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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

greason.kevin@mayo.edu