Posterior pericardial window: a simple and reproducible technique in order to prevent pericardial tamponade in paediatric cardiac surgery

OBJECTIVE

Pericardial tamponade, which increases postoperative mortality and morbidity, is still not uncommon after paediatric cardiac surgery. We considered that posterior pericardiotomy may be a useful and safe technique in order to reduce the incidence of early and late pericardial tamponade. Herein, we present our experience with creation of posterior pericardial window following congenital cardiac surgical procedures.

METHODS

This retrospective study evaluated 229 patients who underwent paediatric cardiac surgical procedures between June 2021 and January 2023. A posterior pericardial window was created in all of the patients. In neonates and infants, pericardial window was performed at a size of 2x2 cm, whereas a 3x3 cm connection was established in elder children and young adults. A curved chest tube was placed and positioned at the posterolateral pericardiophrenic sinus. An additional straight anterior mediastinal chest tube was also inserted in every patient. Transthoracic echocardiographic evaluations were performed daily to assess postoperative pericardial effusion.

RESULTS

A total of 229 (135 male, 94 female) patients were operated. Mean age and body weight were 24.2 ± 26.7 months and 10.2 ± 6.7 kg, respectively. Eight (3.5%) of the patients were neonates where 109 (47.6%) were infants and 112 (48.9%) were in childhood. Fifty-two (22.7%) re-do operations were performed. Six (2.6%) patients underwent postoperative surgical re-exploration due to surgical site bleeding. Any early or late pericardial tamponade was not encountered in the study group.

CONCLUSIONS

Posterior pericardial window is an effective and safe technique in order to prevent both the early and late pericardial tamponade after congenital cardiac surgery.

Pleuropericardial Window Prevents Pericardial Effusion Following Surgical Atrial Septal Defect Closure

Background:

Methods:

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Conclusions:

Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial

BACKGROUND

Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery.

METHODS

In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA₂DS₂-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete.

FINDINGS

Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA₂DS₂-VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen.

INTERPRETATION

Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications.

FUNDING

None.

Intrapericardial instillation of bleomycin prevents recurrence of malignant pericardial effusions: Series of 46 cases and comprehensive literature review

INTRODUCTION

Malignant pericardial effusion is a severe complication of lung and breast cancer. The median survival is less than 4 months and recurrences occurs in about 40% of cases. Systemic chemotherapy and/or local treatments are necessary, even if there is no consensus.

METHODS

We collected data from patients in our center from 1997 to 2016 who received at least one intrapericardial instillation of bleomycin (60mg). At the same time, we conducted a review of the relevant literature on the subject.

RESULTS

We included 46 patients in the analysis. Median survival was 2.6 months [95% CI: 1.7; 4.7]. Overall survival was 49% [33%; 63%] at 3 months and 28% [15%; 42%] at 6 months. In the lung cancer subgroup, overall survival was 18% [3%; 44%] at 3 months. In the breast cancer subgroup, overall survival was 73% [44%; 89%] at 3 months and 46% [21%; 69%] at 6 months.

DISCUSSION

The best response rates in the literature are obtained with local instillation of bleomycin or cisplatin. Malignant pericardial effusions in breast cancer patients had a better prognosis. This is certainly related to the prognosis of the underlying disease. We have not found an increase in overall survival with intrapericardial chemotherapy injections, but preventing recurrence of malignant pericardial effusions is a benefit in itself, thus avoiding a lethal complication.

Effect of colchicine in prevention of pericardial effusion and atrial fibrillation: a meta-analysis

Randomized, controlled trials (RCTs) have assessed the effect of colchicine therapy in prevention of pericardial effusion (PE) and atrial fibrillation (AF). However, the effects are still inconclusive. PubMed, Cochrane Library, Google Scholar, and EMBASE database were searched. Primary outcome was the risk of PE and AF. Ten RCTs with 1981 patients and a mean follow-up of 12.6 months were included. Colchicine therapy was not associated with a significantly lower risk of post-operative PE (RR, 0.89; 95 % CI 0.70-1.13; p = 0.33, I (2) = 72.8 %) and AF (RR, 0.77; 95 % CI 0.52-1.13; p = 0.18, I (2) = 47.3 %). However, rates of pericarditis recurrence, symptoms persistence, and pericarditis-related hospitalization were significantly decreased with colchicine treatment. In addition, cardiac tamponade occurrence was similar between groups, and adverse events were significantly higher in the colchicine group. Colchicine may not significantly decrease the post-operative risk of PE and AF. However, only limited studies about patients undergoing cardiac surgery provide data about PE and AF.

