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Welch H, Harris J, Pufulete M, Dimagli A, Benedetto U, Maskell N. Does previous asbestos exposure increase the risk of a post coronary artery bypass graft (CABG) pleural effusion - a routine data study? BMC Pulm Med 2023; 23:307. [PMID: 37605147 PMCID: PMC10441712 DOI: 10.1186/s12890-023-02555-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/06/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Development of pleural effusion (PE) following CABG is common. Post-CABG PE are divided into early- (within 30 days of surgery) and delayed-onset (30 days-1 year) which are likely due to distinct pathological processes. Some experts suggest asbestos exposure may confer an independent risk for late-onset post-CABG PE, however no large studies have explored this potential association. RESEARCH QUESTION To explore possible association between asbestos exposure and post-CABG PE using routine data. METHODS All patients who underwent CABG 01/04/2013-31/03/2018 were identified from the Hospital Episode Statistics (HES) Database. This England-wide population was evaluated for evidence of asbestos exposure, pleural plaques or asbestosis and a diagnosis of PE or PE-related procedure from 30 days to 1 year post-CABG. Patients with evidence of PE three months prior to CABG were excluded, as were patients with a new mesothelioma diagnosis. RESULTS 68,150 patients were identified, of whom 1,003 (1%) were asbestos exposed and 2,377 (3%) developed late-onset PE. After adjusting for demographic data, Index of Multiple Deprivation and Charlson Co-morbidity Index, asbestos exposed patients had increased odds of PE diagnosis or related procedure such as thoracentesis or drainage (OR 1.35, 95% CI 1.03-1.76, p = 0.04). In those with evidence of PE requiring procedure alone, the adjusted OR was 1.66 (95% CI 1.14-2.40, p = 0.01). Additional subgroup analysis of the 518 patients coded for pleural plaques and asbestosis alone revealed an adjusted OR of post-CABG PE requiring a procedure of 2.16 (95% CI 1.38-3.37, p = 0.002). INTERPRETATION This large-scale study demonstrates prior asbestos exposure is associated with modestly increased risk of post-CABG PE development. The risk association appears higher in patients with assigned clinical codes indicative of radiological evidence of asbestos exposure (pleural plaques or asbestosis). This association may fit with a possible inflammatory co-pathogenesis, with asbestos exposure 'priming' the pleura resulting in greater propensity for PE evolution following the physiological insult of CABG surgery. Further work, including prospective studies and clinicopathological correlation are suggested to explore this further.
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Affiliation(s)
- Hugh Welch
- University of Bristol, Bristol, UK.
- Academic Respiratory Unit, North Bristol NHS Trust 2nd Floor Office, Learning and Research Building Southmead Hospital Southmead Way, Bristol, BS10 5NB, UK.
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Schiefenhövel F, Poncette AS, Boyle EM, von Heymann C, Menk M, Vorderwülbecke G, Grubitzsch H, Treskatsch S, Balzer F. Pleural effusions are associated with adverse outcomes after cardiac surgery: a propensity-matched analysis. J Cardiothorac Surg 2022; 17:298. [PMID: 36476289 PMCID: PMC9727876 DOI: 10.1186/s13019-022-02050-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pleural effusions commonly occur in patients recovering from cardiac surgery; however, the impact on outcomes is not well characterized. The purpose of this study is to characterize the clinical outcomes of cardiac surgery patients with pleural effusion. METHODS All patients undergoing cardiac surgery between 2006 and 2019 at a tertiary care university hospital were included in this observational, cross-sectional analysis using propensity matching. RESULTS Of 11,037 patients that underwent cardiac surgery during the study period, 6461 (58.5%) had no pleural effusion (Group 0), 3322 (30.1%) had pleural effusion only (Group 1), and 1254 (11.4%) required at least one secondary drainage procedure after the index operation (Group 2). After propensity matching, the mortality of patients who underwent secondary drainage procedures was 6.1% higher than in Group 1 (p < 0.001). Intensive care unit (ICU) stay was longer for those with pleural effusions (18 [IQR 9-32] days in Group 2, 10 [IQR 6-17] days for Group 1, and 7 [IQR 4-11] days for Group 0, p < 0.001). Patients with pleural effusions had a higher incidence of hemodialysis (246 [20.0%] in Group 2, 137 [11.1%] in Group 1, 98 [7.98%] in Group 0), and a longer ventilation time in the ICU (57 [IQR 21.0-224.0] hours in Group 2, 25.0 [IQR 14.0-58.0] hours in Group 1, 16.0 [IQR 10.0-29.0] hours in Group 0). CONCLUSION Pleural effusions, especially those that require a secondary drainage procedure during recovery, are associated with significantly worse outcomes including increased mortality, longer length of stay, and higher complication rates. These insights may be of great interest to scientists, clinicians, and industry leaders alike to foster research into innovative methods for preventing and treating pleural effusions with the aim of improving outcomes for patients recovering from cardiac surgery.
