Management of Postoperative Pleural and Pericardial Effusions
Kevin L. Greason, M.D. American Association of Thoracic Surgery Meeting April 28, 2012
No disclosures
Kevin L. Greason, M.D. American Association of Thoracic Surgery Meeting April 28, 2012
Objectives
• Review the incidence and management of pleural effusions after cardiac operation.
• Review the incidence and significance of postoperative pericardial effusions after cardiac operation.
• Define a reasonable approach to the radiologic and echocardiographic assessment of the postoperative cardiac surgery patient.
Pleural or Pericardial Effusion and Cardiac Operation
Results: 1 to 20 of 8672
Case Presentation #1
• 84 y/o woman
• Severe AS
• Creatinine 2.5 mg/dL
• NYHA Class IV
• Cardiogenic shock
• Ejection fraction 30%
• Emergent status
• STS risk 23.5%
POD #5
• S/P BAV
• S/P Root enlargement
• S/P AVR
• Dopamine infusion
• Lasix
• Coumadin (INR 2.9)
• Creatinine 1.2 mg/dL
• Weight + 3 kg
Case Presentation #2
POD #1 POD #3
Physiology of Pleural Fluid Movement
Brunelli et al. EJCTS;2011;40:291-297
How Common Are Pleural Effusions?
Vargas et al. Rev Hosp Clin Fac Med S. Paulo. 2002;57(4):135-142.
How Common Are Pleural Effusions?
Vargas et al. Rev Hosp Clin Fac Med S. Paulo. 2002;57(4):135-142.
Mayo Clinic Effusion Interventions*
Procedure Total (n) Pleural effusion
(n) Percent
CABG 11320 289 2.6
AVR 2895 93 3.2
AVR/CABG 2278 94 4.1
MVP 1863 37 2.0
MVP/CABG 802 39 4.9
MVR 747 36 4.8
MVR/CABG 256 12 4.7
Total 20161 600 3.0
*Mayo Clinic Rochester STS Data: 1993-2010
Mayo Clinic Effusion Interventions*
Procedure Total (n) Pleural effusion
(n) Percent
CABG 11320 289 2.6
AVR 2895 93 3.2
AVR/CABG 2278 94 4.1
MVP 1863 37 2.0
MVP/CABG 802 39 4.9
MVR 747 36 4.8
MVR/CABG 256 12 4.7
Total 20161 600 3.0
*Mayo Clinic Rochester STS Data: 1993-2010
Mayo Clinic Effusion Interventions*
Procedure Total (n) Pleural effusion
(n) Percent
CABG 11320 289 2.6
AVR 2895 93 3.2
AVR/CABG 2278 94 4.1
MVP 1863 37 2.0
MVP/CABG 802 39 4.9
MVR 747 36 4.8
MVR/CABG 256 12 4.7
Total 20161 600 3.0
*Mayo Clinic Rochester STS Data: 1993-2010
Mayo Clinic Effusion Interventions*
Procedure Total (n) Pleural effusion
(n) Percent
CABG 11320 289 2.6
AVR 2895 93 3.2
AVR/CABG 2278 94 4.1
MVP 1863 37 2.0
MVP/CABG 802 39 4.9
MVR 747 36 4.8
MVR/CABG 256 12 4.7
Total 20161 600 3.0
*Mayo Clinic Rochester STS Data: 1993-2010
Review
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Etiology
Chylothorax
Empyema
Pulmonary
embolism
Heart
Failure
IMA
Harvest
Atelectasis
Pleural
effusion Common Uncommon
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Clinical Characteristics
Etiology Clinical characteristics
Atelectasis Immediate postoperative period; often associated with splinting
IMA harvest Small to large effusion
Heart failure Dyspnea, lower extremity edema, PND, orthopnea
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Radiograph Findings
Etiology Radiograph Findings
Atelectasis Ipsilateral volume loss, small, left-sided effusion
IMA harvest Left sided, small to large effusion
Heart failure Bilateral effusions; right > left; pulmonary edema
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Pleural Fluid Analysis
Characteristic Transudate Exudate
Appearance Clear Cloudy or turbid
Specific gravity < 1.015 > 1.015
Total protein < 2.5 gm/dL > 3 gm/dL
Fluid protein-to-serum protein ratio
< 0.5 > 0.5
Fluid LDH-to-serum LDH ratio
< 0.6 > 0.6
Cholesterol < 55 mg/dL > 55 mg/dL
WBC count < 100/mm3 > 1000/mm3
Pleural fluid analysis
Etiology Pleural fluid analysis
Atelectasis Transudate
IMA harvest Bloody, neutrophilic, exudate
Heart failure Mononuclear predominant transudate, BNP > 1500 pg/dL
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Proposed Mechanism
Etiology Proposed mechanism
Atelectasis Phrenic nerve dysfunction; splinting
IMA harvest Pleural injury from IMA harvesting
Heart failure Myocardial edema from SIRS; underlying ischemia
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Management
Etiology Management
Atelectasis Pulmonary toilette, spontaneous resolution
IMA harvest Thoracentesis if symptomatic large effusion; usually resolves spontaneously
Heart failure Heart failure management
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Sequelae
Etiology Sequelae
Atelectasis Resolution of diaphragm dysfunction can be slow (over weeks)
IMA harvest Can progress to chronic lymphocytic effusion of unknown cause
Heart failure None
Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.
