (such as pulmonary hypertension [PH] and bleeding disorders) and medications (such as anticoagulants) that may increase the risk of procedural complications are reviewed so that associated risk can be managed. (See 'Management of concurrent conditions' above.)

●Choice of pericardial drainage procedure – Pericardial fluid removal can be accomplished by percutaneous pericardiocentesis or by a surgical procedure (open surgical drainage with or without a pericardial window or video-assisted thoracoscopic pericardial window). The choice of procedure for pericardial fluid drainage is based largely upon whether the pericardial effusion is accessible to percutaneous drainage and whether there is a critical cardiac or aortic bleeding site that requires surgical management (algorithm 1).

•Pericardiocentesis – Pericardiocentesis is the treatment of choice for most patients with an indication for pericardial fluid drainage. (See 'Percutaneous pericardiocentesis' above.)

For patients undergoing percutaneous pericardiocentesis, we suggest echocardiographic guidance rather than no or only fluoroscopic guidance (Grade 2C). Echocardiographic guidance allows the operator to select the shortest safe route from the skin to the effusion, generally near the cardiac apex or near an edge of the sternum. (See 'Technique' above.)

Pericardiocentesis is routinely followed by catheter drainage for up to five days until fluid return is <25 to 50 mL/day, with consideration of a surgical pericardial window if there is persistent pericardial fluid drainage greater than 50 mL/day. (See 'Postprocedure care' above.)

•Surgical drainage – Surgical drainage with direct or video visualization is preferred if the effusion is inaccessible to percutaneous drainage (eg, loculated, thick, and/or coagulated) or if there is a crucial cardiac or aortic bleeding site that requires surgical management (eg, penetrating chest trauma, aortic dissection, myocardial rupture). An advantage of surgical drainage is that a pericardial window can be created (to reduce the risk of recurrent pericardial effusion) and/or pericardial biopsies can be obtained during the procedure.

●Monitoring and treatment of cause – Patients in whom the initial approach is observation (or who have undergone pericardiocentesis) should undergo serial clinical and echocardiographic evaluation (eg. every five to seven days or sooner if clinically indicated), avoid volume depletion, and receive treatment for the underlying cause of the pericardial effusion, if known. (See 'General management' above and 'Treatment of cause' above.)

●Management of recurrence – For patients deemed at high risk for recurrent pericardial effusion (including those with malignant pericardial effusion or purulent pericarditis), initial management with pericardial fluid removal may be combined with or followed by one or more measures to prevent or treat recurrent pericardial effusion, such as mechanical pericardial interventions (prolonged catheter drainage, repeated pericardiocentesis, or surgical pericardiotomy [pericardial window]), along with treatment of the underlying cause of the effusion. (See 'Management of recurrent pericardial effusion' above and "Pericardial disease associated with cancer: Management", section on 'Prevention and treatment of recurrent malignant pericardial effusion' and "Purulent pericarditis", section on 'Pericardial drainage'.)