Drainage Of Pericardial Effusion Research Articles

Role of point-of-care ultrasound (POCUS) in clinical hepatology.

Hospitalized patients with cirrhosis frequently require critical care management for sepsis, HE, respiratory failure, acute variceal bleeding, acute kidney injury (AKI), shock, and optimization for liver transplantation, while outpatients have unique care considerations. Point-of-care ultrasonography (POCUS) enhances bedside examination of the hepatobiliary system and relevant extrahepatic sites. POCUS includes cardiac US and is used to assess volume status and hemodynamic parameters like cardiac output, systemic vascular resistance, cardiac contractility, and pulmonary artery pressure, which aid in the early and accurate diagnosis of heart failure, cirrhotic cardiomyopathy, porto-pulmonary hypertension, hepatopulmonary syndrome, arrhythmia, and pulmonary embolism. This also helps in fluid management and vasopressor use in the resuscitation of patients with cirrhosis. Lung ultrasound (LUS) can help in differentiating pneumonia, effusion, and edema. Further, US guides interventions such as line placement, drainage of abdominal collections/abscesses, relief of tension pneumothorax, drainage of pleural and pericardial effusions, and biliary drainage in cholangitis. Additionally, its role is essential to assess liver masses foci of sepsis, for appropriate sites for paracentesis, and to assess for vascular disorders such as portal vein or hepatic vein thrombosis. Renal US can identify renal and postrenal causes of AKI and aid in diagnosis of prerenal AKI through volume assessment. In this review, we address the principles and methods of POCUS in hospitalized patients and in outpatients with cirrhosis and discuss the application of this diverse modality in clinical hepatology.

Small Left Ventricular Size Is a Risk Factor for Recurrent Pericardial Effusion after Percutaneous Drainage.

Background: Significant pericardial effusion requires percutaneous drainage. Some patients experience recurrent pericardial effusion following index drainage, but its risk factors remain unknown. Such knowledge should further improve the clinical management of individuals presenting with pericardial effusion for risk stratification and the construction of therapeutic and management strategies beforehand. Methods: Patients who underwent percutaneous drainage for pericardial effusion between 2018 and 2023 were retrospectively included and were followed for 2 years or until November 2023. Baseline factors associated with recurrent pericardial effusion that required percutaneous drainage again were investigated to identify the high-risk cohort. Results: A total of 39 patients (83 years on median, 28 males) were included. During the 2-year observation period, 11 patients had the primary outcome. The left ventricular end-diastolic diameter at baseline was independently associated with the primary outcome with an adjusted hazard ratio of 0.88 (95% confidence interval 0.80-0.97, p = 0.013) with a cutoff of 42 mm, which significantly stratified the cumulative incidence of the primary outcome (53% versus 10%, p = 0.011). Conclusions: Recurrent pericardial effusion after percutaneous drainage is not a rare phenomenon. A smaller left ventricular endo-diastolic diameter was an independent risk factor for recurrent pericardial effusion. The clinical implications of our findings in daily clinical practice should be validated in future prospective studies. Further studies are warranted to clarify the underlying causality between them.

Half-dose direct oral anticoagulation versus warfarin for atrial fibrillation following cardiac surgery.

Optimal anticoagulation strategies have not been defined for patients with atrial fibrillation following cardiac surgery. From a total cohort of 228 patients with pre-existing or new onset atrial fibrillation following coronary artery bypass grafting and/or valve surgery, we compared in-hospital and 30-day outcomes in 119 patients treated with low-dose aspirin and a half-dose direct oral anticoagulant (DOAC) versus 109 treated with low-dose aspirin and warfarin. DOAC patients were older (73.1±7.0 vs. 68.7±11.4 years, P<0.001) and had a lower incidence of preoperative atrial fibrillation (37 [31.1%] vs. 69 [63.3%], P<0.001). Otherwise, the two cohorts were well matched for baseline demographics, cardiovascular risk factors, comorbidities, prior cardiac history and STS Risk Score. In comparison to Warfarin patients, DOAC patients had a shorter length of post-surgical stay (6 [5-8] vs. 7 [5-10] days, P=0.037). The two cohorts, however, had a similar incidence of stroke, transient ischemic attack, reoperation for bleeding and postoperative blood bank product usage. Follow-up 30-day outcomes did not differ between the two groups with respect to mortality (0 [0.0%] vs. 0 [0.0%], P=1.000) and hospital readmission (16 [13.4%] vs. 14 [12.8%], P=0.893), although two DOAC patients required drainage of sanguineous pericardial effusions. In comparison to warfarin, half-dose DOAC anticoagulation in patients with atrial fibrillation following cardiac surgery is associated with a shorter postoperative length of stay, without a significant increase in stroke/transient ischemic attack, reoperation for bleeding or postoperative blood product transfusion. Follow-up echocardiography in anticoagulated patients is recommended to rule out significant sanguineous pericardial effusions in the early postoperative period following hospital discharge.