Delayed methotrexate excretion in infants and young children with primary central nervous system tumors and postoperative fluid collections

PURPOSE

High-dose methotrexate (HD-MTX) has been used to treat children with central nervous system tumors. Accumulation of MTX within pleural, peritoneal, or cardiac effusions has led to delayed excretion and increased risk of systemic toxicity. This retrospective study analyzed the association of intracranial post-resection fluid collections with MTX plasma disposition in infants and young children with brain tumors.

METHODS

Brain MRI findings were analyzed for postoperative intracranial fluid collections in 75 pediatric patients treated with HD-MTX and for whom serial MTX plasma concentrations (MTX) were collected. Delayed plasma excretion was defined as (MTX) ≥1 μM at 42 hours (h). Leucovorin was administered at 42 h and then every 6 h until (MTX) <0.1 μM. Population and individual MTX pharmacokinetic parameters were estimated by nonlinear mixed-effects modeling.

RESULTS

Fifty-eight patients had intracranial fluid collections present. Population average (inter-individual variation) MTX clearance was 96.0 ml/min/m² (41.1 CV %) and increased with age. Of the patients with intracranial fluid collections, 24 had delayed excretion; only 2 of the 17 without fluid collections (P < 0.04) had delayed excretion. Eleven patients had grade 3 or 4 toxicities attributed to HD-MTX. No significant difference was observed in intracranial fluid collection, total leucovorin dosing, or hydration fluids between those with and without toxicity.

CONCLUSIONS

Although an intracranial fluid collection is associated with delayed MTX excretion, HD-MTX can be safely administered with monitoring of infants and young children with intracranial fluid collections. Infants younger than 1 year may need additional monitoring to avoid toxicity.

The posterior pericardiotomy. Does it reduce the incidence of postoperative atrial fibrillation after coronary artery bypass grafting?

Atrial fibrillation (AF) is the most common arrhythmia after coronary artery bypass graft surgery (CABG). Posterior pericardiotomy (PP) has been reported toreduce pericardial effusion, AF triggel; and reduce the length of hospital stay and hospital costs without significant complications. A total of 20 patients, diagnosed with coronary artery diseases to be treated by an elective or urgent CABG between August and December 2013, were randomly divided into two groups; 10 patients received PP (PP group) and 10 patients did not receive PP (control group). The incidence ofAF was equal (40% in both groups). Early pericardial effusion was slightly higher in the PP group (PP 70%, control 60%; p = 1.00). The incidence of left pleural effusion and pneumonia were higher in the PP group than in the control. Moreover, one patient in the PP group developed perioperative myocardial infarction (MI) that required intensive care with medication. The duration of ICU stay of the PP group was significantly longer than that of the control group. In conclusion, PP did not reduce the incidence of postoperative AF nor did early pericardial effusion. Rather, PP increased post-operative complications such asperioperative MI, left pleural effusion, and pneumonia resulting in the prolonged ICU stay.

Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation: the COPPS-2 randomized clinical trial

IMPORTANCE

Postpericardiotomy syndrome, postoperative atrial fibrillation (AF), and postoperative effusions may be responsible for increased morbidity and health care costs after cardiac surgery. Postoperative use of colchicine prevented these complications in a single trial.

OBJECTIVE

To determine the efficacy and safety of perioperative use of oral colchicine in reducing postpericardiotomy syndrome, postoperative AF, and postoperative pericardial or pleural effusions.

DESIGN, SETTING, AND PARTICIPANTS

Investigator-initiated, double-blind, placebo-controlled, randomized clinical trial among 360 consecutive candidates for cardiac surgery enrolled in 11 Italian centers between March 2012 and March 2014. At enrollment, mean age of the trial participants was 67.5 years (SD, 10.6 years), 69% were men, and 36% had planned valvular surgery. Main exclusion criteria were absence of sinus rhythm at enrollment, cardiac transplantation, and contraindications to colchicine.

INTERVENTIONS

Patients were randomized to receive placebo (n=180) or colchicine (0.5 mg twice daily in patients ≥70 kg or 0.5 mg once daily in patients <70 kg; n=180) starting between 48 and 72 hours before surgery and continued for 1 month after surgery.