Treatment
Pulmonary
toilette
Thoracentesis Chest tube
management
Heart failure
Rx
Diuretics
Multimodal
treatment
POD #24
Discussion Points
• What imaging studies should be obtained?
• How often should studies be obtained?
• Does every left pleural effusion need to be tapped?
• Can we predict when diuretics alone will lead to resolution of pleural effusions?
Discussion Points
• What imaging studies should be obtained?
• Chest x-rays (portable, PA & Lat)
• How often should studies be obtained?
• Does every left pleural effusion need to be tapped?
• Can we predict when diuretics alone will lead to resolution of pleural effusions?
Discussion Points
• What imaging studies should be obtained?
• Chest x-rays (portable, PA & Lat)
• How often should studies be obtained?
• Daily while CT in place and then prior to D/C
• Does every left pleural effusion need to be tapped?
• Can we predict when diuretics alone will lead to resolution of pleural effusions?
Discussion Points
• What imaging studies should be obtained?
• Chest x-rays (portable, PA & Lat)
• How often should studies be obtained?
• Daily while CT in place and then prior to D/C
• Does every left pleural effusion need to be tapped?
• No, only symptomatic or not responsive to therapy
• Can we predict when diuretics alone will lead to resolution of pleural effusions?
Discussion Points
• What imaging studies should be obtained?
• Chest x-rays (portable, PA & Lat)
• How often should studies be obtained?
• Daily while CT in place and then prior to D/C
• Does every left pleural effusion need to be tapped?
• No, only symptomatic or not responsive to therapy
• Can we predict when diuretics alone will lead to resolution of pleural effusions?
• Yes, when renal insufficiency develops
Case Presentation #2
• 70 y/o woman
• Severe TR
• Obese BMI 48
• ARF (Cr 2.5 mg/dL)
• NYHA Class IV
• PHTN (58 mm Hg)
• EF 58%
• S/P PE
Chest Tube Output
POD #5
• S/P TVR
• Dopamine infusion
• Lasix infusion
• Metolazone oral
• Creatinine 2.0 mg/dL
• Weight + 10 kg
TTE POD #5
TTE POD #5
TTE POD #5
Postoperative Pericardial Effusion
Meurin et al. Chest. 2004;125:2182-2197.
Effusion Grade
Meurin et al. Chest. 2004;125:2182-2197.
Effusion at 20 Days
Meurin et al. Chest. 2004;125:2182-2197.
Effusion at 20 Days
Meurin et al. Chest. 2004;125:2182-2197.
Effusion at 20 Days
Meurin et al. Chest. 2004;125:2182-2197.
Effusion at 20 Days
Meurin et al. Chest. 2004;125:2182-2197.
Effusion at 30 Days
Meurin et al. Chest. 2004;125:2182-2197.
Effusion at 30 Days
Meurin et al. Chest. 2004;125:2182-2197.
Tamponade and Effusion Grade
Meurin et al. Chest. 2004;125:2182-2197.
The Question of Coumadin
Kuvin et al. ATS. 2002;74:1148-1153.
Coumadin and Tamponade
Kuvin et al. ATS. 2002;74:1148-1153.
Discussion Points
• Should we get echo pre-discharge in all patients?
• How about patients on Coumadin?
• Does every moderate pericardial effusion without tamponade need to be drained?
Discussion Points
• Should we get echo pre-discharge in all patients?
• Routinely on all valve patients
• How about patients on Coumadin?
• Does every moderate pericardial effusion without tamponade need to be drained?
Discussion Points
• Should we get echo pre-discharge in all patients?
• Routinely on all valve patients
• How about patients on Coumadin?
• Not necessarily, if everything is perfect
• Does every moderate pericardial effusion without tamponade need to be drained?
Discussion Points
• Should we get echo pre-discharge in all patients?
• Routinely on all valve patients
• How about patients on Coumadin?
• Not necessarily, if everything is perfect
• Does every moderate pericardial effusion without tamponade need to be drained?
• No, but it needs to be followed
Post-cardiotomy Injury Syndrome
Effusions
Elevated
ESR
Elevated
WBC Rub
Fever
Chest pain
Weeks after
operation
Syndrome
Conclusions
• Pleural and pericardial effusions are common after heart surgery
• Most patients respond to conservative measures and do not require invasive therapy
• Post-cardiotomy Injury Syndrome develops in up to 30% of patients and these patients require close follow-up