Post-cardiac injury syndrome and pericardial effusion recurrence after pericardial effusion drainage in chronic idiopathic pericardial effusion

IntroductionThe management of even large pericardial effusions in asymptomatic patients is still a matter of debate. Aim of the present study is to explore, in a multicenter setting, the rate of post-cardiac injury syndromes (PCIS) and pericardial effusion recurrence after pericardial effusion drainage procedure. Material and MethodsThis is a multicenter international retrospective study including a consecutive cohort of patients diagnosed with large, chronic and idiopathic pericardial effusions, prospectively evaluated from January 2003 to December 2021 who underwent a clinically indicated pericardial drainage procedure. Two separate end-points were recorded: 1) recurrence of pericardial effusion after drainage without any sign of pericardial inflammation 2) occurrence of PCIS, defined as the new onset of pericarditis 1 to 6 weeks after pericardial intervention. Results124 patients were enrolled (50 % female, mean age 64 years old). A mean follow-up of 29.6 ± 25.6 months was obtained in 110 patients (88 %). 110 patients were treated with pericardiocentesis (89 %), 25 with pleuro-pericardial windows (20 %), and 1 with pericardiectomy (1 %). PCIS occurred in 21 out of 124 patients followed for at least 6 weeks (16.9%). Recurrence of pericardial effusion after drainage without any sign of pericardial inflammation occurred in 68 out of 110 patients at a longer follow-up (61.8 %). At multivariate analysis only inflammatory cells in pericardial fluid was associated with PCIS and pericardiocentesis with pericardial effusion recurrency. ConclusionOur data support the need of caution with the use of pericardiocentesis in asymptomatic patients with large pericardial effusion as it is often associated with pericardial effusion recurrence. Of interest the presence of inflammatory cells in the pericardial fluid is associated with PCIS after pericardial drainage procedures.

Abstract 18155: A Rare Case of Acute Purulent Pericarditis Secondary to Invasive Streptococcal Infection (S. Pyogenes) With Cardiac Tamponade in an Immunocompetent 37-Year Old Female: A Case Report

BACKGROUND: Purulent pericarditis is a rare occurrence in the era of modern antibiotics. It is most often caused by organisms such as Staphylococcus aureus, Streptococcus pneumoniae, viridans streptococci, Haemophilus influenzae, and anaerobic bacteria with Streptococcus pyogenes (S. pyogenes) being a possible, though very uncommon etiology. It is usually associated with an underlying infection or compromised immune system. Purulent bacterial pericarditis is a high mortality entity and represents only 1% of the causes of pericarditis, among these only a few cases have been reported of Streptococcus pyogenes pericarditis. This is an extremely rare case of acute purulent bacterial pericarditis caused by S. pyogenes in an immunocompetent adult patient with no underlying chronic medical conditions. CASE PRESENTATION: A 37-year-old healthy female with no known comorbidities came in for chills, dyspnea, chest pain radiating to the upper back aggravated by deep breathing and relieved with leaning forward. She initially presented with unstable vital signs (hypotension and tachycardia). Electrocardiography demonstrated diffuse ST-segment elevation and PR segment depression, while chest Xray and CT scan showed lobar pneumonia. Blood tests showed leukocytosis with neutrophilic predominance indication infection and workup for autoimmune disease was done which was negative. 2D echo showed large pericardial effusion with tamponade physiology. An urgent pericardiocentesis was done with drainage of 350cc nonclotting purulent serous fluid. Cultures grew Streptococcus pyogenes (S. pyogenes) confirming the diagnosis of acute purulent bacterial pericarditis. Management for pericarditis including daily drainage of pericardial effusion, colchicine, ibuprofen was initiated together with antibiotics for the pneumonia and the patient had resolution of the pericardial effusion as documented by repeat 2DED upon follow up.