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Affiliation(s)
- Fridtjof Schiefenhövel
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Charitéplatz 1, 10117 Berlin, Germany ,grid.15474.330000 0004 0477 2438Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Department of Anaesthesiology and Intensive Care, Munich, Germany ,grid.15474.330000 0004 0477 2438Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Institute of Artificial Intelligence and Informatics in Medicine, Munich, Germany
| | - Akira-Sebastian Poncette
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charitéplatz 1, 10117 Berlin, Germany ,grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Charitéplatz 1, 10117 Berlin, Germany
| | - Edward M. Boyle
- grid.416611.5Department of Cardiothoracic Surgery, St. Charles Medical Center, Bend, OR USA
| | - Christian von Heymann
- grid.415085.dDepartment of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Mario Menk
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charitéplatz 1, 10117 Berlin, Germany ,grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Charitéplatz 1, 10117 Berlin, Germany
| | - Gerald Vorderwülbecke
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charitéplatz 1, 10117 Berlin, Germany
| | - Herko Grubitzsch
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Department of Cardiovascular Surgery, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sascha Treskatsch
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Felix Balzer
- grid.6363.00000 0001 2218 4662Charité – Universitätsmedizin Berlin, corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Charitéplatz 1, 10117 Berlin, Germany
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Small Drainage Volumes of Pleural Effusions Are Associated with Complications in Critically Ill Patients: A Retrospective Analysis. J Clin Med 2021; 10:jcm10112453. [PMID: 34205925 PMCID: PMC8197788 DOI: 10.3390/jcm10112453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022] Open
Abstract
Pleural effusions are a common finding in critically ill patients and small bore chest drains (SBCD) are proven to be efficient for pleural drainage. The data on the potential benefits and risks of drainage remains controversial. We aimed to determine the cut-off volume for complications, to investigate the impact of pleural drainage and drained volume on clinically relevant outcomes. Medical records of all critically ill patients undergoing insertion of SBCD were retrospectively examined. We screened 13,003 chest radiographs and included 396 SBCD cases in the final analysis. SBCD drained on average 900 mL, with less amount in patients with complications (p = 0.003). A drainage volume of 975 mL in 24 h represented the optimal threshold for complications. Pneumothorax was the most frequent complication (4.5%), followed by bleeding (0.8%). Female and lighter-weighted patients experienced a higher risk for any complication. We observed an improvement in the arterial partial pressure of oxygen and respiratory quotient (p < 0.001). We conclude that the small drainage volumes are associated with complications in critically ill patients—the more you drain, the safer the procedure gets. The use of SBCD is a safe and efficient procedure, further investigations regarding the higher rate of complications in female and lighter-weighted patients are desirable.
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Lehto J, Kiviniemi T. Postpericardiotomy syndrome after cardiac surgery. Ann Med 2020; 52:243-264. [PMID: 32314595 PMCID: PMC7877990 DOI: 10.1080/07853890.2020.1758339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/30/2020] [Accepted: 04/16/2020] [Indexed: 12/13/2022] Open
Abstract
Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.
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Affiliation(s)
- Joonas Lehto
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Motono N, Iwai S, Funasaki A, Sekimura A, Usuda K, Uramoto H. What is the allowed volume threshold for chest tube removal after lobectomy: A randomized controlled trial. Ann Med Surg (Lond) 2019; 43:29-32. [PMID: 31194145 PMCID: PMC6551566 DOI: 10.1016/j.amsu.2019.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 05/18/2019] [Accepted: 05/24/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The management of chest tubes and the volume threshold for chest tube removal after pulmonary resection remain controversial. Several studies have reported the volume threshold for chest tube removal following pulmonary resection to range from 200 to 450 mL/24 h. METHODS A prospective randomized single-blind clinical study was performed with data collected from patients who had undergone lobectomy and lymph node dissection at our hospital between June 2014 and April 2018. The patients were randomly assigned to the High group (removal of chest tube when drainage was <450 mL/24 h) or Low group (removal of chest tube when drainage was <200 mL/24 h) at postoperative day (POD) 2. The primary end point was drainage time. The secondary end point were complications and rate of thoracentesis. RESULTS Seventy patients met the inclusion criteria and were randomized, with 35 patients assigned to the High group and 35 patients to the Low group. The average duration of chest tube placement was 2.05 days in the High group and 2.31 days in the Low group. The duration of chest tube placement in the High group was significantly shorter than that in the Low group (p = 0.02). There were no major postoperative complications in either group. Thoracentesis was not necessary in either group. CONCLUSION Pleural effusion of 450 mL/day is tolerable as the volume threshold for the removal of a chest tube after pulmonary resection.
