Introduction

Malignant pericardial effusion is a severe and often late-stage complication of advanced oncological diseases, with lung adenocarcinoma being the most frequent underlying aetiology. The condition is characterised by the accumulation of fluid within the pericardial sac, which can precipitate cardiac tamponade – a life-threatening state of haemodynamic instability resulting from cardiac compression. The clinical presentation is predominantly symptomatic; a recent systematic review identified dyspnoea as the leading symptom, affecting 90% of patients, while overt cardiac tamponade was present in nearly 80% of cases at the time of diagnosis. In the palliative setting, the primary therapeutic goal is to secure durable symptom relief and prevent fluid re-accumulation. Although pericardiocentesis is widely utilised for immediate decompression, it is associated with limited long-term efficacy. Data indicate that isolated pericardiocentesis carries a recurrence rate of approximately 38%, whereas surgical creation of a pericardial window significantly reduces this risk to less than 7%. Consequently, surgical fenestration represents a critical intervention for preventing recurrent tamponade and improving the quality of life in patients with poor prognosis [1].

Case report

A 69-year-old man with stage IV non-small cell lung carcinoma was admitted due to recurrent pericardial effusion resulting in syncope. Prior to his admission in our clinic, the patient had been hospitalised twice at other facilities due to symptoms of impending cardiac tamponade. On 9 January 2025, 1680 ml of pericardial fluid was drained. However, the effusion recurred rapidly, necessitating a repeat pericardiocentesis on 16 January 2025, with the evacuation of another 1000 ml. The rapid re-accumulation of fluid demonstrated the limited efficacy of repeated needle aspiration. On admission on 29 January 2025, his general condition was fair; he was conscious but disoriented to time and place. His performance status was assessed as Eastern Cooperative Oncology Group (ECOG) 2 (capable of self-care, unable to work, spending less than 50% of the day in bed). Subsequently, the patient reported worsening dyspnoea and stenocardial pain, expressing a pessimistic attitude toward treatment due to symptom progression. According to the patient’s daughter, he had experienced significant unintentional weight loss exceeding 10 kg over the preceding 6 months.

Seven days prior to the scheduled surgery (30 January), echocardiography revealed a large amount of peri- ardial fluid: in the parasternal long-axis (LAX) view, 16 mm near the inferolateral wall and 27 mm near the right ventricle; in the short-axis (SAX) view, 20 mm near the inferolateral wall; in the apical four-chamber view, up to 24 mm near the lateral wall, 26 mm anteriorly, 15 mm inferiorly, and approximately 30 mm near the right ventricle. In the subxiphoid view, the fluid layer near the right ventricle and atrium measured approximately 28 mm. A chest radiograph obtained on 29 January 2025 revealed a significantly enlarged cardiac silhouette with a globular shape (the “water bottle” sign), indicative of a large pericardial effusion despite previous drainage attempts (Figure 1). This imaging was followed by a chest computed tomography scan (on 30 January 2025), which confirmed a massive presence of fluid with a width up to 50 mm. The scan also identified a central spicular tumour in the 6^th segment of the left lung (43  30 mm) and nodular enhancing lesions within the periardial layers, highly suggestive of metastatic dissemination.

Due to the confirmed tamponade risk, a third pericardiocentesis was performed on 31 January 2025, yielding 1080 ml of fluid. Upon transfer to the Clinical Oncology Department (maintained ECOG 2 status), a multidisciplinary tumour board convened on 6 February 2025 and qualified the patient for a pericardial fenestration. Prior to surgery, cytological analysis of the pericardial fluid confirmed a non-small cell lung carcinoma, warranting surgical intervention. Preoperative laboratory tests indicated a spreading inflammatory process, with an elevated C-reactive protein of 55.6 mg/l (normal: 0.0–5.0). Low levels of total protein and albumin suggested cancer-related cachexia and were likely associated with the effusion. The patient also presented with uncompensated respiratory alkalosis (pH 7.502, pCO₂ 28.6 mm Hg, HCO₃^– 22.4 mmol/l), likely due to both tumour progression and pericardial effusion. A decision was made to perform a pericardial window procedure via right-sided video-assisted thoracoscopic surgery (VATS). During the operation, a sample of the thickened and infiltrated pericardium was taken for intraoperative histological analysis, which confirmed the diagnosis of a malignant tumour. Subsequent paraffin-embedded sections identified a non-small cell carcinoma with an immunophenotype consistent with adenocarcinoma (panCK+, TTF1+, p40–). A free drainage route for pericardial fluid into the pleural cavity was created during surgery (Figure 2).

Postoperatively, the patient remained haemodynamically stable and did not experience any complications due to surgery (besides an episode of tachycardia, which resolved after removal of the pericardial catheter). This underscores the importance of close postoperative monitoring, especially in the palliative setting, where any clinical event can significantly impact the patient’s quality of life. Four days after surgery, the patient reported a complete resolution of symptoms. In contrast to preoperative findings, echocardiography performed five days after surgery indicated improved cardiac haemodynamics, with an ejection fraction slightly below the normal range – 50% (normal: 53–85%). A small amount of pericardial fluid was still present: approximately 5 mm in the LAX view near the inferolateral wall (up to 12 mm in the recess), 10–14 mm near the right ventricle with an 8 mm compact layer possibly representing fibrin; in the SAX view near the inferolateral wall, 7 mm; and in the apical four-chamber view, up to 11 mm near the lateral and anterior walls, and 5 mm near the inferior wall. In the subxiphoid view, fluid measured 8 mm near the right ventricle. Control chest X-ray taken 12 days after surgery demonstrated a significant improvement in the radiographic appearance of the chest compared to the pre-operative state. Most notably, there was a visible reduction in the transverse diameter of the cardiac silhouette, indicating effective decompression of the pericardial sac. The “water bottle” sign was absent, confirming the patency of the surgically created window (Figure 3).