Management of Pericardial Effusion in Patients With Solid Tumor: An Algorithmic, Multidisciplinary Approach Results in Reduced Mortality After Paradoxical Hemodynamic Instability.

This study compared outcomes in patients with solid tumor treated for pericardial effusion with surgical drainage versus interventional radiology (IR) percutaneous drainage and compared incidence of paradoxical hemodynamic instability (PHI) between cohorts. Patients with advanced-stage solid malignancies may develop large pericardial effusions requiring intervention. PHI is a fatal and underreported complication that occurs following pericardial effusion drainage. Clinical characteristics and outcomes were compared between patients with solid tumors who underwent s urgical drainage or IR percutaneous drainage for pericardial effusion from 2010 to 2020. Among 447 patients, 243 were treated with surgical drainage, of which 27 (11%) developed PHI, compared with 7 of 204 patients (3%) who were treated with IR percutaneous drainage ( P =0.002); overall incidence of PHI decreased during the study period. Rates of reintervention (30-day: 1% vs 4%; 90-day: 4% vs 6%, P =0.7) and mortality (30-day: 21% vs 17%, P =0.3; 90-day: 39% vs 37%, P =0.7) were not different between patients treated with surgical drainage and IR percutaneous drainage. For both interventions, OS was shorter among patients with PHI than among patients without PHI (surgical drainage, median [95% confidence interval] OS, 0.89mo [0.33-2.1] vs 6.5mo [5.0-8.9], P <0.001; IR percutaneous drainage, 3.7mo [0.23-6.8] vs 5.0mo [4.0-8.1], P =0.044). With a coordinated multidisciplinary approach focusing on prompt clinical and echocardiographic evaluation, triage with bias toward IR percutaneous drainage than surgical drainage and postintervention intensive care resulted in lower incidence of PHI and improved outcomes.

SAT325 Recurrent Pericardial Effusion As Initial Presentation Of Primary Adrenal Insufficiency

Abstract Disclosure: S. Ward: None. A.L. Champion: None. A. Mrkaic: None. Recurrent Pericardial Effusion as Initial Presentation of Primary Adrenal Insufficiency: Background: Primary adrenal insufficiency (PAI) is a rare but serious endocrinopathy. High clinical suspicion is important to avoid delay in diagnosis and treatment. We present a rare case of recurrent pericardial effusion as initial presentation. Clinical Case: 63 year old male with hypertension and diabetes presented to ED complaining of SOB and chest pain. Workup revealed pericardial effusion causing cardiac tamponade treated with emergent pericardiocentesis. He was admitted to ICU for hypotension. He was also diagnosed with COVID-19 and acute kidney injury. Labs showed hyperkalemia ranging from 5.3 to 7.2 mmol/l (n= 3.5-5.1 mmol/l) and hyponatremia 132 mmol/L (n= 136-145 mmol/L). He was started on dexamethasone for COVID-19 infection. Etiology of pericardial effusion was unclear; infectious disease workup was unremarkable, cytology showed no malignant cells, autoimmune panel was negative. Initial echo showed EF &amp;gt;55%. After initiation of steroids, symptoms improved with normalization of electrolytes and improvement of hypotension, however was discharged on midodrine 2.5 mg TID. Seven days after discharge patient called 911 complaining of worsening shortness of breath. He was found to be severely hypotensive with BP 67/40. Echo showed moderate to large pericardial effusion causing tamponade. Emergent pericardial window was performed. Labs showed hyponatremia 123 mmol/L and potassium ranging from 4.9-5.4 mmol/L. Patient remained hypotensive requiring pressors despite pericardial effusion drainage. With persistent hypotension, hyperkalemia, and hyponatremia there was strong suspicion for adrenal insufficiency and workup was consistent with PAI. Labs showed 8:00 am cortisol 2.7 ug/dl (n= 3.7-19.4 ug/dl), ACTH 256.0 pg/ml (n=7.2-63.3pg/ml), aldosterone &amp;lt;1.0 ng/dL, renin 4.216 ng/mL/hr (n= 0.167-5.380 ng/mL/hr). Due to his critical illness patient was started on stress dose hydrocortisone 50 mg Q6 hr. With initiation of steroids, hyponatremia, hypokalemia, and hypotension resolved. Patient was weaned to physiological doses of hydrocortisone and started on fludrocortisone at time of discharge. Conclusion: Timely diagnosis of PAI is essential and can be lifesaving, if untreated it can lead to adrenal crisis with high mortality. Having a high clinical suspicion is crucial to a prompt diagnosis. Pericardial effusion should prompt clinical suspicion for PAI as multiple cases have now been reported in the literature. Our patient has multiple potential causes of pericardial effusion including PAI, acute kidney injury, and COVID-19 infection. Although we cannot show definitive causation from PAI, it most certainly contributed and prompt diagnosis and treatment may have prevented recurrence. It is important to raise awareness of PAI as a differential in pericardial effusion. Presentation: Saturday, June 17, 2023