MAIN OUTCOMES AND MEASURES

Occurrence of postpericardiotomy syndrome within 3 months; main secondary study end points were postoperative AF and pericardial or pleural effusion.

RESULTS

The primary end point of postpericardiotomy syndrome occurred in 35 patients (19.4%) assigned to colchicine and in 53 (29.4%) assigned to placebo (absolute difference, 10.0%; 95% CI, 1.1%-18.7%; number needed to treat = 10). There were no significant differences between the colchicine and placebo groups for the secondary end points of postoperative AF (colchicine, 61 patients [33.9%]; placebo, 75 patients [41.7%]; absolute difference, 7.8%; 95% CI, -2.2% to 17.6%) or postoperative pericardial/pleural effusion (colchicine, 103 patients [57.2%]; placebo, 106 patients [58.9%]; absolute difference, 1.7%; 95% CI, -8.5% to 11.7%), although there was a reduction in postoperative AF in the prespecified on-treatment analysis (placebo, 61/148 patients [41.2%]; colchicine, 38/141 patients [27.0%]; absolute difference, 14.2%; 95% CI, 3.3%-24.7%). Adverse events occurred in 21 patients (11.7%) in the placebo group vs 36 (20.0%) in the colchicine group (absolute difference, 8.3%; 95% CI; 0.76%-15.9%; number needed to harm = 12), but discontinuation rates were similar. No serious adverse events were observed.

CONCLUSIONS AND RELEVANCE

Among patients undergoing cardiac surgery, perioperative use of colchicine compared with placebo reduced the incidence of postpericardiotomy syndrome but not of postoperative AF or postoperative pericardial/pleural effusion. The increased risk of gastrointestinal adverse effects reduced the potential benefits of colchicine in this setting.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01552187.

[Prevention of the postpericardiotomy syndrome, postoperative effusions, and atrial fibrillation after cardiac surgery, efficacy and safety of colchicine: evidence from the COPPS trial and substudies]

Colchicine has been recently demonstrated to be efficacious and safe for the prevention of several postoperative complications including the postpericardiotomy syndrome (PPS), postoperative pericardial and pleural effusions, and postoperative atrial fibrillation according to the results of the COPPS trial. The aim of the present paper is to critically review the premise, results and implications of this trial for current clinical practice and future research. The COPPS study is a multicenter, double-blind, randomized trial. On the third postoperative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males) were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients <70 kg or intolerant to the highest dose). Colchicine significantly reduced the incidence of the PPS at 12 months [relative risk reduction (RRR) 58%; number needed to treat (NNT) 8], postoperative pericardial (RRR 43.9%; NNT 10) and pleural effusions (RRR 52.3%; NNT 8) as well as the incidence of postoperative atrial fibrillation (RRR, 45%; NNT 11) with similar side effects in the study groups. Colchicine is a promising drug for the prevention of several postoperative complications (PPS, postoperative effusions and postoperative atrial fibrillation) based on its anti-inflammatory effects and good tolerability at the study doses. Although further studies are needed before routine recommendation of the drug will be possible for patients undergoing cardiac surgery, colchicine seems to have the potentiality of becoming a new therapeutic standard in the perioperative period.

Aortic tube grafts wrapping with hemostatic fleeces reduces postoperative pericardial effusions

Pericardial effusions often complicate the postoperative course of ascending aortic surgery. We evaluated whether an unconventional use of hemostatic fleeces (TachoSil, Nycomed; Austria), wrapped around aortic tube grafts, may reduce such complication. Twenty-nine consecutive patients undergoing button-Bentall were submitted - according to surgeon's choice - to 360 degrees wrapping of the aortic grafts with hemostatic fleeces immediately before sternal wiring (11 patients - group A) or sternal wiring without any wrapping of the prosthesis (18 patients - group B). Hospital outcome was recorded. No differences were recorded in hospital mortality and major organ morbidity. When pericardial complications were considered, group A showed lower chest drains (P=0.0001), time of chest drainage (P=0.002), pretamponade/tamponade with need for pericardiocentesis (P=0.039), predischarge echocardiographic amount of pericardial effusion (P=0.026), fever (P=0.029), need for anti-inflammatory (P=0.05) or antibiotic drugs (P=0.007), hospital stay (P=0.010) and white blood cell count (P=0.016 on postoperative day 3; P=0.014 on day 6). Wrapping of aortic tube grafts with hemostatic fleeces is effective in reducing pericardial effusion and its deleterious effects following aortic surgery.

