Prognostic role of incidental pleural effusion diagnosed during echocardiographic evaluation

The Emerging Role of Multimodality Imaging in the Diagnosis and Management of Post Pericardiotomy Syndrome

PURPOSE OF REVIEW

This review aims to evaluate current diagnostic and therapeutic strategies for postpericardiotomy syndrome (PPS), with a focus on the evolving role of multimodality imaging, including echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance imaging (CMR). The review also explores the potential benefits of advanced imaging in improving the accuracy and management of PPS.

RECENT FINDINGS

PPS, a common complication following cardiac surgery, presents with pleuritic chest pain, fever, and pericardial or pleural effusion. Traditional diagnostic methods like echocardiography and X-ray are increasingly supplemented by advanced imaging modalities such as CCT and CMR. These tools allow for better visualization of pericardial inflammation and effusion, aiding in diagnosis and guiding treatment. Colchicine and NSAIDs remain the most effective treatments for PPS, while the role of corticosteroids remains uncertain. Biological treatments have shown promising results in managing recurrent pericarditis. This review presents a proposed algorithm for the diagnosis and management of PPS, drawing on our institutional experience. Multimodality imaging is emerging as an essential tool in diagnosing and managing PPS. It enhances diagnostic precision, informs treatment strategies, and provides prognostic insights. As imaging technology advances, integrating these modalities into PPS care has the potential to improve patient outcomes.

Clinical characteristics and prognostic factors of non-malignant pleural effusions in hospitalised patients: a retrospective cohort study

OBJECTIVE

Non-malignant pleural effusions (NMPE) are common in hospitalised patients. Data on NMPE inpatients are scarce and the factors influencing the prognosis are unknown.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

We conducted a retrospective cohort of inpatients (n=86 645) admitted to the Chinese PLA General Hospital from 2018 to 2021, based on electronic medical records. The observations of 4934 subjects with effusions confirmed by chest radiological tests (CT or X-ray) without a diagnosis of malignancy were followed during admission. Logistic regression was used to analyse organ damage and other factors associated with in-hospital death. Patients were clustered according to their laboratory indicators, and the association between the clustering results and outcomes was studied.

OUTCOME

The outcome of this study was in-hospital mortality.

RESULTS

Among 4934 patients, heart failure + pneumonia + renal dysfunction was the most common (15.12%) among 100 different diagnostic groups. 318 (6.4%) patients died during hospitalisation. Lung (OR 3.70, 95% CI 2.42 to 5.89), kidney (OR 2.88, 95% CI 2.14 to 3.90) and heart (1.80, 95% CI 1.29 to 2.55) damage were associated with in-hospital mortality. Hierarchical clustering of laboratory indicators (estimated glomerular filtration rate, white blood cell count, platelet count, haemoglobin, N-terminal pro-B-type natriuretic peptide, serum albumin) demonstrated the ability to discriminate patients at high risk of in-hospital death.

CONCLUSION

Comorbidities and multiorgan failure are the prominent characteristics of NMPE patients, which increase the risk of in-hospital mortality, and comprehensive intervention for specific comorbidity patterns is suggested.

The Global Burden of Pleural Diseases

Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced quality of life. The global burden of diseases reflects regional differences in conditions and exposures associated with pleural disease, such as smoking, pneumonia, tuberculosis, asbestos, cancer, and organ failure. Disease burden in high-income countries is overrepresented given the availability of data and disease burden in lower-income countries is likely underestimated. In the United States, in 2016, there were 42,215 treat-and-discharge visits to the emergency room for pleural diseases and an additional 361,270 hospitalizations, resulting in a national cost of $10.1 billion.

Quantification of pleural effusions by two-dimensional transthoracic echocardiography

PURPOSE

There is lack of validated methods for quantifying the size of pleural effusion from standard transthoracic (TTE) windows. The purpose of this study is to determine whether pleural effusion (Peff) measured from routine two-dimensional (2D) TTE views correlate with chest radiograph (CXR).

MATERIALS AND METHODS

We retrospectively identified all inpatients who underwent a TTE and CXR within 2 days in a large tertiary care center. Peff was measured on TTE from parasternal long axis (PLAX), apical four-chamber (A4C), and subcostal views and on CXR. Logistic regression models were used determine optimal cut points to predict moderate or greater Peff.