The timing of pericardial drainage catheter removal and restart of the anticoagulation in patients suffered from perioperative pericardial tamponade during atrial fibrillation catheter ablation and uninterrupted dabigatran: Experiences from 20 cases

Objective: To investigate the timing of pericardial drainage catheter removal and restart of the anticoagulation in patients with atrial fibrillation (AF) suffered from perioperative pericardial tamponade during atrial fibrillation catheter ablation and uninterrupted dabigatran. Methods: A total of 20 patients with pericardial tamponade, who underwent AF catheter ablation with uninterrupted dabigatran in Beijing Anzhen Hospital from January 2019 to August 2021, were included in this retrospective analysis. The clinical characteristics of enrolled patients, information of catheter ablation procedures, pericardial tamponade management, perioperative complications, the timing of pericardial drainage catheter removal and restart of anticoagulation were analyzed. Results: All patients underwent pericardiocentesis and pericardial effusion drainage was successful in all patients. The average drainage volume was (427.8±527.4) ml. Seven cases were treated with idarucizumab, of which 1 patient received surgical repair. The average timing of pericardial drainage catheter removal and restart of anticoagulation in 19 patients without surgical repair was (1.4±0.7) and (0.8±0.4) days, respectively. No new bleeding, embolism and death were reported during hospitalization and within 30 days following hospital discharge. Time of removal of pericardial drainage catheter, restart of anticoagulation and hospital stay were similar between patients treated with idarucizumab or not. Conclusion: It is safe and reasonable to remove pericardial drainage catheter and restart anticoagulation as soon as possible during catheter ablation of atrial fibrillation with uninterrupted dabigatran independent of the idarucizumab use or not in case of confirmed hemostasis.

NURSING CARE FOR PATIENTS VICTIM OF ACUTE MYOCARDIAL INFARCTION

INTRODUCTION: Acute Myocardial Infarction (AMI) is characterized by reduced oxygen supply to the affected site, due to decreased blood flow in the coronary arteries, with consequent myocardial necrosis. OBJECTIVES: To analyze, through a literature review, the importance of nursing care for patients suffering from AMI and the relationship between the complexity of care provided and the duration of nursing care. MATERIALS AND METHODS: Refers to a literature review study focusing on Acute Myocardial Infarction, identifying the care and nursing care time required to care for clients affected by the disease. RESULTS AND DISCUSSION: For the planning and implementation of nursing care for patients diagnosed with AMI, one of the studies took into account the following complaints from female clients admitted to the ICU: Chest pain, cramps, headache with difficulties in falling asleep and incisional pain due to pericardial effusion drainage, tachycardia, nausea, cold and pale skin, hypotension, hypoactivity, bradycardia with irregular heart rate, slow response to verbal commands, in addition to anxiety. CONCLUSION: This integrative review study showed that AMI is a serious public health problem due to its high morbidity and mortality in Brazil.