The patient reported feeling well with the resolution of severe symptoms, and was discharged home shortly after. On 11 February 2025, he was qualified for systemic treatment. However, during the follow-up visit on 3 March 2025, systemic therapy was excluded due to rapid disease progression and the exhaustion of therapeutic options. At this visit, the patient presented with weakness and dyspnoea; importantly, these symptoms were attributed to increasing pleural effusions secondary to cancer progression rather than cardiac tamponade. Control ultrasonography confirmed the sustained efficacy of the fenestration, demonstrating a non- enlarged left ventricle and the absence of right heart chamber compression despite the presence of fluid. Follow-up imaging performed 5–6 weeks after operation confirmed the durability of the pericardial drainage. While the patient required management for a left-sided pleural effusion, serial chest X-rays (10–28 March) showed no recurrence of the massive pericardial effusion. The cardiac silhouette remained stable, with no radiological signs of recurring tamponade, validating the effectiveness of the fenestration in preventing cardiac compression despite the progression of the neoplastic disease. Comparison of pre- and postoperative imaging, along with the long-term follow-up, confirms the efficacy of the pericardial window in preventing tamponade recurrence even in the terminal stage of the disease.

Discussion

Pericardial effusion is a significant complication of advanced malignancies, necessitating interventions that balance efficacy with patient safety. The surgical management of this condition has a long history, dating back to the early 19^th century when Larrey first described the subxiphoid approach (1829), yet the therapeutic paradigm shifted significantly with the advent of VATS. As described by Cantó et al. [2] in 1993, this minimally invasive technique revolutionised the field by allowing for the creation of a pleuro-pericardial window without the morbidity associated with full thoracotomy.

In current practice, echocardiography-guided pericardiocentesis remains the first-line intervention in approximately 80% of cases due to its accessibility. However, in the context of malignant aetiology, simple drainage is associated with high recurrence rates ranging 30–60% [3], creating a clinical dilemma between repeating less invasive procedures or opting for a more definitive surgical solution [4]. The decision to proceed with surgery is not trivial, primarily due to the risks associated with general anaesthesia in patients with cardiac tamponade, where the loss of sympathetic drive can precipitate haemodynamic collapse. Nevertheless, the literature suggests that surgical drainage techniques, including pericardial fenestration, are associated with a significantly lower risk of effusion recurrence (< 10%) compared to pericardiocentesis or extended catheter drainage [1, 5].

In the presented case, the choice of a VATS pericardial window was dictated by the need for durable palliation and the avoidance of the “revolving door” phenomenon of repeated hospitalisations for drainage, which severely impacts the quality of life in palliative care [6, 7]. This approach aligns with the paradigm shift observed in the European Society of Cardiology (ESC) Guidelines [8]. While the 2015 Guidelines emphasised intrapericardial instillation of cytostatic agents as a primary option [9], the 2025 update elevates pericardial fenestration to a Class I recommendation for relapsing malignant effusions [8]. This evolution reflects growing evidence that systemic treatment supported by effective mechanical drainage is superior to local cytostatic instillation or repeated needle aspiration.

The uniqueness of this case lies in the successful implementation of surgical fenestration prior to its formal prioritisation in the 2025 ESC Guidelines, serving as a clinical validation of this paradigm shift. It demonstrates that even in the terminal stage of lung cancer, moving away from conservative drainage towards early surgical intervention is safe and yields a tangible improvement in the patient’s remaining quality of life. Although official epidemiological data regarding the exact annual volume of palliative pericardial fenestrations are not widely reported in current literature, the procedure appears to be clinically underutilised despite its proven efficacy in preventing recurrence [1].

Furthermore, the utility of VATS extends beyond drainage; it provides a unique opportunity for diagnostic precision. Unlike blind pericardiocentesis, VATS enables direct visualisation and resection of thickened pericardium for histological analysis [2, 5]. In our patient, this allowed for the definitive confirmation of metastatic adenocarcinoma (confirming stage M1a/IVa), which is crucial for guiding further oncological management according to National Comprehensive Cancer Network Guidelines. Consequently, despite the availability of less invasive bedside procedures, pericardial fenestration represents a safe and effective early intervention. It successfully bridges the gap between immediate symptom relief and long-term control of the effusion, validating its role as a first-line treatment strategy in the modern algorithm for malignant pericardial diseases.

Conclusions

In a palliative setting, therapeutic decisions must prioritise life expectancy, patient comfort, and minimisation of procedural risks including rare postoperative complications described in the literature such as organ herniation [10]. Even though pericardial fenestration is rarely performed, it significantly improves the patient’s quality of life by preventing effusion recurrence and eliminating the need for constant drainage [6]. From a practical clinical perspective, this procedure should be considered a standard early intervention rather than a last resort. Clinicians should qualify patients with cytologically confirmed malignant pericardial effusion, specifically those who experience fluid recurrence after initial pericardiocentesis, for surgical consultation. According to the 2025 ESC Guidelines, fenestration is now recommended as a first-line treatment in such cases, offering superior efficacy over repeated needle drainage, which carries higher infection risks [8]. Therefore, upon the first signs of recurrence – manifested by symptoms such as worsening dyspnoea or hemodynamic instability – patients should be promptly referred to a thoracic surgery department. The procedure of choice is a pericardial window performed via VATS, which not only ensures durable drainage into the pleural cavity but also enables essential intraoperative histopathological verification [2, 5].

Disclosures

1. Institutional review board statement: Not applicable.

2. Assistance with the article: None.

3. Financial support and sponsorship: None.

4. Conflicts of interest: None.

5. Patient consent: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

References