Decreased incidence of postoperative pericardial effusions after cardiac surgery for congenital heart disease

Incidence and predictors of pericardial effusion following surgical closure of atrial septal defect in children: A single center experience

OBJECTIVES

To evaluate the incidence of pericardial effusion (PE) after surgical atrial septal defect (ASD) closure and to investigate the presence of predictive risk factors for its development.

METHODS

We collected data from 203 patients followed at Bambino Gesù Children's Hospital of Rome who underwent cardiac surgery for ASD repair between January 2015 and September 2019.

RESULTS

A total of 200/203 patients with different types of ASD were included. Patients were divided into two groups: Group 1) 38 (19%) who developed PE and Group 2) 162 (81%) without PE. No differences were noted between the two groups with regard to gender or age at the surgery. Fever in the 48 h after surgery was significantly more frequent in group 1 than in group 2 (23.7 vs. 2.5%; p < 0.0001). ECG at discharge showed significant ST-segment elevation in children who developed PE, 24.3 vs. 2.0% in those who did not (p < 0.0001). Group 1 patients were divided into two subgroups on the basis of the severity of PE, namely, 31 (81.6%) with mild and 7 (18.4%) with moderate/severe PE. Patients with moderate/severe PE had a significantly higher BMI value (median 19.1 Kg/m²) (range 15.9-23.4, p = 0.004).

CONCLUSION

The presence of fever and ST-segment elevation after surgery predicts subsequent development of PE suggesting a closer follow-up for these categories of patients. A higher BMI appears to be associated with a higher risk of moderate/severe PE.

Efficacy of Short-Term Oral Prednisolone Treatment in the Management of Pericardial Effusion Following Pediatric Cardiac Surgery

A standard treatment for pericardial effusion without cardiac tamponade after pediatric cardiac surgery has not been established. We evaluated the efficacy of short-term oral prednisolone administration, which is the initial treatment for postoperative pericardial effusion without cardiac tamponade at our institution. Between October 2008 and March 2020, 1429 pediatric cardiac surgeries were performed at our institution. 91 patients required postoperative treatment for pericardial effusion. 81 were treated with short-term oral prednisolone. Pericardial effusion was evaluated using serial echocardiography during diastole. Pericardial drainage was performed for patients with circumferential pericardial effusion with a maximum diameter of ≥ 10 mm or signs of cardiac tamponade. Short-term oral prednisolone treatment was administered to patients with circumferential pericardial effusion with a maximum diameter of < 10 mm or localized pericardial effusion with a maximum diameter of ≥ 5 mm. Patients with localized pericardial effusion with a maximum diameter of < 5 mm were observed. Prednisolone (2 mg/kg/day) was administered orally for 3 days, added as needed. Short-term oral prednisolone treatment was effective in 71 cases and 90% of patients were regarded as responders. The remaining patients were deemed non-responders who required pericardial drainage. Overall, 55 responders were deemed early responders whose pericardial effusion disappeared within 3 days. There were no cases of deaths, infections, or recurrence of pericardial effusion. The amount of drainage fluid on the day of surgery was higher in the non-responders. In conclusion, short-term oral prednisolone treatment is effective and safe for treating pericardial effusion without cardiac tamponade after pediatric cardiac surgery.

The Efficacy, Safety, and Side Effects of Intrapericardial Triamcinolone Treatment in Children with Post-surgical Pericardial Effusion: A Case Series

Intrapericardial triamcinolone can be used to treat chronic pericardial effusion (PE) in adults; however, pediatric data are lacking. In this case series we aim to evaluate the efficacy, safety, and side effects of intrapericardial triamcinolone in children with PE. The incidence and treatment of post-surgical PE from 2009 to 2019 were determined using the institutional surgical database and electronic patient records. Furthermore, a retrospective analysis of efficacy, safety, and side effects of intrapericardial triamcinolone treatment for chronic post-surgical PE was performed. The incidence of postoperative PE requiring treatment was highest after atrial septal defect (ASD) closure when compared to other types of cardiac surgery (9.7% vs 4.3%). Intrapericardial treatment with triamcinolone resolved pericardial effusion in 3 out of 4 patients. All patients developed significant systemic side effects. Surgical ASD closure is associated with an increased risk of development of PE requiring treatment. Intrapericardial triamcinolone is an effective treatment for chronic postoperative PE in children, but is always associated with significant systemic side effects. Close monitoring and treatment of adrenal insufficiency are mandatory in these cases.