Transthoracic Color Doppler Ultrasound-Guided Grooved Negative Pressure Drainage Tube Implantation in Pericardial Effusion After Cardiac Surgery.

Pericardial effusion is a common complication without a standard postoperative effusion treatment after cardiac surgery. The grooved negative pressure drainage tube has many advantages as the emerging alternative for drainage of pericardial effusion, such as it changes the structure of the traditional side hole, uses the capillary function to ensure drainage smooth, etc. The purpose of this study was to assess the feasibility and effectiveness of transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation in pericardial effusion after cardiac surgery. All patients with pericardial effusion after cardiac surgery who underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation between January 2019 and December 2021 were retrospectively analyzed. Treatment results (including clinical symptoms, effusion volume, color Doppler ultrasonography, and computed tomography scan) were investigated to evaluate the effectiveness and safety of this method. A total of 20 patients successfully underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation. After the operation, their symptoms (chest tightness, shortness of breath, etc.) were all relieved, and dark red or light red drainage fluid (> 200 ml) appeared in the newly placed drainage bottle. Color Doppler ultrasonography showed that the volume of pericardial effusion decreased significantly. The transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube is a safe and effective method for the treatment of postoperative pericardial effusion with less trauma, faster recovery, shorter in-hospital stay, and fewer complications.

1256: DIFFERENTIATING OBSTRUCTIVE SHOCK: A CASE OF SIMULTANEOUS CARDIAC TAMPONADE AND PULMONARY EMBOLISM

Introduction: Obstructive shock is an obstruction of blood flow in the central vessels of the systemic or pulmonary circulation causing hemodynamic compromise. Here, we describe the unique challenge of managing a patient in shock with simultaneous hemorrhagic pericardial effusion and bilateral mainstem pulmonary emboli (PE) in setting of disseminated intravascular coagulation (DIC). Description: A 63-year-old female former smoker with recent deep venous thrombosis presented with 4 days of weakness, shortness of breath, and inability to tolerate oral intake, including apixaban. She was tachycardic, tachypneic and hypotensive. She was fluid resuscitated and BP improved from 83/43mmHg to 104/56mmHg. She later became hypoxic, requiring 6L oxygen by nasal cannula. Labs showed platelets 20k/mm3, D-dimer >35.2mg/L, Troponin T 0.56ng/mL and NT-proBNP 1864pg/mL. Bedside echocardiogram showed a large pericardial effusion. Chest CT angiography showed an acute PE involving the bilateral main pulmonary arteries and a new 4.0 cm spiculated right lung mass. A heparin drip was started and her oxygenation improved, however she became more hypotensive, requiring further fluid resuscitation. Repeat labs showed lactate 4.8mmol/L, platelets 4k/mm3, INR 3.6, aPTT 47s, haptoglobin < 10mg/dL and fibrinogen 50mg/dL, demonstrating DIC. Follow up echocardiogram showed tamponade physiology. The patient was transfused with fresh frozen plasma and platelets, eventually requiring vasopressor support. She was taken for CT-guided pericardiostomy with resolution of her shock. The pericardial fluid was grossly bloody, and the pathology showed adenocarcinoma. Discussion: This patient presented a diagnostic dilemma in ascertaining the primary cause of her obstructive shock. Echocardiographic features of obstructive shock due to RV failure secondary to central pulmonary embolism may not be evident in the setting of concurrent pericardial effusion. The clinical findings of a small right ventricle, worsening hypotension after heparinization as well as improvement in hemodynamics after pericardiostomy confirms that cardiac tamponade was the primary etiology for her obstructive shock. Findings of RV dilatation and hypokinesis after near complete drainage of pericardial effusion suggests that the PE was causing hemodynamic compromise as well.

Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center

Objectives Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR. Methods This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding. Results Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities. Conclusions The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.

Percutaneous pericardial catheter drainage for symptomatic uremic pericardial effusions with narrow safety margins.