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Affiliation(s)
- Nozomu Motono
- Department of Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa, 920-0293, Japan
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Huggins JT, Maldonado F, Chopra A, Rahman N, Light R. Unexpandable lung from pleural disease. Respirology 2017; 23:160-167. [DOI: 10.1111/resp.13199] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/10/2017] [Accepted: 07/12/2017] [Indexed: 11/29/2022]
Affiliation(s)
- John T. Huggins
- Department of Medicine; Medical University of South Carolina; Charleston SC USA
| | - Fabien Maldonado
- Department of Medicine; Vanderbilt University Medical Center; Nashville TN USA
| | - Amit Chopra
- Department of Medicine; Albany Medical College; Albany NY USA
| | - Najib Rahman
- Oxford Centre for Respiratory Medicine, Oxford Respiratory Trials Unit; University of Oxford; Cambridge UK
| | - Richard Light
- Department of Medicine; Vanderbilt University Medical Center; Nashville TN USA
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Fiorelli A, Caronia F, Prencipe A, Santini M, Stiles B. The role of video-assisted thoracoscopic surgery for management of symptomatic pleural effusion after coronary artery bypass surgery: a best evidence topic report. J Thorac Dis 2017; 9:2339-2343. [PMID: 28932537 DOI: 10.21037/jtd.2017.06.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A best evidence topic in thoracic surgery was written addressing whether video-assisted thoracoscopic surgery (VATS) talc pleurodesis could be justified in patients with pleural effusion (PE) after coronary artery bypass graft (CABG) surgery and no-responded to repeated thoracentesis. Ten papers were identified to answer the question. Of these, two were case-series study including ≥4 patients, 7 retrospective analytical studies, and one observational study but no randomized controlled trial (RCTs) was included in the analysis. The score of the level of evidence was low; only one study presented a level of evidence of 2, 7 studies a level of 3b; and two studies a level of evidence of 4. The incidence of symptomatic post-CABG PE ranged from 2% to 9.7%. Management strategies included medical management, thoracentesis, and/or surgical drainage. Most of the authors treated early and late PE with thoracentesis or chest drainage, while VATS with pleurodesis was reserved only for selected patients with persistent effusion after repeating thoracentesis and/or chest drainage. All studies but one do not include follow-up, thus rendering it difficult to define the real role of thoracentesis or chest drainage as definitive treatments for effusion, given the incomplete data regarding how many patients' effusions recur. Conversely, with follow up reported, no case of recurrence was found after VATS procedure. In patients who underwent delayed VATS, it was common to identify the formation of tenacious peel that trapped the lung. In three cases conversion to thoracotomy was required to decorticate the inflammatory peel that covered the pleura and did not allow the lung re-expansion. However, only five papers showed that VATS for management of post-CABG PEs is safe and efficacious and its use could help to prevent trapped lung through the resection of adhesions and loculations sometimes associated with multiple previous thoracentesis or chest drainage. As the low grade of evidence from the present analysis, future randomized controlled studies are wanted to define the real effectiveness of VATS in this field.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Caronia
- Thoracic Surgery Unit, Istituto Oncologico del Mediterraneo, Catania, Italy
| | - Aldo Prencipe
- Cardio-thoracic Surgery Unit, Spedali Civili di Brescia, Brescia, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università della Campania Luigi Vanvitelli, Naples, Italy
| | - Brendon Stiles
- Department of Cardiothoracic Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Use of Indwelling Pleural Catheter for Recurrent Pleural Effusion Due to Postpericardiotomy Syndrome: A Case Report. J Bronchology Interv Pulmonol 2017; 23:160-2. [PMID: 26905442 DOI: 10.1097/lbr.0000000000000196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pleural effusion secondary to postpericardiotomy syndrome (PPS) is a relatively common complication after cardiac surgery. These effusions and syndrome complex usually respond well to anti-inflammatory agents. The use of indwelling pleural catheter (IPC) for nonmalignant recurrent pleural effusions is growing. We report the use of IPC for a case of recurrent pleural effusion due to PPS in a gentleman that could not tolerate anti-inflammatory medications. To our knowledge, there has been no other report of the use of IPC due to recurrent pleural effusion from PPS.
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Shah SR, Alweis R, Shah SA, Arshad MH, Manji AAK, Arfeen AA, Javed M, Shujauddin SM, Irfan R, Shabbir S, Shaikh S. Effects of colchicine on pericardial diseases: a review of the literature and current evidence. J Community Hosp Intern Med Perspect 2016; 6:31957. [PMID: 27406462 PMCID: PMC4942520 DOI: 10.3402/jchimp.v6.31957] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 05/02/2016] [Indexed: 11/14/2022] Open
Abstract
Colchicine, extracted from the colchicum autumnale plant, used by the ancient Greeks more than 20 centuries ago, is one of the most ancient drugs still prescribed even today. The major mechanism of action is binding to microtubules thereby interfering with mitosis and subsequent modulation of polymorphonuclear leukocyte function. Colchicine has long been of interest in the treatment of cardiovascular disease; however, its efficacy and safety profile for specific conditions have been variably established in the literature. In the subset of pericardial diseases, colchicine has been shown to be effective in recurrent pericarditis and post-pericardiotomy syndrome (PPS). The future course of treatment and management will therefore highly depend on the results of the ongoing large randomized placebo-controlled clinical trial to evaluate the efficacy and safety of colchicine for the primary prevention of several postoperative complications and in the perioperative period. Also, given the positive preliminary outcomes of colchicine usage in pericardial effusions, the future therapeutical use of colchicine looks promising. Further study is needed to clarify its role in these disease states, as well as explore other its role in other cardiovascular conditions.