[Postcardiotomy syndrome outside a cardiosurgical clinic]

Postcardiotomy syndrome (PCTS) is an idiopathic inflammatory disease affecting pericardium and pleura; it complicates the postoperative period in cardiosurgery. High efficiency of corticosteroid therapy suggests autoimmune nature of PCTS. As a rule, this condition develops within two weeks after surgery although cases of its delayed onset (after 1 year) were reported too. PCTS may proceed both as an acute disease and as a mild disorder characterized by general inflammation and obscure serositis making difficult its diagnosis. The existence of such "restricted" forms of PCTS is not universally recognized, however glucoocticoids are widely prescribed to patients with this condition.

Ultrasound-guided vascular access in adults and children: beyond the internal jugular vein puncture

Based on our clinical experience and a review of the current literature, this paper describes a large variety of ultrasound-guided vascular puncture techniques used in adults and children far beyond the well described puncture of the internal jugular vein. This includes low or posterior approaches of the internal jugular vein, puncture of the subclavian vein and its variant in children, infraclavicular access to the axillary vein and also more peripheral punctures of the basilic, brachial and cephalic veins. Arterial line placement in the radial, humeral, axillary or femoral are also described as well as the aid of ultrasonography for peripheral insertion of central catheters (PICC Lines). Additional information on ultrasonographic assessment of potentially related complications, like pneumothorax or hemopericardium, will complete this review.

Effects of posterior pericardiotomy on the incidence of pericardial effusion and atrial fibrillation after coronary revascularization

BACKGROUND

The aim of this prospective, randomized study was to assess the efficacy of posterior pericardiotomy in decreasing the prevalence of pericardial effusion and postoperative atrial fibrillation (AF).

MATERIAL/METHODS

The study was performed in 100 patients who underwent elective coronary artery bypass grafting surgery (CABG) between October 2003 and July 2005. They were randomized to receive posterior pericardiotomy (Group A) or no posterior pericardiotomy (Group B). A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in group A patients. Posterior pericardiotomy was not performed in group B patients.

RESULTS

Early pericardial effusion developed in 6 patients (12%) of group A and 21 patients (42%) of group B; no late pericardial effusion developed in group A, but did in 3 patients (6%) of group B. The number of patients who developed postoperative AF was significantly lower in the fenestration group compared with the control group (10% vs. 30%, p < 0.010). The overall incidence of supraventricular tachycardia in patients with early pericardial effusion was significantly higher than in patients without early pericardial effusion (18 patients vs. 9 patients).

CONCLUSIONS

These findings suggest that posterior pericardiotomy reduces the prevalence of early pericardial effusion and related AF by improving pericardial drainage in patients undergoing coronary artery bypass surgery.

Effect of posterior pericardial drainage on the incidence of pericardial effusion after ascending aortic surgery

OBJECTIVE

Pericardial effusion and cardiac tamponade after ascending aortic surgery are higher than anticipated after cardiac surgery. We evaluated a thin closed-suction drain system to prevent posterior pericardial effusion in patients undergoing ascending aortic surgery.

METHODS

One hundred forty patients who underwent ascending aortic surgery were prospectively randomized into group A and group B. In group A (n = 70) we used a 32F drain placed anteriorly overlying the heart and a 16F thin drain placed retrocardially. In group B (n = 70) only a 32F drain placed anteriorly was used. In group A we removed the large drain on the first postoperative day and continued drainage with the thin drain until the drainage was less than 50 mL in a 24-hour period. In group B we removed the drain after the first postoperative day when the drainage was less than 50 mL in an 8-hour period. Preoperative, perioperative, and postoperative parameters of the patients were compared.

RESULTS

No significant posterior pericardial effusion and late cardiac tamponade developed in patients in group A. In group B 10 (14.3%) patients experienced significant posterior pericardial effusion and 4 (5.7%) patients experienced late cardiac tamponade; the incidence of significant pericardial effusion in group B was significantly higher (P = .001). Postoperative new-onset atrial fibrillation developed in 6 (10.4%) patients in group A and in 18 (32.7%) patients in group B (P = .03).

CONCLUSIONS

We demonstrated that effective posterior drainage is important to prevent posterior pericardial effusion, and use of a thin drain placed retrocardially appears to be sufficient for these results.