Percutaneous pericardial catheter drainage (PCD) for pericardial effusion is generally known to be limited by the high risk associated with effusions that are less than 10 mm thick. The objective was to report cases who underwent percutaneous PCD for symptomatic uremic pericardial effusions, which were less than 10 mm thick after cardiologist declined to perform the PCDs because of the narrow safety margins. Thirteen consecutive cases (11 patients) (median age, 56 years, range, 31-83) with symptomatic uremic pericardial effusion (thickness <10 mm) affecting the pericardial space anterior to the right ventricle underwent ultrasound- and fluoroscopy-guided percutaneous PCD between September 2015 and April 2022. Information regarding the clinical criteria, echocardiographic features, PCD details, nature of effusion, and outcomes, including success and complications were retrospectively evaluated. Pigtail catheter (8.5-Fr) insertion was successful for all patients, with a median procedure time of 7 minutes (range 4~12) without procedure-related complications. The median amount of drainage on the day of PCD was 700 mL (range, 250-1100). The median duration of catheter indwelling was 5 days (range, 1~32). In one case, the catheter was removed after 1 day due to chest pain. For all patients, pericardial effusion evacuation was achieved with relief of associated symptoms, representing 100% clinical success. Percutaneous PCD may be safely performed for patients with symptomatic uremic pericardial effusions and narrow safety margins of less than 10 mm.

ED point-of-care ultrasonography is associated with earlier drainage of pericardial effusion: A retrospective cohort study

ObjectivesTo determine the association between emergency department point-of-care cardiac ultrasonography (POCUS) utilization and time to pericardial effusion drainage during an 8-year period when the emergency ultrasound program was established at our institution. MethodsWe performed a single-center retrospective cohort study in patients undergoing pericardiocentesis or other procedure for evacuation of pericardial effusion. Data was collected using both direct queries to the electronic health record database and two-examiner chart review. The primary outcome was time to intervention for pericardial effusion drainage. Multivariable Cox regression, with and without inverse probability weighting for likelihood to receive POCUS, was used to determine the association between POCUS and time to intervention. Secondary outcomes included 28-day mortality. Results257 patient encounters were included with 137 receiving POCUS and 120 who did not. The proportion of patients receiving POCUS increased from 18.5% to 69.5% during the early to late periods of the study. POCUS was associated with an earlier median time to intervention of 21.6 h (95% CI 17.2, 24.2) compared to 34.6 h (27.0, 50.5) in the No POCUS group. After adjustment for patient demographics, anticoagulation, time of presentation and hemodynamic instability, POCUS was associated with earlier intervention (HR 2.08 [95% CI 1.56, 2.77]). POCUS use was not associated with a difference in 28-day mortality, which was evaluated as a secondary outcome. However, diagnosis of pericardial effusion by the ED physician using any means (POCUS or other imaging) was associated with decreased 28-day mortality (9.7% vs. 26.0%, −16.3% for POCUS [95% CI −29.1, −3.5]). ConclusionPOCUS was associated with an earlier time to intervention for pericardial effusions after adjustment for multiple confounding factors. Failure to diagnose pericardial effusion in the ED using any diagnostic testing including POCUS, was associated with increased 28-day mortality.

Drainage of Pericardial Effusions: Percutaneous or Surgical?

Drainage of Pericardial Effusions: Percutaneous or Surgical?

Clinical outcomes of image-guided percutaneous drainage of pericardial effusion in cancer patients: A single-center retrospective analysis.

