PBP superior to pericardiocentesis in reducing malignant pericardial effusion recurrence

Percutaneous balloon pericardiotomy (PBP) significantly reduces recurrence of malignant pericardial effusion (MPE) by 85 percent compared with pericardiocentesis (PC), according to the randomized controlled PMAP trial conducted by a multispecialty team of researchers from the Chinese University of Hong Kong (CUHK).

“In Hong Kong, approximately 100–150 patients with metastatic cancer require PC for MPE every year,” said Professor Stephen Lam Chan of the Department of Clinical Oncology at CUHK. “Because of the high MPE recurrence rate [of 60 percent] after PC, patients often require multiple hospitalizations for repeat PC, each lasting several days. This raises the risk of infection and substantially reduces their quality of life [QoL].”

First RCT to demonstrate PBP’s superiority

To compare the efficacy of PBP vs PC in reducing MPE recurrence, CUHK’s researchers conducted the multicentre, prospective, randomized, open-label PAMP study in Hong Kong. Between 1 January 2020 and 28 January 2024, 50 patients (mean age, 62 years; female, 66 percent) with histologically confirmed active malignancy and a ≥10 mm pericardial effusion were randomized 1:1 to receive PBP or PC. [Eur Heart J 2025;doi:10.1093/eurheartj/ehaf516]

“Although previous registries have highlighted the feasibility of PBP, this is the first randomized controlled trial [RCT] demonstrating the superiority of PBP in reducing MPE recurrence over PC,” highlighted Dr Guang-Ming Tan of the Department of Medicine & Therapeutics, CUHK.

MPE recurrence reduced by 85 percent

Median time to MPE recurrence was longer with PBP vs PC (30 vs 14 days).

The primary endpoint of 6-month MPE recurrence rate was significantly lower with PBP vs PC (12 vs 60 percent; hazard ratio [HR], 0.15; 95 percent confidence interval [CI], 0.05–0.51; p=0.001).

“Five patients assigned to PBP received routine PC due to logistical issues, while two in the PC group underwent PBP per physician discretion,” added the researchers. “In the sensitivity analysis based on the actual treatment patients received, the HR was 0.30 [95 percent CI, 0.11–0.85; p=0.023] consistently in favour of PBP.”

“The lower recurrence rate with PBP may be attributable to the mandatory extended catheter drainage, which might promote the formation of a pericardial–pleural or pericardial–peritoneal fistula, facilitating pericardial fluid drainage,” explained the researchers.

Additionally, PBP significantly reduced the risk of cardiac tamponade vs PC (4 vs 40 percent; HR, 0.09; p=0.006), and all events were managed with emergency PC.

Median overall survival, procedural complication rates, and QoL were comparable between the two groups (p>0.05 for all).

“PBP can effectively prevent recurrence of pericardial effusion, thereby reducing hospitalizations, shortening hospital stays, and lowering overall healthcare costs,” commented Professor Randolph Hung-Leung Wong, Chief of the Division of Cardiothoracic Surgery, Department of Surgery, CUHK.

“PBP is not yet widely adopted in Hong Kong’s public hospitals for treating MPE, as the technique is still under trial,” said Professor Bryan Ping-Yen Yan of the Department of Medicine & Therapeutics, CUHK, first author of the study. “Our team hopes to expand the study to more hospitals and train more clinicians in this technique, so that more patients can benefit.”