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Affiliation(s)
- Syed Raza Shah
- Department of Medicine, Dow University of Health Sciences (DUHS), Karachi, Pakistan;
| | - Richard Alweis
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Syed Arbab Shah
- Department of Medicine, Ziauddin Medical University Hospital, Karachi, Pakistan
| | | | - Adil Al-Karim Manji
- Department of Biological Sciences, Karachi Grammar School, Karachi, Pakistan
| | - Arham Amir Arfeen
- Department of Biological Sciences, Karachi Grammar School, Karachi, Pakistan
| | - Maheen Javed
- Department of Biological Sciences, Karachi Grammar School, Karachi, Pakistan
| | | | - Rida Irfan
- Department of Biological Sciences, The Lyceum, Karachi, Pakistan
| | - Sakina Shabbir
- Department of Biological Sciences, The Lyceum, Karachi, Pakistan
| | - Shehryar Shaikh
- Department of Biological Sciences, Beaconhouse College Campus Defense, Karachi, Pakistan
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Lehto J, Kiviniemi TO, Gunn J, Mustonen P, Airaksinen J, Biancari F, Rautava P, Sipilä J, Kytö V. Occurrence of postpericardiotomy syndrome admissions: A population-based registry study. Ann Med 2016; 48:28-33. [PMID: 26671291 DOI: 10.3109/07853890.2015.1122223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Postpericardiotomy syndrome (PPS) is a common complication after cardiac surgery. Previous epidemiological descriptions of the syndrome, however, are scarce. MATERIAL AND METHODS This retrospective analysis included all patients hospital admission due to PPS in patients aged 20-79 years. Data were collected from the Finnish national registry that included data on all cardiovascular hospital admissions (n = 51 7669) during 9.5 years in 29 Finnish hospitals nationwide. RESULTS There were 760 hospital admissions due to PPS during the study period. The patients were more likely male than female (67.8% versus 32.2%) with an age-adjusted RR of 2.37 (95% CI 1.85-3.02) for men (p < 0.0001). When evaluating the rate of PPS in relation to cardiac surgeries, female gender was associated with a higher incidence of PPS (RR 1.78; 95% CI 1.45-2.19; p < 0.001). The rate of PPS in relation to the number of cardiac surgery was highest in youngest patients followed by a gradual decrease (RR 0.59; 95% CI 0.55-0.65; p < 0.0001 per 10-year increment in age) with aging. CONCLUSIONS Hospital admission due to PPS was most common in men in their sixties. When stratified by the total number of performed cardiac operations the incidence of PPS was higher among women and younger patients.
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Affiliation(s)
- Joonas Lehto
- a Heart Center, Turku University Hospital , Turku , Finland
| | - Tuomas O Kiviniemi
- a Heart Center, Turku University Hospital , Turku , Finland ;,b Department of Internal Medicine , University of Turku , Turku , Finland
| | - Jarmo Gunn
- a Heart Center, Turku University Hospital , Turku , Finland ;,c Department of Surgery , University of Turku , Turku , Finland
| | - Pirjo Mustonen
- d Department of Cardiology , Keski-Suomi Central Hospital , Jyväskylä , Finland
| | | | - Fausto Biancari
- e Department of Surgery , Oulu University Hospital , Oulu , Finland
| | - Päivi Rautava
- f Clinical Research Centre, Turku University Hospital , Turku , Finland ;,g Department of Public Health , University of Turku , Turku , Finland
| | - Jussi Sipilä
- h Division of Clinical Neurosciences, Department of Neurology , Turku University Hospital , Turku , Finland ;,i Department of Neurology , University of Turku , Turku , Finland
| | - Ville Kytö
- a Heart Center, Turku University Hospital , Turku , Finland ;,b Department of Internal Medicine , University of Turku , Turku , Finland ;,j Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku , Turku , Finland
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Yukumi S, Ichiki H, Funada J, Suzuki H, Morimoto M, Fujita T, Izumi N, Abe M. Postcardiac injury syndrome following vascular interventional radiofrequency ablation for paroxysmal atrial fibrillation. Respir Med Case Rep 2015; 15:89-91. [PMID: 26236613 PMCID: PMC4501502 DOI: 10.1016/j.rmcr.2015.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 11/25/2022] Open
Abstract
Postcardiac injury syndrome (PCIS) occurs following a pericardial or myocardial injury. On the other hand, PCIS following cardiac catheter intervention is rare and can be difficult to diagnose because of its delayed onset. A 24-year-old man underwent radiofrequency ablation (RFA) for paroxysmal atrial fibrillation and suffered from general fatigue and left-sided pleural effusion three months after the procedure. His symptoms and effusion were effectively treated within a month by administrating nonsteroidal anti-inflammatory drugs. However, seven months later, he developed left-sided chest pain and low-grade fever. Computed tomography showed a thickening of the parietal pleura and reccurence of the pleural effusion. Pleural biopsy by video-assisted thoracoscopy demonstrated chronic pleuritis with a non-necrotizing granulomatous reaction. Given the previous RFA, and in the absence of infection or malignant disease, he was diagnosed with PCIS and treated with colchicine.