Catheter removal, survival, and recurrence rates after percutaneous pericardial effusion drainage in cancer patients are not fully understood. We evaluated the clinical outcomes of image-guided percutaneous pericardial effusion drainage in cancer patients. From January 2014 to September 2017, 113 percutaneous drainages for symptomatic pericardial effusion were performed in 100 cancer patients (median 60 years; range, 7-84 years) using ultrasound or angio-computed tomography. An 8-Fr drainage catheter was placed using the Seldinger technique via the subxiphoid (n=73), apical (n=23), or left parasternal (n=17) routes. Success rates, complications, and postprocedural clinical outcomes of drainages were retrospectively assessed. The technical and clinical success rates were 100% and 99%, respectively, without major complications. The median duration of catheterization and evacuated pericardial effusion volume were 6 days (range, 1-72 days) and 970ml (range, 140-7635ml), respectively. Catheters were removed after the first drainage in 86 cases (86%). Symptomatic pericardial effusion recurred in nine patients after catheter removal, in whom redrainages were performed 13 times with a median duration to redrainage time of 48 days (range, 13-529 days). During the follow-up period (median 106 days [range, 1-1396 days]), 61 patients died. The median survival was 140 days (95% confidence interval [CI], 95-276 days), and the median catheter-free survival was 111 days (95% CI, 60-152 days). Image-guided percutaneous pericardial effusion drainage for cancer patients is safe and helps alleviate symptoms. Additionally, catheter removal is possible in most patients, allowing a catheter-free period for patients.

The Epidemiology and Outcome of Pericardial Effusion in Hospitalized Children: A National Database Analysis

To describe the epidemiology of pericardial effusion in hospitalized children and evaluate risk factors associated with the drainage of pericardial effusion and hospital mortality. A retrospective study of a national pediatric discharge database. We analyzed hospitalized pediatric patients from the neonatal age through 20years in the Kids' Inpatient Database 2016, extracting the cases of pericardial effusion. Of the 6 266 285 discharged patients recorded, 6417 (0.1%) were diagnosed with pericardial effusion, with the highest prevalence of 2153 patients in teens (13-20years of age). Pericardial effusion was drained in 792 (12.3%), and the adjusted risk of pericardial drainage was statistically low with rheumatologic diagnosis (OR, 0.485; 95% CI, 0.358-0.657, P<.001). The overall mortality in children with pericardial effusion was 6.8% and 10.9% of those who required pericardial effusion drainage (P<.001). The adjusted risk of mortality was statistically high with solid organ tumor (OR, 1.538; 95% CI, 1.056-2.239, P=.025) and pericardial drainage (OR, 1.430; 95% CI, 1.067-1.915, P=.017) and low in all other age groups compared with neonates, those with cardiac structural diagnosis (OR, 0.322; 95% CI, 0.212-0.489, P<.001), and those with rheumatologic diagnosis (OR, 0.531; 95% CI, 0.334-0.846, P=.008). The risk of mortality in hospitalized children with pericardial effusion was higher in younger children with solid organ tumors and those who required pericardial effusion drainage. In contrast, it was lower in older children with cardiac or rheumatologic diagnoses.

Pericardiocentesis or surgical drainage: A national comparison of clinical outcomes and resource use.

BackgroundWhile institutional series have sought to define the optimal strategy for drainage of pericardial effusions, large-scale comparisons remain lacking. Using a nationally representative sample, the present study examined clinical and financial outcomes following pericardiocentesis (PC) and surgical drainage (SD) in patients admitted for pericardial effusion and tamponade.MethodsAdults undergoing PC or SD within 2 days of admission for non-surgically related pericardial effusion or tamponade were identified in the 2016–2019 Nationwide Readmissions Database. Multivariable logistic and linear models were developed to evaluate the association between intervention type and outcomes. The primary outcome of interest was mortality while secondary endpoints included reintervention, periprocedural complications, hospital length of stay (LOS), hospitalization costs and 30-day non-elective readmission.ResultsOf an estimated 44,637 records meeting inclusion criteria, 28,862 (64.7%) underwent PC while the remainder underwent SD for initial management of pericardial effusion or tamponade. PC was associated with significantly increased odds of in-hospital mortality, reintervention and 30-day readmission relative to SD. PC was also associated with greater odds of cardiac complications but lower odds of infection, respiratory failure and blood transfusions compared to SD. Although PC was associated with shorter index hospital length of stay and costs, the two strategies yielded similar 30-day cumulative costs.ConclusionManagement of pericardial effusion with PC is associated with greater odds of mortality, reintervention and 30-day readmission but similar 30-day cumulative costs compared to SD. In the setting of adequate hospital capability and operator expertise, SD is a reasonable initial treatment strategy for pericardial effusion.