Site-specific delivery of dexamethasone from biodegradable implants reduces formation of pericardial adhesions in rabbits

Repeated sternotomy often leads to serious complications in patients due to the formation of cardiac adhesions. In this study we characterized dexamethasone-loaded biodegradable poly(lactide)-poly(ethyleneglycol) copolymer films for site-specific drug delivery and examined their efficacy in the rabbit model of postoperative cardiac adhesions. Tritiated dexamethasone-loaded films were used to determine the in vitro release and in vivo drug distribution. Dexamethasone release in serum was biphasic with 69% drug released after 72 hr. The implants produced sustained drug levels at the implantation site with low distribution into the peripheral tissues. The matrices were implanted in rabbits between the epicardium and the sternum following sternotomy, pericardiectomy and epicardium abrasion, with the drug-releasing surface facing the epicardium. The tenacity and density of the adhesions was examined 21 days post procedure in comparison to both groups of untreated and rabbits implanted with blank matrices. Similarly tenacious and dense adhesions were observed in both control groups. In contrast, epicardial adhesions' formation was significantly reduced and the anatomy was preserved in the treated animals. It is concluded that local delivery of dexamethasone from biodegradable implants provides a promising approach for the prevention of pericardial adhesions while potentially minimizing the systemic adverse effects inherent to systemic therapy or high blood levels of the drug.

Effect of Posterior Pericardiotomy on Early and Late Pericardial Effusion After Valve Replacement

OBJECTIVE

Pericardial effusion (PE) after cardiac surgery is frequent. It is more frequently seen after valve replacement or other types of heart surgery. Oral anticoagulants and antiplatelet agents may induce effusion development after open heart surgery. Our objective was to determine the efficiency of posterior pericardiotomy (PP) after cardiac valve operation for reducing the incidence of early and late PE and tamponade.

METHODS

This prospective randomized study was carried out in 100 consecutive patients undergoing mechanical valve replacement between August 2001 and May 2003 in our institution. Patients were divided into two groups; each group consisted of 50 patients. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in Group 1. Posterior pericardiotomy was not done in Group 2.

RESULTS

Early PE was detected in four patients (8%) and in 19 patients (38%) in Group 1 and Group 2, respectively (p < 0.001). No late PE effusion was developed in Group 1 despite nine (18%) late PE developing in Group 2 (p < 0.003). The rate of delayed pericardial tamponade was lower in Group 1, but this difference was not statistically significant (0% vs 10%; p < 0.056).

CONCLUSION

These findings suggest that PP is an easy, feasible, and beneficial technique for reducing both the occurrence of early and late PE or pericardial tamponade in patients undergoing valve replacement.

[A case of effective weekly paclitaxel administration for gastric cancer recurrence with carcinomatous pericarditis]

We reported a case of effective weekly paclitaxel administration for gastric cancer recurrence with carcinomatous pericarditis. A 69-year-old man underwent distal gastrectomy for gastric cancer in December 2001. However, he was re-admitted to the hospital for dyspnea in November 2002. A diagnosis of cardiac tamponade caused by gastric cancer relapse was made, and the patient was treated by weekly paclitaxel administration (90 mg/body) after drainage. It was effective in preventing reaccumulation of the pericardial effusion until his death 73 days after the diagnosis. It is thought that weekly paclitaxel administration can be a treatment for carcinomatous pericarditis.

The Importance of Intrapericardial Drain Selection in Cardiac Surgery

INTRODUCTION

To explore the impact of intrapericardial and infracardiac drains on pericardial effusions in cardiac surgery.

MATERIALS AND METHODS

Patients undergoing coronary artery bypass grafting were randomized into two groups. At the end of the intervention, an intrapericardial and infracardiac Blake drain was placed in patients in group 1 (n = 97), and an intrapericardial and infracardiac semirigid drain was placed in patients in group 2 (n = 105). In addition, a semirigid drain was placed into mediastinum in all cases. The amount of drainage was calculated at six different time points postoperatively: postoperative 0 to 2 h, postoperative 2 to 4 h, postoperative 4 to 6 h, postoperative 6 to 12 h, postoperative 12 to 24 h, and postoperative 24 to 48 h. The amount of pericardial effusion was estimated by transthoracic echocardiography after the drains were removed.

