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not responding to medical therapy, or when a search for aetiological agents is needed (e.g. suspicion of cancer, bacterial infection). Whenever possible, pericardiocentesis should not drain a large amount of pericardial fluid (usually <500 mL) to prevent pericardial decompression syndrome. Complete drainage of the PEff can be achieved, leaving a drain to be removed when the daily drainage is <30 mL. Surgical drainage is required when percutaneous pericardiocentesis is not feasible or purulent effusion is present, to allow complete drainage of the effusion and prevent its organization. Clinical triage has been proposed to indicate urgent management.118 An overall score of >6 indicates the need for urgent pericardiocentesis, whereas a lower score suggests delaying the intervention (see Figure 12). Imaging is an essential component for guiding percutaneous pericardiocentesis. Under echocardiography, CT, or fluoroscopic guidance, a needle (usually 16–20 gauge) should be introduced into the subxyphoid space, although an apical or left-lateral approach might be used. The catheter should usually remain in situ for a few days, also based on the type and efficacy of concomitant systemic and/or topic pharmacological treatment.1

6.3.2.2 Percutaneous balloon pericardiotomy

Percutaneous balloon pericardiotomy represents a percutaneous alternative to the endoscopic or surgical pleuro-pericardial window, which allows relapsing pericardial fluid to be absorbed through the ample pleural serosa, especially as palliative and temporary relief.1 It should not be used as a first- or second-line intervention, but rather reserved for very rare cases, such as recurrent neoplastic PEff and CTP, as well as for absolute contraindications for surgery or in the case of a very poor quality of life in terminal patients (see Supplementary data online, Table S8).1

6.3.2.3 Intrapericardial drug administration

Percutaneous access to the pericardium is done using an intrapericardial catheter following pericardial drainage. It may be used to deliver drugs targeting different conditions. Anti-inflammatory agents have been delivered with some efficacy. Intrapericardial crystalloid triamcinolone, 300 mg/m2 of body surface, can be used for autoreactive or recurrent PEffs that do not respond to other conventional therapies, and to avoid or limit systemic side effects of oral corticosteroids. Chemotherapeutics have also been delivered, such as cisplatin and thiotepa (usually for lung and breast cancer, respectively), with demonstrated reduction of PEff relapse.302–304 Currently, due to improved chemotherapy, the systemic route is favoured, and therapeutic planning should involve a multidisciplinary team with cardiologists and oncologists. Sclerosing agents, such as talc, to enhance pericardium–epicardium adherence and to reduce relapsing PEff, should not be used, because of reduced efficacy compared with a pericardial window or pericardiectomy, and the risk of inducing constriction.305,306

6.3.2.4 Pericardioscopy

This procedure is sometimes considered as part of the diagnostic workup, allowing pericardial biopsy. Pericardial access is also increasingly used for mapping and ablation of the epicardial substrates of VA, with an improved success rate and avoidance of a surgical procedure.

6.3.2.5 Pericardial fluid analysis, pericardial and epicardial biopsy

Percutaneous pericardial access may be used also to provide fluid samples for pathological and pathogen examinations (bacterial or viral aetiology), and/or to perform pericardial as well as epicardial biopsies, particularly in cancer screening (see Supplementary data online, Table S7).1 6.3.2.6 Circulatory support

Mechanical circulatory support has been shown to be applied in up to 12% of pericardiectomy patients with pre-procedural RV dilatation/ dysfunction,307–309 and is sometimes considered peri-operatively.307– 309 The association of pre-procedural RV dilatation/dysfunction and reduced LV function also represent risk factors for a peri-procedural risk of early mortality, calling for timely and prophylactic MCS.308

6.4 Surgical therapy

6.4.1. Myocarditis The surgical treatment of myocarditis mainly accounts for HT, when there is no myocardial recovery. In addition to infective or autoimmune aetiologies, radiation-induced myopericarditis (usually secondary to haematological cancer) may contribute to the indications for such an intervention. Limited series of HTs due to radiation-induced myocarditis have been described with satisfactory results. Secondary malignancy, lung and kidney failure are negative prognostic factors for post-operative morbidity and mortality.310 A durable ventricular assist device (VAD) or a total artificial heart are other alternatives for advanced cardiac support.295

6.4.2 Pericarditis

6.4.2.1. Surgical pericardiocentesis Surgical pericardiocentesis is rarely performed for urgent/emergency conditions, but for large PEff requiring expeditious drainage, not achievable with percutaneous-based drainage (e.g. for purulent PEff or clot aspiration).

6.4.2.2 Pericardiotomy/pericardial window

These surgical procedures are carried out to create a connection, namely a pleuro-pericardial window, usually between the lateral or left posterior pericardium and the left pleura. The indication is relapsing PEff with haemodynamic compromise despite conservative treatment or percutaneous drainage. The pleuro-pericardial window is meant to promote drainage from the pericardium to the left pleural space.1 Such a window may be created by a small thoracotomy or endoscopically. In selected cases, a pericardial window can also be created in the peritoneal cavity.

Recommendation Table 12 — Recommendations for interventional techniques in pericarditis (see Evidence Table 12)

Recommendations Classa Levelb

Pericardiocentesis (echocardiography-, CT-, or fluoroscopy-guided) is recommended for cardiac tamponade, or suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large pericardial effusion despite medical therapy. I C Surgical pericardial drainage is recommended in patients with pericardial effusion when percutaneous pericardiocentesis is not feasible or with purulent pericardial effusion to allow complete drainage and to prevent constriction. I C Surgical pleuro-pericardial window is recommended in patients with relapsing pericardial effusion despite medical therapy. I C © ESC 2025

CT, computed tomography. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/46/40/3952/8234483 by guest on 07 October 2026