Chylothorax After Orthotopic Heart Transplant - A Rare Complication

<h3>Introduction</h3> A high output chylothorax is a therapeutic challenge and a cause of major morbidity due to persistent drainage of lymph, resulting in immune suppression, malnutrition and electrolyte abnormalities. Postop. chylothorax is rare (0.42% after general thoracic surgery). Chylothorax after thoracic organ transplant is very rare and mostly reported after lung transplant (1.38%) while after heart transplant it is extremely rare with only a handful of case reports. <h3>Case Report</h3> A 53yr old lady with Arrhythmogenic right ventricular dysfunction underwent orthotopic heart transplantation. She had multiple past ablations for VT and paroxysmal AF for which she was on Amiodarone. She also had a CRT device which was explanted at the time of transplant. Hypothyroidism& renal dysfunction were the other significant problems. Her transplant was complicated by primary graft dysfunction and bleeding from the right lower lobe of lung. Bronchoscopy did not reveal any cause. She was weaned off support and mobilised by the end of the 1st week. Immunosuppression and infection prophylaxis were as per institutional protocol. The chylothorax presented as large pericardial effusion and right pleural effusion on screening Echo and CXR done on postop day 7. This was confirmed on CT scan. Sub xiphoid drainage of pericardial effusion and intercostal drainage was done. The fluid was confirmed to be chyle with a triglyceride level of 8 mmol/l. The fluid was sterile. Low fat diet was started, in spite of which there was persistent drainage more than 500 ml /day. She was put on a more aggressive fat free, fruit only diet and s/c octreotide 100mcg 8 hrly. Drain output was closely monitored and surgery deferred considering the risks. Close monitoring of the nutritional status and dietary input was done. Slow but progressive decline in drainage permitted drain removal in three weeks. The dietary restrictions were eased over 3 to 4 months with no recurrence of leak. <h3>Summary</h3> Chylothorax is rare after heart transplantation. Prompt diagnosis and treatment are of paramount importance. Chyle leak is a challenge in these immunosuppressed patients given the concern for infection and the requirements of rigorous dietary modification. The risks of surgery have to be balanced against nutritional depletion and deconditioning. Close monitoring and multidisciplinary input is required for a successful outcome by conservative treatment.

Pericardial effusion after congenital heart surgery

ObjectivePericardial effusion after cardiac surgery remains an important cause of morbidity and mortality. We describe the risk factors of pericardial effusion after congenital heart surgery through analyzing data from a nationwide, multi-institutional registry. MethodsThe Japan Congenital Cardiovascular Surgery Database, which reflects routine clinical care in Japan, was used for this retrospective cohort study. Multivariable regression analysis was done after univariable comparison of patients with pericardial effusion and no pericardial effusion. ResultsThe study enrolled 64,777 patients registered with the Japan Congenital Cardiovascular Surgery Database between 2008 and 2016; 909 of these had postoperative pericardial effusion (1.4%) and were analyzed along with 63,868 patients without pericardial effusion. Univariable analysis found no difference between the groups in terms of gender, early delivery, or preoperative mechanical ventilatory support. In the pericardial effusion group, cardiopulmonary bypass use was lower (58.4% vs 62.1%), whereas the cardiopulmonary bypass time (176.9 vs 139.9 minutes) and aortic crossclamp time (75.1 vs 62.2 minutes) were longer, and 30-day mortality was higher (4.1% vs 2.2%). Multivariable analysis identified trisomy 21 (odds ratio, 1.54), 22q.11 deletion (odds ratio, 2.17), first-time cardiac surgery (odds ratio, 2.01), and blood transfusion (odds ratio, 1.43) as independent risk factors of postoperative pericardial effusion. In contrast, neonates, infants, ventricular septal defect, atrial septal defect, tetralogy of Fallot repair, and arterial switch operation were correlated with a low risk of pericardial effusion development. ConclusionsThe incidence of postoperative pericardial effusion in congenital cardiac surgery was 1.4%. Trisomy 21, 22q.11 deletion, first-time cardiac surgery, and blood transfusion were identified as the principal factors predicting the need for pericardial effusion drainage.