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Affiliation(s)
- Shungo Yukumi
- Department of Surgery, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Hiraku Ichiki
- Respiratory Medicine, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Junichi Funada
- Cardiology, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Hideaki Suzuki
- Department of Surgery, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Masamitsu Morimoto
- Department of Surgery, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Teppei Fujita
- Cardiology, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Naoki Izumi
- Cardiology, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
| | - Masahiro Abe
- Respiratory Medicine, National Hospital Organization Ehime Medical Center, 366 Yokogawara, Toon, Ehime 791-0281, Japan
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Olivencia-Yurvati AH, Cherry BH, Gurji HA, White DW, Newton JT, Scott GF, Hoxha B, Gourlay T, Mallet RT. Novel Split Chest Tube Improves Post-Surgical Thoracic Drainage. JOURNAL OF CLINICAL & EXPERIMENTAL CARDIOLOGY 2014; 5. [PMID: 25478289 PMCID: PMC4251778 DOI: 10.4172/2155-9880.1000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective Conventional, separate mediastinal and pleural tubes are often inefficient at draining thoracic effusions. Description We developed a Y-shaped chest tube with split ends that divide within the thoracic cavity, permitting separate intrathoracic placement and requiring a single exit port. In this study, thoracic drainage by the split drain vs. that of separate drains was tested. Methods After sternotomy, pericardiotomy, and left pleurotomy, pigs were fitted with separate chest drains (n=10) or a split tube prototype (n=9) with internal openings positioned in the mediastinum and in the costo-diaphragmatic recess. Separate series of experiments were conducted to test drainage of D5W or 0.58 M sucrose, an aqueous solution with viscosity approximating that of plasma. One litre of fluid was infused into the thorax, and suction was applied at −20 cm H2O for 30 min. Results When D5W was infused, the split drain left a residual volume of 53 ± 99 ml (mean value ± SD) vs. 148 ± 120 for the separate drain (P=0.007), representing a drainage efficiency (i.e. drained vol/[drained + residual vol]) of 95 ± 10% vs. 86 ± 12% for the separate drains (P = 0.011). In the second series, the split drain evacuated more 0.58 M sucrose in the first minute (967 ± 129 ml) than the separate drains (680 ± 192 ml, P<0.001). By 30 min, the split drain evacuated a similar volume of sucrose vs. the conventional drain (1089 ± 72 vs. 1056 ± 78 ml; P = 0.5). Residual volume tended to be lower (25 ± 10 vs. 62 ± 72 ml; P = 0.128) and drainage efficiency tended to be higher (98 ± 1 vs. 95 ± 6%; P = 0.111) with the split drain vs. conventional separate drains. Conclusion The split chest tube drained the thoracic cavity at least as effectively as conventional separate tubes. This new device could potentially alleviate postoperative complications.
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Affiliation(s)
- Albert H Olivencia-Yurvati
- Departments of Surgery, University of North Texas Health Science Center, Fort Worth, TX, USA ; Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Brandon H Cherry
- Departments of Integrative Physiology, University of North Texas Health Science Center, Fort Worth, TX, USA ; Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Hunaid A Gurji
- Departments of Integrative Physiology, University of North Texas Health Science Center, Fort Worth, TX, USA ; Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Daniel W White
- Departments of Integrative Physiology, University of North Texas Health Science Center, Fort Worth, TX, USA ; Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - J Tyler Newton
- Departments of Surgery, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Gary F Scott
- Departments of Integrative Physiology, University of North Texas Health Science Center, Fort Worth, TX, USA ; Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Besim Hoxha
- Departments of Surgery, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Terence Gourlay
- Bioengineering Unit, Wolfson Centre, University of Strathclyde, Glasgow, UK
| | - Robert T Mallet
- Departments of Surgery, University of North Texas Health Science Center, Fort Worth, TX, USA ; Departments of Integrative Physiology, University of North Texas Health Science Center, Fort Worth, TX, USA ; Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
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13
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Abstract
Pleural effusion management is a common clinical situation associated with numerous pulmonary, pleural or extra-pulmonary diseases. A systematic approach is needed to enable a rapid diagnosis and an appropriate treatment. Pleural fluid analysis is the first step to perform which allows a presumptive diagnosis in most cases. Otherwise, further analysis of the pleural fluid or thoracic imaging or pleural biopsy may be necessary. This review aims at highlighting the important elements of the work-up required by a pleural effusion.
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Kim JH, Hwang YH, Youn YN, Yoo KJ. Effect of postoperative constrictive physiology on early outcomes after off-pump coronary artery bypass grafting. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:22-6. [PMID: 23422841 PMCID: PMC3573161 DOI: 10.5090/kjtcs.2013.46.1.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/22/2012] [Accepted: 10/09/2012] [Indexed: 11/25/2022]
Abstract
Background Constrictive pericarditis after coronary artery bypass surgery has been known to affect cardiac output by limiting diastolic ventricular filling. We aimed to assess the influence of postoperative constrictive physiology on the early outcomes of patients undergoing off-pump coronary artery bypass grafting (OPCAB). Materials and Methods Between January 2008 and July 2011, 903 patients underwent an isolated OPCAB and postoperative transthoracic-echocardiography. The patient cohort was classified into two groups: group A, constrictive physiology and group B, control group without constrictive physiology. Early outcomes were analyzed between the two groups. Results Of the total 903 patients, group A consisted of 153 patients (16.9%). The amount of blood loss in group A during the postoperative 24 hours was greater than that of group B, but this was not statistically significant (p=0.20). No significant differences were found in the mortality rates (group A, 0.6%; group B, 1.4%; p=0.40) and 30-day major adverse cardiac and cerebrovascular events (MACCEs; group A, 3.3%; group B, 6.1%; p=0.42). Conclusion Postoperative constrictive physiology does not affect 30-day MACCEs or other major complications after OPCAB. The results of this study suggest that patients with early postoperative constrictive physiology do not need medical or surgical treatment, and that conservative care is sufficient.
