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* From the Divisions of Cardiovascular Diseases and Internal Medicine (Drs. Tsang, Hayes, Freeman, and Seward, and Mss. Barnes and Osborn Butler) and Thoracic and Cardiovascular Surgery (Dr. Dearani), Mayo Clinic and Mayo Foundation, Rochester, MN.
Correspondence to: Teresa S. M. Tsang, MD, Mayo Clinic, 200 First St, SW, Rochester, MN 55905
Study objectives: This study assessed the clinical features, timing of presentation, and echocardiographic characteristics associated with clinically significant pericardial effusions after cardiothoracic surgery. The outcomes of echocardiographically (echo-) guided pericardiocentesis for the management of these effusions were evaluated.
Design: From the prospective Mayo Clinic Registry of Echo-guided Pericardiocentesis (February 1979 to June 1998), 245 procedures performed for clinically significant postoperative effusions were identified. Clinical features, effusion causes, echocardiographic findings, and management outcomes were studied and analyzed. Cross-referencing the registry with the Mayo Clinic surgical database provided an estimate of the incidence of significant postoperative effusions and the number of cases in which primary surgical management was chosen instead of pericardiocentesis.
Results: Use of anticoagulant
therapy was considered a significant contributing factor in 86% and
65% of early effusions (
7 days after surgery) and late effusions
(> 7 days after surgery), respectively. Postpericardiotomy syndrome
was an important factor in the development of late effusions (34%).
Common presenting symptoms included malaise (90%), dyspnea (65%), and
chest pain (33%). Tachycardia, fever, elevated jugular venous
pressure, hypotension, and pulsus paradoxus were found in 53%, 40%,
39%, 27%, and 17% of cases, respectively. Transthoracic
echocardiography permitted rapid diagnosis and hemodynamic assessment
of all effusions except for three cases that required transesophageal
echocardiography for confirmation. Echo-guided pericardiocentesis was
successful in 97% of all cases and in 96% of all loculated effusions.
Major complications (2%), including chamber lacerations (n = 2) and
pneumothoraces (n = 3), were successfully treated by surgical repair
and chest tube reexpansion, respectively. Median follow-up duration for
the study population was 3.8 years (range, 190 days to 16.4 years). The
use of extended catheter drainage was associated with reduction in
recurrence for early and late postoperative effusions by 46% and 50%,
respectively.
Conclusions: The symptoms and physical findings of clinically significant postoperative pericardial effusions are frequently nonspecific and may be inadequate for a decision regarding intervention. Echocardiography can quickly confirm the presence of an effusion, and pericardiocentesis under echocardiographic guidance is safe and effective. The use of a pericardial catheter for extended drainage is associated with lower recurrence rates, and the majority of patients so treated do not require further intervention.
Key Words: cardiac tamponade • echo-guided pericardiocentesis • postoperative pericardial effusions • two-dimensional echocardiography
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