Needle aspiration for treating iatrogenic pneumothorax after cardiac electronic device implantation: a pilot study

Dominika Domokos,Robert Gabor Kiss,Gyongyver Banhegyi,Istvan Marczell,Istvan Hizoh,Balazs Polgar,Bela Merkely,Gabor Zoltan Duray,Peter Bogyi,Zsolt Bari,Leticia Papp,Andras Szabo

doi:10.1007/s10840-019-00596-x

Abstract

PurposePneumothorax (PTX) following cardiac implantable electronic device procedures is traditionally treated with chest tube drainage (CTD). We hypothesized that, in a subset of patients, the less invasive needle aspiration (NA) may also be effective. We compared the strategy of primary NA with that of primary CTD in a single-center observational study.MethodsOf the 970 procedures with subclavian venous access between January 2016 and June 2018, 23 patients had PTX requiring intervention. Beginning with March 2017, the traditional primary CTD (9 cases) has been replaced by the “NA first” strategy (14 patients). Outcome measures were procedural success rate and duration of hospitalization evaluated both as time to event (log-rank test) and as a discrete variable (Wilcoxon-Mann-Whitney test).ResultsNeedle aspiration was successful in 8/14 (57.1%) of the cases (95% CI 28.9–82.3%), whereas PTX resolved in all patients after CTD was 9/9 (100%, 95% CI 66.4–100.0%, p = 0.0481). Regarding length of hospital stay, intention to treat time to event analysis showed no difference between the two approaches (p = 0.73). Also, the median difference was not statistically significant (− 2.0 days, p = 0.17). In contrast, per protocol evaluation revealed reduced risk of prolonged hospitalization for NA patients (p = 0.0025) with a median difference of − 4.0 days (p = 0.0012). Failure of NA did not result in a meaningful delay in discharge timing as median difference was 1.5 days (p = 0.28).ConclusionsOur data suggest that in a number of patients iatrogenic PTX may be successfully treated with NA resulting in shorter hospitalization without the risk of meaningful discharge delay in unsuccessful cases.

Highlights

Iatrogenic pneumothorax (PTX) is a major complication of cardiac implantable electronic device (CIED) procedures
Traditional chest tube drainage was performed in all patients until March 2017 (“historic” control group, 9 cases), when the institutional protocol changed and primary CTD was replaced by the novel “needle aspiration first” strategy (14 patients)
Besides intention to treat (ITT) and per protocol (PP) analyses, we investigated the effect of secondary CTD (i.e., needle aspiration (NA) failure) on discharge timing

Summary

Introduction

Iatrogenic pneumothorax (PTX) is a major complication of cardiac implantable electronic device (CIED) procedures. The incidence of PTX after CIED implantation varies between 0.7 and 1.7% according to recent publications [1,2,3]. Pneumothorax requiring intervention is traditionally treated by large-bore chest tube drainage (CTD). Needle aspiration (NA) has been found to be effective for primary and secondary spontaneous pneumothoraces in recent randomized trials [8, 9]. Though there is still no general consensus regarding this therapeutic modality, the British Thoracic Society recommended needle aspiration as a firstline therapy for primary spontaneous pneumothorax and as an option for small secondary spontaneous PTX as early as 2010 [10]. There are no data available about needle aspiration as a treatment option for iatrogenic PTX after CIED implantation. At least in a subset of patients, NA might be effective in this clinical setting

Methods

Results

Conclusion