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Affiliation(s)
- Jung-Hwan Kim
- Division of Cardiovascular Surgery, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Korea
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15
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16
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Maslove DM, Chen BTM, Wang H, Kuschner WG. The diagnosis and management of pleural effusions in the ICU. J Intensive Care Med 2013; 28:24-36. [PMID: 22080544 DOI: 10.1177/0885066611403264] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Pleural effusions are common in critically ill patients. Most effusions in intensive care unit (ICU) patients are of limited clinical significance; however, some are important and require aggressive management. Transudative effusions in the ICU are commonly caused by volume overload, decreased plasma oncotic pressure, and regions of altered pleural pressure attributable to atelectasis and mechanical ventilation. Exudates are sequelae of pulmonary or pleural infection, pulmonary embolism, postsurgical complications, and malignancy. Increases in pleural fluid volume are accommodated principally by chest wall expansion and, to a lesser degree, by lung collapse. Studies in mechanically ventilated patients suggest that pleural fluid drainage can result in improved oxygenation for up to 48 hours, but data on clinical outcomes are limited. Mechanically ventilated patients with pleural effusions should be semirecumbant and treated with higher levels of positive-end expiratory pressure. Rarely, large effusions can cause cardiac tamponade or tension physiology, requiring urgent drainage. Bedside ultrasound is both sensitive and specific for diagnosing pleural effusions in mechanically ventilated patients. Sonographic findings of septation and homogenous echogenicity may suggest an exudative effusion, but definitive diagnosis requires pleural fluid sampling. Thoracentesis should be carried out under ultrasound guidance. Antibiotic regimens for parapneumonic effusions should be based on current pneumonia guidelines, and anaerobic coverage should be included in the case of empyema. Decompression of the pleural space may be necessary to improve respiratory mechanics, as well as to treat complicated effusions. While small-bore catheters inserted under ultrasound guidance may be used for nonseptated effusions, surgical consultation should be sought in cases where this approach fails, or where the effusion appears complex and septated at the outset. Further research is needed to determine the effects of pleural fluid drainage on clinical outcomes in mechanically ventilated patients, to evaluate weaning strategies that include pleural fluid drainage, and to better identify patients in whom pleural effusions are more likely to be infected.
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Affiliation(s)
- David M Maslove
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
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17
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Abstract
Virtually, every pulmonary disease and most non-pulmonary diseases may be associated with a pleural effusion. The presence of a pleural effusion allows the clinician to 'diagnose' or narrow the differential diagnosis and aetiology of the fluid collection. However, pleural fluid analysis (PFA) in isolation rarely provides a definitive diagnosis. This review discusses the rationale for evaluating patients with a pleural effusion. If the clinician obtains a detailed history, performs a comprehensive physical examination, reviews pertinent blood tests, and evaluates the chest imaging findings prior to thoracentesis, there should be a high likelihood of establishing a firm clinical diagnosis based on the appropriate PFA. This manuscript reviews the clinical presentation, chest imaging findings, duration and natural course of specific pleural effusions to help narrow the range of pre-thoracentesis diagnoses. A diagnosis of transudative effusion confirms an imbalance in hydrostatic and oncotic pressures, normal pleura and a limited differential diagnosis, which is typically apparent from the clinical presentation. Exudates are the result of infections, malignancies, inflammation, impaired lymphatic drainage or the effects of drugs, and pose a greater diagnostic challenge. The differential diagnosis for a pleural exudate can be narrowed if LDH levels exceed 1000 IU/L, the proportion of lymphocytes is ≥80%, pleural fluid pH is <7.30 or there is pleural eosinophilia of >10%.