Echocardiographic Screening for Postoperative Pericardial Effusion in Children

Pericardial effusion (PE) after cardiac surgery can be life threatening without timely detection, and the optimal screening method is unknown. We sought to evaluate the role of a surveillance echocardiogram on postoperative day 10 (± 2), determine the incidence of postoperative PE, and identify risk factors. We conducted a retrospective cohort study including all pediatric patients who underwent open heart surgery at a single institution over a 7-month period. To identify risk factors for PE, medical records of patients with PE detected within 6 weeks after surgery (cases) were compared with patients without PE (controls). Of 203 patients, 52 (26%) had PE within 6 weeks; 42 (81%) were trivial-small and 10 (19%) were moderate-large. Twenty-nine (56%) were first detected within 7 days post-operatively, including all cases developing cardiac tamponade (n = 3). An echocardiogram was done 10 (± 2) days post-operatively in 41/52 cases, of which 12/41 (29%) did not have a PE at this time, 24/41 (59%) had a trivial-small PE, and 5/41(12%) had a moderate-large PE; 2 of the latter had no prior detected PE. Closure of an atrial septal defect had the highest incidence of PE (42%). PE cases were associated with postoperative nasopharyngeal detection of a respiratory virus (OR 3.8, p = 0.03). In conclusion, the majority of PE cases were detected within 7 days post-operatively, including all cases subsequently developing cardiac tamponade. Day 10 echocardiography infrequently detected a moderate or large effusion that had previously gone undiagnosed. A positive perioperative nasopharyngeal aspirate for a respiratory virus was associated with postoperative PE.

Prevalence and Risk Factors for Pericardial Effusions Requiring Readmission After Pediatric Cardiac Surgery

Pericardial effusion (PE) may require readmission after cardiac surgery and has been associated with postoperative morbidity and mortality. We sought to identify the prevalence and risk factors for postoperative PE requiring readmission in children. A retrospective analysis of the Pediatric Health Information System database was performed between January 1, 2003, and September 30, 2014. All patients ≤18 years old who underwent cardiac surgery were identified by ICD-9 codes. Those readmitted within 1 year with an ICD-9 code for PE were identified. Logistic regression analysis was performed to determine risk factors for PE readmissions. Of the 142,633 surgical admissions, 1535 (1.1%) were readmitted with PE. In multivariable analysis, older age at the initial surgical admission [odds ratio (OR) 1.17, p < 0.001], trisomy 21 (OR 1.24, p = 0.015), geographic region (OR 1.33-1.48, p ≤ 0.001), and specific surgical procedures [heart transplant (OR 1.82, p < 0.001), systemic-pulmonary artery shunt (OR 2.23, p < 0.001), and atrial septal defect surgical repair (OR 1.34, p < 0.001)] were independent risk factors for readmission with PE. Of readmitted patients, 44.2% underwent an interventional PE procedure. Factors associated with interventions included shorter length of stay (LOS) for the initial surgical admission (OR 0.85, p = 0.008), longer LOS for the readmission (OR 1.37, p < 0.001), and atrial septal defect surgery (OR 1.40, p = 0.005). In this administrative database of children undergoing cardiac surgery, readmissions for PE occurred after 1.1% of cardiac surgery admissions. The risk factors identified for readmissions and interventions may allow for improved risk stratification, family counseling, and earlier recognition of PE for children undergoing cardiac surgery.

Controversies in the prophylaxis and treatment of postsurgical pericardial syndromes: a critical review with a special emphasis on paediatric age

Postsurgical pericardial syndromes are common complications after cardiac surgery; however, their treatment is not well established yet. We reviewed the accuracy and limits of clinical trials of prophylaxis and treatment of these diseases to identify an evidence-based therapeutic approach. We performed a literature search in the National Library of Medicine using the keywords pericardial effusion, cardiac surgery and paediatric/congenital. The research was then redefined adding separately the keywords postpericardiotomy syndrome, NSAIDs, steroids and colchicine. We found 12 clinical trials (eight for the prophylaxis and four regarding treatment), testing three major agent classes: NSAIDs, corticosteroids and colchicine. Therapy is generally based on NSAID with or without steroids with the adjunct of colchicine for recurrences. Only a few randomized controlled trials (RCTs) in adults support NSAID therapy. Efficacy of steroids has been proved only in small paediatric works, whereas no studies are available for colchicine. Studies furthermore presented some limitations: not univocal endpoints (not allowing for a meta-analysis), a limited sample size, scarce attention to confounders (such as the underlying cardiac disease and diuretic/analgesic regimen). Moreover, different agents were not assessed, nor when to start therapy. More evidence (two wide RCT plus a meta-analysis) supports the role of colchicine for prophylaxis in adults. Prophylaxis with NSAID/corticosteroids instead failed to have significant advantage in children, whereas a few data are available for adults. Evidence for the treatment of postsurgical pericardial syndromes is incomplete, making it difficult to understand when to treat and which agent to employ, especially in children.

Pericardial effusion after pediatric cardiac surgeries: a single center observation

Background:

Development of fibrinous pericarditis after pericardiotomy is a well-recognized reaction. Within a few post-operative days, the inflammated surface of pericardium begins to fuse to the overlying sternum.