RESULTS

In 200 patients (mean age 69.3 ± 14.3 years, 49.5% female), we found statistically significant associations between Peff size assessed by all TTE views and CXR, with weak to moderate correlation (PLAX length: 0.21 (95% CI [0.05, 0.35]); PLAX depth: 0.21 (95% CI [0.05, 0.35]); A4C left: 0.31 (95% CI [0.13, 0.46]); A4C right: 0.39 (95% CI [0.17, 0.57]); subcostal: 0.38 (95% CI [0.07, 0.61]). The best TTE thresholds for predicting moderate or greater left-sided Peff on CXR was PLAX length left >  = 8.6 cm (sensitivity 78%, specificity 54%, PPV 26%, and NPV 92%). The best TTE thresholds for predicting moderate or greater right-sided Peff on CXR was A4C right >  = 2.6 cm (sensitivity 87%, specificity 60%, PPV 37%, and NPV 94%).

CONCLUSIONS

We identified statistically significant associations with Peff size measured on TTE and CXR. The predictive ability of TTE to identify moderate or large pleural effusion is limited.

Mortality Among Hospitalized Patients With Pleural Effusions. A Multicenter, Observational, Prospective Study

Background

Data regarding the prognostic significance of pleural effusion (PE) are scarce.

Objective

Explore the impact of PE on mortality among hospitalized patients.

Methods

Multicenter prospective observational study. Patients that underwent computed tomography (thorax and/or abdomen) and in which PE was detected, were admitted to the study. PE was classified by size on CT, anatomical distribution, diagnosis, and Light's criteria. Charlson comorbidity index (CCI), APACHE II, and SOFA score were calculated. Mortality at 1 month and 1 year were recorded.

Results

Five hundred and eight subjects, mean age 78 years. Overall mortality was 22.6% at 1 month and 49.4% at 1 year. Bilateral effusions were associated with higher mortality than unilateral effusions at 1 month (32 vs. 13.3%, p = 0.005) and large effusions with higher mortality than small effusions at 1 year (66.6 vs. 43.3%, p < 0.01). On multivariate analysis age, CCI, APACHE II, SOFA score, and bilateral distribution were associated with short-term mortality, while long-term significant predictors were CCI, APACHE II, SOFA, and malignant etiology. Exudates (excluding MPE) exhibited a survival benefit at both 1 month and 1 year but due to the smaller sample, fluid characteristics were not included in the multivariate analysis.

Conclusions

Pleural effusion is a marker of advanced disease. Mortality is higher within the first month in patients with PEs related to organ failure, while patients with MPE have the worst long-term outcome. Independent predictors of mortality, apart from CCI, APACHE II, and SOFA scores, are age and bilateral distribution in the short-term, and malignancy in the long-term.

Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion

Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.

Lung Ultrasound Findings Detected During Inpatient Echocardiography Are Common and Associated With Short- and Long-term Mortality

OBJECTIVES

Although pulmonary abnormalities are easily seen with standard echocardiography or pocket-sized ultrasound devices, we sought to observe the prevalence of lung ultrasound apical B-lines and pleural effusions and their associations with inpatient, 1-year, and 5-year mortality when found in hospitalized patients referred for echocardiography.

METHODS

We reviewed 486 initial echocardiograms obtained from consecutive inpatients over a 3-month period, in which each examination included 4 supplemental images of the apex and the base of both lungs. Kaplan-Meier survival curves were used to compare mortality rates among patients with versus without lung findings. Cox proportional hazard regression was used to determine the relative contributions of age, sex, effusions, and B-lines to overall mortality.

RESULTS

Of the 486 studies, the mean patient age ± SD was 68 ± 17 years; the median age was 70 years (interquartile range, 27 years); and 191 (39%) had abnormal lung findings. The presence versus absence of abnormal lung findings was related to initial-hospital (8.9% versus 2.0%; P = .001), 1-year (33% versus 14%; P < .001), and 5-year (56% versus 31%; P < .001) mortality. Ultrasound apical B-lines and pleural effusions were both independently associated with increased mortality during initial hospitalization (hazard ratio [HR], 4.3; 95% confidence interval [CI], 1.7-11.0; and HR, 2.5; 95% CI, 1.1-6.0, respectively). Pleural effusions were also associated with increased 1-year mortality (HR, 2.3; 95% CI, 1.5-3.4).

CONCLUSIONS

In hospitalized patients undergoing echocardiography, the simple addition of 4 quick 2-dimensional pulmonary views to the echocardiogram often detects abnormal findings that have important implications for short- and long-term mortality.