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Affiliation(s)
- Steven A Sahn
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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18
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Ferreiro L, González-Barcala FJ, Valdés L. Derrame pleural tras la cirugía de revascularización mediante derivación aortocoronaria. Med Clin (Barc) 2012; 138:300-5. [DOI: 10.1016/j.medcli.2011.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 06/30/2011] [Accepted: 07/05/2011] [Indexed: 10/17/2022]
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19
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Imazio M, Brucato A, Rovere ME, Gandino A, Cemin R, Ferrua S, Maestroni S, Barosi A, Simon C, Ferrazzi P, Belli R, Trinchero R, Spodick D, Adler Y. Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. Am J Cardiol 2011; 108:1183-7. [PMID: 21798503 DOI: 10.1016/j.amjcard.2011.06.025] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 06/02/2011] [Accepted: 06/02/2011] [Indexed: 11/24/2022]
Abstract
Contemporary series of postpericardiotomy syndrome (PPS) are lacking. The aim of this study was to evaluate the incidence, time course, features at presentation, risk factors, and prognosis of PPS. The study population consisted of 360 consecutive candidates to cardiac surgery enrolled in a prospective cohort study. PPS was diagnosed in 54 patients (15.0%; mean age 66 ± 12 years, 48.1% women): 79.6% in the first month, 13.0% in the second month, and 7.4% in the third month. Specific symptoms, signs, or features were pleuritic chest pain (55.6%), fever (53.7%), elevated markers of inflammation (74.1%), pericardial effusion (88.9%), and pleural effusion (92.6%). Cardiac tamponade was rare at presentation (1.9%). Female gender (hazard ratio 2.32, 95% confidence interval 1.22 to 4.39, p = 0.010), and pleura incision (hazard ratio 4.31, 95% confidence interval 2.22 to 8.33, p <0.001) were identified as risk factors in multivariate analysis. Patients with PPS had longer cardiac surgery stays (11.5 ± 4.6 vs 9.9 ± 4.7 days, p = 0.021) and rehabilitation stays (16.4 ± 6.7 vs 12.4 ± 6.2 days, p <0.001) and more readmissions (13.0% vs 0%, p <0.001). Adverse events after a mean follow-up period of 19.8 months were recurrences (3.7%), cardiac tamponade (<2%), but no cases of constriction. In conclusion, despite advances in cardiac surgery techniques, PPS is a common postoperative complication, generally occurring in the first 3 months after surgery. Severe complications are rare, but the syndrome is responsible for hospital stay prolongation and readmissions. Female gender and pleura incision are risk factors for PPS.
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20
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Imazio M, Brucato A, Rovere ME, Gandino A, Cemin R, Ferrua S, Maestroni S, Zingarelli E, Barosi A, Simon C, Sansone F, Patrini D, Vitali E, Belli R, Ferrazzi P, Trinchero R, Spodick DH, Adler Y. Colchicine prevents early postoperative pericardial and pleural effusions. Am Heart J 2011; 162:527-32.e1. [PMID: 21884871 DOI: 10.1016/j.ahj.2011.05.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 05/21/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND No preventive pharmacologic strategies have been proven efficacious for the prevention of postoperative effusions after cardiac surgery. Colchicine is safe and efficacious for the prevention of pericarditis. On this basis, we realized a substudy of the COPPS trial to assess the efficacy and safety of colchicine for the prevention of postoperative pericardial and pleural effusions. METHODS The COPPS is a multicenter, double-blind, randomized trial, where 360 consecutive patients (mean age 65.7 ± 12.3 years, 66% men), 180 in each treatment arm, were randomized on the third postoperative day to receive placebo or colchicine for 1 month (1.0 mg twice daily for the first day, followed by a maintenance dose of 0.5 mg twice daily in patients ≥70 kg, and halved doses for patients <70 kg). The incidence of postoperative effusions was evaluated in each study group. RESULTS Despite similar baseline features, colchicine significantly reduced the incidence of postoperative pericardial (12.8% vs 22.8%, P = .019, relative risk reduction 43.9%, no. of patients needed to treat 10) and pleural effusions (12.2% vs 25.6%, P = .002, relative risk reduction 52.3%, no. of patients needed to treat 8). The rate of side effects (only gastrointestinal intolerance) and drug withdrawal was similar in the study groups with a trend toward an increased rate of both events for colchicine. In multivariable analysis, female gender (hazard ratio 1.76, 95% CI 1.03-3.03, P = .040) and pleura incision (hazard ratio 2.58, 95% CI 1.53-4.53, P < .001) were risk factors for postoperative effusions. CONCLUSIONS Colchicine is safe and efficacious for the primary prevention of postoperative effusions after cardiac surgery.
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21
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Kim JB, Park NH, Choi SY, Kim H. Transient constrictive pericarditis after coronary bypass surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:64-7. [PMID: 22263127 PMCID: PMC3249276 DOI: 10.5090/kjtcs.2011.44.1.64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 05/31/2010] [Accepted: 06/25/2010] [Indexed: 12/03/2022]
Abstract
Constrictive pericarditis is a rare complication after coronary artery bypass grafting In most cases pericardiectomy is required as a definitive treatment. However, there are several types of constrictive pericarditis such as transient cardiac constriction. Some types of constrictive pericarditis can only be managed with medical therapy. We report a 72-year-old female patient who developed subacute transient constrictive pericarditis with persistent left pleural effusion as a result of postcardiac injury syndrome. The patient went through coronary bypass surgery that was successfully treated with postoperative steroid therapy.