RESULTS

In all measurements, the amount of drainage from intrapericardial Blake drains was higher, the total amount of drainage being equal to 330.7 +/- 29.4 mL and 193.2 +/- 19.6 mL in the Blake drain and semirigid drain groups, respectively (p = 0.000) [mean +/- SD]. When the drains were removed, the volume of pericardial effusion was 3.86 +/- 0.76 mm in Blake drain group and 7.59 +/- 1.16 mm in semirigid drain group (p = 0.000). The incidence of postoperative atrial fibrillation was 11.3% in the group with Blake drains, and 23.8% in the group with semirigid drains (p = 0.016).

CONCLUSION

The more effective drainage obtained with infracardiac Blake drains compared to semirigid drains helps to reduce the amount of postoperative pericardial effusion and the risk of atrial fibrillation.

The role of posterior pericardiotomy on the incidence of atrial fibrillation after coronary revascularization

AIM

Pericardial effusion and atrial fibrillation (AF) are two common complications in coronary revascularization surgery. The aim of this study was to evaluate the efficiency of posterior pericardiotomy in pericardial effusion and AF.

METHODS

This randomized prospective study includes 113 patients who underwent isolated CABG procedure between May 2000 and December 2000 in our hospital. Posterior pericardiotomy incision was done in Group I (n=54). Group II constituted the control group (n=59). Postoperative pericardial effusion was assessed by echocardiography and rhythm follow-up was done by the same cardiologist.

RESULTS

There was no significant difference between study group and the control group considering the chest drainage (940.18+/-367.96 vs 894.92+/-360.65; p=0.507). The number of patients with remarkable intrapericardial effusion (>50 ml) was significantly lower in the posterior pericardiotomy group (25.93% vs 47.45%, p=0.020). The incidence of postoperative AF was no different between the posterior pericardiotomy group and the control group (12.96% vs 20.34%; p=0.32). In both groups, the incidence of AF was significantly higher in patients with mild or moderate pericardial effusion (29%), compared to patients with no or minimal pericardial effusion (10%), (p=0.017).

CONCLUSION

Posterior pericardiotomy significantly reduces the pericardial effusion in coronary bypass procedure postoperatively. Patients with pericardial effusion were subjected to AF more frequently.

Effect of timing of chest tube removal on development of pericardial effusion following cardiac surgery

BACKGROUND

There are no standard criteria for the timing of drain removal. The objective of this study was to determine whether the macroscopic appearance of chest tube drainage fluid to serosanguineous may be used as a criteria for drain removal.

METHODS

2,359 patients were assessed retrospectively and 80 randomized patients were followed prospectively who underwent cardiac surgery. In both parts of the study, patients were divided into two groups according to the timing of drain removal. Group I consisted of patients whose chest tubes were removed as soon as the macroscopic appearance of the drainage fluid turned to serosanguineous. Group II consisted of patients whose chest tubes were removed at the second postoperative day when the drainage output declined to less than 50 mL in a five-hour period. In the retrospective part, cases of hemodynamically significant pericardial effusion observed within seven days postoperatively were reviewed. In the prospective part, just before the drain removal, the fluid sample hematocrit obtained from the drain lines and patients' blood hematocrit were measured and recorded. Patients were evaluated with echocardiography for pericardial effusion.

RESULTS

No statistically significant difference was detected in the frequency of hemodynamically significant pericardial effusion and incidence or amount of pericardial effusion between the two study groups. The drain hematocrit to blood hematocrit ratios before drain removal showed a significant correlation with pericardial effusion. The strength of correlation between the drain hematocrit to blood hematocrit ratios before drain removal and pericardial effusion was also studied using receiver operating characteristic curve, which suggests that a drain hematocrit to blood hematocrit ratio of < or = 0.3 is strongly predictive that pericardial effusion would be absent or mild between the fifth and seventh postoperative days.

CONCLUSIONS

It is safe to remove the chest tubes as soon as the macroscopic appearance of the drainage fluid turns to serosanguineous since this practically indicates cessation of active bleeding.

