Management of Postoperative Pleural and Pericardial Effusions. Kevin L. Greason, M.D. American Association of Thoracic Surgery Meeting April 28, 2012

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.

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 Atelectasis Chylothorax IMA Harvest Uncommon Pleural effusion Common Empyema Heart Failure Pulmonary embolism Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.

Clinical Characteristics Etiology Atelectasis IMA harvest Heart failure Clinical characteristics Immediate postoperative period; often associated with splinting Small to large effusion Dyspnea, lower extremity edema, PND, orthopnea Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.

Radiograph Findings Etiology Atelectasis IMA harvest Heart failure Radiograph Findings Ipsilateral volume loss, small, left-sided effusion Left sided, small to large effusion 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-toserum protein ratio Fluid LDH-toserum LDH ratio < 0.5 > 0.5 < 0.6 > 0.6 Cholesterol < 55 mg/dl > 55 mg/dl WBC count < 100/mm 3 > 1000/mm 3

Pleural fluid analysis Etiology Atelectasis IMA harvest Heart failure Transudate Pleural fluid analysis Bloody, neutrophilic, exudate Mononuclear predominant transudate, BNP > 1500 pg/dl Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.

Proposed Mechanism Etiology Atelectasis IMA harvest Heart failure Proposed mechanism Phrenic nerve dysfunction; splinting Pleural injury from IMA harvesting Myocardial edema from SIRS; underlying ischemia Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.

Management Etiology Atelectasis IMA harvest Heart failure Management Pulmonary toilette, spontaneous resolution Thoracentesis if symptomatic large effusion; usually resolves spontaneously Heart failure management Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.

Sequelae Etiology Atelectasis IMA harvest Heart failure Sequelae Resolution of diaphragm dysfunction can be slow (over weeks) Can progress to chronic lymphocytic effusion of unknown cause None Heidecker and Sahn. Clin Chest Med. 2006;27:267-283.

Treatment Diuretics Pulmonary toilette Multimodal treatment Heart failure Rx Thoracentesis Chest tube management

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

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 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 Weeks after operation Effusions Chest pain Elevated ESR Syndrome Fever Elevated WBC Rub

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