Objectives:

Our aim was to assess the prevalence, risk factors, time course and therapy response of pericardial effusion (PE) after cardiac surgeries in children.

Patients and Methods:

PE occurrence was assessed prospectively in 486 children who underwent cardiac surgery for congenital heart diseases by serial echocardiography. Clinical manifestations were observed and response to different therapies was analyzed.

Results:

The prevalence of PE was about 10% for all cardiac surgeries. Symptoms were exclusively seen in patients who had moderate to large effusions. The mean onset of pericardial effusion was 11 (± 8) days after surgery procedure, with 87 % (42 of 48) of cases being diagnosed on or before day 13 after operation. The prevalence of effusion after Fontan-type procedures and AVSD repair (29 %, 5 of 17 for both) was significantly higher than other types of cardiac surgeries. Aspirin administration was effective in 77 % and prednisone in 90 % of the cases.

Conclusions:

PE may be developed as late as weeks after cardiac surgeries. PE after palliative cardiac surgeries is not uncommon. Low doses of aspirin and corticosteroids are usually effective for treating this complication.

The effect of short-term prophylactic acetylsalicylic acid on the incidence of postpericardiotomy syndrome after surgical closure of atrial septal defects

Postpericardiotomy syndrome (PPS), a potential complication of open heart surgery, has a variable clinical course and severity. This study evaluated the effectiveness of acetylsalicylic acid (ASA) prophylaxis in preventing PPS after surgical closure of atrial septal defects (ASDs) in pediatric patients. A retrospective review was performed for 177 patients who underwent uncomplicated ASD closure from 1986 to 2006. The study group received prophylactic ASA 20 to 50 mg/kg/day for 1 to 6 weeks after surgery, whereas the control group did not. The primary outcome was a diagnosis of PPS based on the presence of two or more of the following symptoms or signs occurring at least 72 h postoperatively: fever (temperature >38 degrees C), pericardial or pleural rub, and worsening or recurring anterior pleuritic chest pain. Consequently, PPS developed in 5 (2.8%) of the 177 children: 2.8% (3/106) in the control group and 2.8% (2/71) in the study group (p = 1.00). The secondary outcomes were frequency of other postoperative complications. Postoperative pericardial effusions experienced by 26.7% of the patients were identified more frequently in the treatment group (p < 0.001). Postoperative prophylaxis ASA at a dose of 20 to 50 mg/kg/day for 1 to 6 weeks after surgical closure of ASD does not decrease the incidence of PPS in pediatric patients.

Prevalence of pericardial effusions in children with large atrial or ventricular septal defect

Recently, a high percentage of adults with isolated secundum atrial septal defects (ASD) and ventricular septal defects (VSD) undergoing surgical repair had a circumferential pericardial effusion (PE), preoperatively. It was our impression that PEs are uncommon in children with unrepaired ASD or VSD. To evaluate this impression, we performed a retrospective study to determine the prevalence of PE in children with ASD compared with those with VSD and with children with normal cardiac anatomy. The preoperative echocardiograms of 90 patients with isolated surgical grade secundum ASDs, 75 patients with isolated VSDs, and 91 normal patients were reviewed to evaluate for the presence or absence of pericardial effusions and also the septal defect size. Only 1 patient (ASD group) of the total 256 had a global PE (0.4%). No large effusions were found in any group. Eighty-one children (32%) had any effusion present in the pericardial space. The prevalence of these small PEs was not significantly different between the ASD (36/90, 40%) and VSD (23/75, 31%, p=0.25) groups. The patients with ASD, however, had a significantly higher prevalence of PEs compared with the control group (22/91, 24%, p<0.03). In conclusion, the presence of global PEs in children with surgical grade ASD or patients with VSD is rare, unlike that reported in adults with the same lesions. Trace effusions are found more commonly in children with ASD than those in VSD or in normal children, which may herald a potential for larger effusions with a longer time before defect closure.

Pericardial effusion after open heart surgery for congenital heart disease

OBJECTIVES

To determine the prevalence and time course of pericardial effusion after open heart surgery for congenital heart diseases and to identify predisposing risk factors.

DESIGN AND PATIENTS

Prospective assessment of development of pericardial effusion in 336 patients (163 males) undergoing open heart surgery for congenital heart disease by serial echocardiography on days 5, 7, 14, 21, and 28 postoperatively.

SETTING

Tertiary paediatric cardiac centre.