Nonmalignant Pleural Effusions: A Prospective Study of 356 Consecutive Unselected Patients

BACKGROUND

Pleural effusion secondary to a nonmalignant cause can represent significant morbidity and mortality. Nonmalignant pleural effusion (NMPE) is common, with congestive heart failure representing the leading cause. Despite this, there are limited data on mortality risk and associated prognostic factors.

METHODS

We recruited 782 consecutive patients presenting to a pleural service between March 2008 and March 2015 with an undiagnosed pleural effusion. Further analysis was conducted in 356 patients with NMPE. Pleural biochemical analysis, cytologic analysis, thoracic ultrasonography, and chest radiography were performed. Echocardiography, CT imaging, radiologically guided biopsy, and medical thoracoscopy were undertaken as clinically indicated. Patients were followed for a minimum duration of 12 months, with the final diagnosis decided through independent review by two respiratory consultants.

RESULTS

Of the 782 patients, 356 were diagnosed with NMPE (46%). These patients had a mean age of 68 years (SD, 17 years) with 69% of them being men. Patients with cardiac, renal, and hepatic failure had 1-year mortality rates of 50%, 46%, and 25%, respectively. Bilateral effusions (hazard ratio [HR], 3.55; 95% CI, 2.22-5.68) and transudative effusions (HR, 2.78; 95% CI, 1.81-4.28) were associated with a worse prognosis in patients with NMPE, with a 57% and 43% 1-year mortality rate, respectively.

CONCLUSIONS

This is the largest prospectively collected series in patients with NMPE, demonstrating that cases secondary to organ dysfunction have extremely high 1-year mortality. In addition, the presence of bilateral and transudative effusions is an indicator of increased mortality. Clinicians should be aware of these poor prognostic features and guide management accordingly.

Creating a Novel Cardiac Limited Ultrasound Exam Curriculum for Internal Medical Residency: Four Unanticipated Tasks

Over the past two decades, our internal medicine residency has created a unique postgraduate education in internal medicine by incorporating a formal curriculum in point-of-care cardiac ultrasound as a mandatory component. The details regarding content and implementation were critical to the initial and subsequent success of this novel program. In this paper, we discuss the evidence-based advances, considerations, and pitfalls that we have encountered in the program's development through the discussion of four unanticipated tasks unique to a point-of-care ultrasound curriculum. The formatted discussion of these tasks will hopefully assist development of ultrasound programs at other institutions.

Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination

The current practice of physical diagnosis is dependent on physician skills and biases, inductive reasoning, and time efficiency. Although the clinical utility of echocardiography is well known, few data exist on how to integrate 2-dimensional screening "quick-look" ultrasound applications into a novel, modernized cardiac physical examination. We discuss the evidence basis behind ultrasound "signs" pertinent to the cardiovascular system and elemental in synthesis of bedside diagnoses and propose the application of a brief cardiac limited ultrasound examination based on these signs. An ultrasound-augmented cardiac physical examination can be taught in traditional medical education and has the potential to improve bedside diagnosis and patient care.

Prognostic role of echocardiographic and hematologic parameters in heart failure patients complicated with incidental pleural effusion diagnosed during echocardiographic evaluation

We aimed to determine long-term prognostic role of echocardiographic and hematologic parameters in heart failure patients complicated with incidental pleural effusion (PE) diagnosed during echocardiographic evaluation. The study was performed by evaluating patient records in which PE was incidentally detected during echocardiographic examination in a tertiary teaching hospital between Jan 2002 and Dec 2012. Total 151 patients with heart failure complicated with PE were analyzed. All patients' mortality data were collected from registry center of Social Insurance Institution which is officially responsible for recording all mortality data in Turkey. Detailed echocardiographic and hematologic parameters including creatinine, uric acid, albumin, sodium, potassium, hemoglobin at the time of hospital admission were analyzed. Data from 151 eligible patients were analyzed. We compared patients who died (n = 51) during follow-up with the survivors (n = 100) in terms of patients' echocardiographic and hematological features. Mean duration of follow-up was 71.5 ± 45.6 months. Fifty-one patients (33.8 %) died during this follow-up period. From all echocardiographic parameters only dilated left atrium (LA) diameter was found to be associated with a poor prognosis (p = 0.034). Low albumin, sodium and hemoglobin levels were associated with poor prognosis (p < 0.001, p = 0.002 and p = 0.007, respectively). We showed that dilated LA, as well as low albumin, low sodium and low hemoglobin levels had a worse prognostic significance than patients with normal LA size, within normal limits of albumin, sodium and hemoglobin levels in patients with heart failure complicated with PE determined incidentally by echocardiography.