# Malignant pericardial effusion: tamponade, drainage, cytology and preventing recurrence

Source: https://onco.cc/protocols/malignant-pericardial-effusion/  
OnCo record `malignant-pericardial-effusion` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Cancer can cause fluid to build up in the sac around the heart. When there is a lot, the heart cannot fill properly: breathlessness, a fast heartbeat, feeling faint or low blood pressure need emergency care. A heart ultrasound finds the fluid, and a needle and drain remove it. Because it often comes back, doctors may leave a drain in for a few days or make an opening in the sac.

## Summary

Malignant pericardial effusion occurs in up to 21% of people with metastatic cancer (PMAP), most often from lung and breast cancer and lymphomas. In a systematic review of 41 published cases (CJC Open 2024), breathlessness was the leading symptom (90%) and 78% had tamponade. Echocardiography is the first-line test; cytology of drained fluid is the diagnostic standard (sensitivity 92%). Pericardiocentesis is immediate if there is tamponade; the review reports that guidelines (the 2015 ESC guideline) also recommend drainage of large confirmed or suspected malignant effusions without tamponade, with extended catheter drainage, systemic treatment of the cancer, and pericardiotomy or sclerosing agents as adjuncts.

Recurrence is the problem. Observational data quoted by the review: 38% after pericardiocentesis alone, 12.1% with extended drainage, 10.8% with sclerosis, 10.3% with balloon pericardiotomy and under 7% with a surgical window. The PMAP trial (Hong Kong, 50 patients, 98% with features of tamponade) is the first randomised comparison: balloon pericardiotomy with extended drainage cut 6-month recurrence from 60% to 12% (HR 0.15) and tamponade from 40% to 4%, without improving survival or quality of life. Median survival with malignant pericardial effusion is short, so the aim is fewer procedures, not longer life. The 2025 ESC pericarditis guideline and the 2022 ESC cardio-oncology guideline could not be read.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: MPE; pericardial effusion in cancer; cardiac tamponade in cancer; pericardiocentesis; balloon pericardiotomy; pericardial window
- Tags: protocol; acute-oncology; oncological-emergency

## Connected records

- cancers: [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [Non-Hodgkin lymphoma (all types)](https://onco.cc/cancers/non-hodgkin-lymphoma/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/)
- technologies: [Cardio-oncology](https://onco.cc/technologies/cardio-oncology/)

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