219 Oesophageal EUS-guided Pericardiocentesis: A Therapeutic Conundrum in Patient with EGFR-positive Metastatic Lung Adenocarcinoma and Posterior Pericardial Tamponade

Abstract

Introduction Treatment for malignant loculated pericardial effusions are limited and they often reaccumulate following surgical management. Here we report a case of oesophageal endoscopic ultrasound (EUS) guided pericardiocentesis for a loculated posterior malignant pericardial effusion causing haemodynamic compromise. Methods The endoscope was introduced to D2 and a 19G needle was used to aspirate the posterior pericardial effusion. Peri-procedural prophylaxis was given with intravenous co-amoxiclav 1.2 g, amikacin 15 mg/kg, and fluconazole 400 mg. Results A 65-year-old man was diagnosed with metastatic lung adenocarcinoma following an emergency presentation with malignant cardiac tamponade. This was drained with transthoracic pericardiocentesis and was subsequently started on osimertinib (EGFR-exon-19 sensitising mutation). After 6 weeks of osimertinib, he was readmitted with symptomatic effusion. He had an urgent pericardial window which was technically difficult due to multiple loculations, densely adherent sac, and poor lung reserve. Re-staging CT showed partial response. 2 weeks following discharge his repeat echocardiogram demonstrated a 4.0 cm loculated posterior effusion compressing the LA with haemodynamic compromise. The location of the effusion was not amenable to a percutaneous approach and was deemed too high anaesthetic risk to undergo a repeat thoracotomy. Due to his good pre-morbid baseline, favourable genomic profile, and response to osimertinib, the MDT decided to trial an unconventional approach with EUS-guided pericardiocentesis. This was done under sedation with peri-procedural antimicrobial prophylaxis. The procedure was uncomplicated and drained 100 mL haemosanguinous fluid with immediate symptomatic relief. There were no post-procedural complications. Pericardial culture was negative and there were no malignant cells. [Formula presented] Conclusion Here, we present one of the only reported EUS-guided pericardiocentesis as a potential alternative for complex loculated pericardial effusion with tamponade. Improved prognosis in patients with metastatic lung cancer, especially those with actionable genomic aberrations, should be considered for more aggressive therapeutic approaches when no other alternatives exist following clear discussion regarding risks and benefits. Disclosure No significant relationships.