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Affiliation(s)
- Jae-Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, College of Medicine, Keimyung University, Korea
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22
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Labidi M, Baillot R, Dionne B, Lacasse Y, Maltais F, Boulet LP. Pleural effusions following cardiac surgery: prevalence, risk factors, and clinical features. Chest 2009; 136:1604-1611. [PMID: 19581352 DOI: 10.1378/chest.09-0689] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pleural effusion is a common complication of cardiac surgery, but its characteristics and predisposing factors should be documented further. Our objective was to determine the prevalence, characteristics, and determinants of clinically significant pleural effusions, defined as those requiring therapeutic pleural drainage according to clinical assessment. METHODS The prevalence and characteristics of patients who had a pleural effusion within 30 days of undergoing coronary artery bypass graft, valve replacement, or both were analyzed retrospectively at our institution over a 2-year period. RESULTS Among the 2,892 patients included in the study (mean age, 66 years; men, 2,139), 192 patients (6.6%) had experienced a clinically significant pleural effusion in the 30 days postsurgery. These effusions occurred after a mean (+/- SD) duration of 6.6 +/- 5.9 days following interventions. Pleural fluid analysis was obtained in 114 patients (59.4%); all met the criteria for an exudate. Pleural fluid was hemorrhagic in 50% of cases. Age, body weight, baseline pulmonary function, and smoking status were similar between patients with and without effusion; however, the proportion of women; the number of patients with previous conditions of heart failure, atrial fibrillation, or peripheral vascular disease; and the number of patients receiving therapy with an anticoagulant or antiarrhythmic agent was higher in the pleural effusion group. Patients with pleural effusion had an increased prevalence of postoperative complications. CONCLUSIONS Pleural effusion is a common complication of heart surgery, is associated with other postoperative complications, and is more frequent in women and in patients with associated cardiac or vascular comorbidities and medications used to treat those conditions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00665015.
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Affiliation(s)
- Moujahed Labidi
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Richard Baillot
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Brigitte Dionne
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Yves Lacasse
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - François Maltais
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Louis-Philippe Boulet
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada.
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23
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Guha A, Munjampalli S, Bandi V, Loebe M, Noon G, Lunn W. Pleural Effusion After Ventricular Assist Device Placement. Chest 2008; 134:382-386. [DOI: 10.1378/chest.07-2777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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24
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Abstract
Unexpandable lung due to pleural disease may manifest itself as a hydropneumothorax after pleural drainage procedure or as an inability to completely drain a pleural effusion due to chest pain. The condition is a mechanical complication of a variety of pleural disorders. Of these, malignant lung entrapment and inflammatory lung entrapment are considered complications of active pleural disease, and management is primarily dependent on the nature of the active process. Trapped lung is a sequela of remote inflammation of the pleural space. Trapped lung is usually asymptomatic but may be the cause of dyspnea in some patients. The only available treatment of symptomatic trapped lung is surgical decortication. Surgical decortication should only be considered after other causes of dyspnea have been excluded.
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25
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Boffa DJ, Mason DP, Su JW, Murthy SC, Feng J, McNeill AM, Budev MM, Mehta AC, Pettersson GB. Decortication after lung transplantation. Ann Thorac Surg 2008; 85:1039-43. [PMID: 18291193 DOI: 10.1016/j.athoracsur.2007.10.096] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Revised: 10/29/2007] [Accepted: 10/30/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Compromise of a pulmonary allograft by restrictive or infectious pleural-space pathology may be amenable to surgical intervention; however, the role of decortication in this patient population has not yet been substantiated. To address this issue, indications and outcomes of decortication after lung transplantation were examined at our institution. METHODS From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%). RESULTS Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days. CONCLUSIONS Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.
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Affiliation(s)
- Daniel J Boffa
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA
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26
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Abstract
STUDY OBJECTIVES To review the pleural fluid characteristics, pleural manometry, and radiographic data of patients who received a diagnosis of trapped lung in our pleural diseases service. DESIGN Retrospective case series. METHODS The procedure records of 247 consecutive patients who underwent pleural manometry at the Medical University of South Carolina between October 2002 and November 2005 were reviewed. Eleven patients in whom a diagnostic pneumothorax was introduced were identified. Manometry data, radiographic findings, pleural fluid analysis, final clinical diagnosis, and information regarding the initial pleural insult were retrieved from the medical record. RESULTS All 11 patients had a clinical diagnosis of trapped lung. The causes of trapped lung were attributed to coronary artery bypass graft surgery, uremia, thoracic radiation, pericardiotomy, spontaneous bacterial pleuritis and repeated thoracentesis, and complicated parapneumonic effusion. Mean pleural fluid pH was 7.30, pleural fluid lactate dehydrogenase (LDH) was 124 IU/L, and pleural fluid total protein was 2.9 g/dL. Pleural fluid was paucicellular with mononuclear cell predominance. Pleural space elastance was increased in all cases and ranged from 19 to 149 cm H(2)O/L of pleural fluid removed. All demonstrated abnormal visceral pleural thickness on air-contrast chest CT. CONCLUSIONS Trapped lung is a clinical entity characterized by the presence of a restrictive visceral pleural peel that was first described in 1967. The pleural fluid is paucicellular, LDH is low, and protein may be in the exudative range. The elevated total pleural fluid protein may be related to factors other than active pleural inflammation or malignancy and does not exclude the diagnosis.
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Affiliation(s)
- John T Huggins
- Division of Pulmonary, Critical Care,, Allergy and Sleep Medicine, Medical University of South Carolina, PO Box 250625, Charleston, SC 29425, USA
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