RESULTS

The prevalence of pericardial effusion was 23% (77 of 336). Of the 77 patients who developed effusion, 43 (56%) had moderate to large effusions and 18 (23%) were symptomatic. Patients who had a large amount of effusion were more likely to be symptomatic than those with only a small to moderate amount (47.4% v 15.5%, p = 0.01). The mean (SD) onset of pericardial effusion was 11 (7) days after surgery, with 97% (75 of 77) of cases being diagnosed on or before day 28 after surgery. The prevalence of effusion after Fontan-type procedures (60%, 6 of 10) was significantly higher than that after other types of cardiac surgery: repair of left to right shunts (22.1%, 43 of 195), repair of lesions with right ventricular outflow tract obstruction (22.6%, 19 of 84), arterial switch operation (6.7%, 1 of 15), and miscellaneous procedures (25%, 8 of 32) (p = 0.037). Univariate analyses showed that female patients (p = 0.009) and those receiving warfarin (p = 0.002) had increased risk of postoperative pericardial effusion. A greater pericardial drain output in the first four hours after surgery also tended to be significant (p = 0.056). Multivariate logistic regression similarly identified warfarin treatment (beta = 1.73, p = 0.009) and female sex (beta for male = -0.63, p = 0.037) as significant determinants.

CONCLUSIONS

Pericardial effusion occurs commonly after open heart surgery for congenital heart disease. Serial echocardiographic monitoring up to 28 days postoperatively is indicated in selected high risk patients such as those with symptoms of postpericardiotomy syndrome and those given warfarin.

Detection of pulsus paradoxus associated with large pericardial effusions in pediatric patients by analysis of the pulse-oximetry waveform

OBJECTIVE

To determine whether analysis of the pulse-oximetry waveform can be useful in detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.

METHODS

A retrospective review of charts of 8 pediatric patients (age range: 5-19 years) who had echocardiographic evidence of large pericardial effusion, subsequently underwent pericardiocentesis, and had pulse-oximetry waveform tracings obtained before and after pericardiocentesis within an 18-month period was conducted in 2 tertiary-care pediatric intensive care units. We analyzed the pulse-oximetry waveform tracings for the presence of a pulsus paradoxus. Other abstracted data included clinical evidence of tamponade, echocardiographic findings, and the volume of pericardial fluid aspirated.

RESULTS

Before pericardiocentesis, a decrease in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform was observed during inspiration in each patient. Echocardiographic evidence of large pericardial effusion with compromised cardiac filling was also present in each patient. Only 6 of these patients had clinical evidence of cardiac tamponade at that time, 4 with a documented pulsus paradoxus using standard methods of blood pressure analysis. After pericardiocentesis, the inspiratory fall in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform lessened in every patient. Echocardiography documented a decrease in the size of the effusion and resolution of the compromised cardiac filling in every patient.

CONCLUSIONS

Analysis of pulse-oximetry waveforms may be a widely available, easily interpretable, and reliable method of detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.

The effect of short-term prophylactic methylprednisolone on the incidence and severity of postpericardiotomy syndrome in children undergoing cardiac surgery with cardiopulmonary bypass

OBJECTIVE

The aim of this study was to determine the effect of prophylactic immune suppression on the incidence and severity ofpostpericardiotomy syndrome (PPS) in children after cardiac surgery with cardiopulmonary bypass (CPB).

BACKGROUND

Prophylactic suppression of the inflammatory response has an unknown effect on the incidence and severity of PPS in children undergoing surgery with CPB.

METHODS

This randomized double-blind placebo controlled trial included two study groups. Group A received pre-CPB intravenous methylprednisolone (1 mg/kg) plus four additional intravenous doses over 24 h, and Group B received intravenous saline placebo at identical intervals. Data included patient demographics, cardiac diagnosis/operation, CPB time, incidence and severity of PPS. Noncomplicated PPS--temperature >100.5 degrees F, pericardial friction rub, patient irritability, small pericardial +/- pleural effusion. Complicated PPS--noncomplicated PPS plus hospital readmission +/- pericardiocentesis or thoracentesis.

RESULTS

We randomized 266 children: 20 exclusions (6 perioperative deaths, 14 reasons unrelated to treatment) leaving Group A (n = 126) and Group B (n = 120). There were no significant group differences in gender, cardiac diagnosis or CPB time. Group mean age differed (p = 0.05) and was treated as a covariate with no substantive outcome effect. In total, 39/246 children (16%) developed PPS (noncomplicated: n = 30, complicated: n = 9). There was no inter-group difference in overall PPS incidence (p = 0.73). However, Group A had a marginally significant increase in complicated PPS (p = 0.05).

CONCLUSIONS

Intravenous methylprednisolone at a standard anti-inflammatory dose administered pre-CPB and early post-CPB neither prevents nor attenuates PPS in children. Short-term pre-CPB and post-CPB methylprednisolone treatment may complicate PPS.

A "friendly" system for pericardial drainage

We describe an alternative to the water-seal system, suitable for drainage of pericardial and eventually pleural effusions, which has been shown to be safe, effective, not painful, and rather "friendly", providing patients with a smoother clinical course.