Prevention of inclusion body hepatitis/hydropericardium syndrome in progeny chickens by vaccination of breeders with fowl adenovirus and chicken anemia virus

The hypothesis that an effective protection of progeny chickens against inclusion body hepatitis/hydropericardium syndrome (IBH/HP) can be achieved by dual vaccination of breeders with fowl adenovirus (FAV) serotype 4 and chicken anemia virus (CAV) was tested. Thus, 17-wk-old brown leghorn pullet groups were vaccinated by different schemes including single FAV (inactivated), single CAV (attenuated), FAV and CAV dually, or were not vaccinated (controls). Subsequent progenies of these breeders were challenged with the virulent strains FAV-341 and CAV-10343 following three strategies: 1) FAV-341 intramuscularly (i.m.) at day 10 of age (only FAV-vaccinated and control progenies); 2) FAV + CAV i.m. simultaneously at day 10 of age (all progenies); 3) CAV i.m. at day 1 and FAV orally at day 10 of age (all progenies). The induction of IBH/HP in these progenies was evaluated throughout a 10-day period. Both breeder groups vaccinated against FAV and those vaccinated against CAV increased virus neutralizing specific antibodies. Challenge strategy 1 showed 26.6% mortality in control progeny chickens and 13.3% in the progeny of FAV-vaccinated breeders. Presence of lesions in the liver of these groups showed no significant differences (P > 0.05), suggesting a discreet protective effect of the vaccine. Challenge strategy 2 showed 29.4% mortality in controls and 94% of chickens showed hepatic inclusion bodies (HIB). Single CAV vaccination of breeders did not demonstrate a beneficial effect, with both mortality and liver lesions resembling the nonvaccinated controls. FAV vaccination of breeders significantly reduced both mortality (7.4%) and liver lesions (26% HIB) (P < 0.05), providing protection against this challenge strategy. Dual vaccination of breeders with FAV and CAV proved to be necessary to achieve maximum protection of the progeny (no mortality and 7% HIB). Challenge strategy 3 produced no mortality but consistent liver damage in controls (96% HIB). In this case, both CAV and FAV + CAV-vaccinated breeders showed best protection results in terms of liver histopathology (8% and 0% HIB, respectively). FAV vaccination alone produced 24% HIB, similar to challenge strategy 2, demonstrating a lower protective effect.

Neoplastic pericardial effusion. Efficacy and safety of intrapericardial treatment with cisplatin

AIMS

To evaluate the clinical efficacy, safety, and long-term effect of intrapericardial treatment with cisplatin in large neoplastic pericardial effusions.

METHODS AND RESULTS

Out of the registry of 260 patients undergoing pericardiocentesis, 42 patients with neoplastic pericardial effusion (69% males, mean age 58.8+/-13.2 years) were selected for treatment with cisplatin (single instillation of 30 mg.m(-2) x 24h(-1)) in addition to the tumour-specific systemic chemotherapy. All patients underwent clinical examination, echocardiography, pericardiocentesis, pericardioscopy, and epicardial biopsy. Pericardial effusion and biopsy analyses included biochemistry, cytology, serology, microbiology, histology, immunohistology, and PCR. The following malignancies were established: lung cancer, 52.4%; breast cancer, 19.0%; Hodgkin's disease, 4.8%; oesophageal cancer, 2.4%; mesothelioma, 2.4%; colon cancer, 4.8%; and undifferentiated cancer of unknown origin, 14.2%. Cisplatin appeared to prevent recurrence of pericardial effusion during the first 3 months of the follow-up in 92.8%, and after 6 months in 83.3% of the patients. Lung cancer patients had fewer effusion relapses at the 6 months follow-up (4.5%) than breast cancer patients (37.5%)(P<0.05). Myocardial ischemia occurred after 1/42 cisplatin instillations, but there were no other complications.

CONCLUSION

Intrapericardial treatment with cisplatin appeared to successfully prevent recurrences of neoplastic pericardial effusion. The treatment was more successful in lung than in breast cancer patients.

Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias and pericardial effusion after coronary artery bypass grafting

OBJECTIVE

The aim of this prospective study was to demonstrate the effectiveness of posterior pericardiotomy in reducing the incidence pericardial effusions and consequently reducing the related supraventricular tachyarrhythmias and development of delayed posterior cardiac effusions.

METHODS

This prospective randomized study was carried out in 150 patients undergoing coronary artery bypass grafting in Bayindir Hospital Department of Cardiovascular Surgery between April 2000 and October 2001. One hundred and fifty patients were divided into two groups; each group included 75 patients. A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in posterior pericardiotomy group (group I). Posterior pericardiotomy was not performed in conventional treatment group (group II).

RESULTS

Atrial fibrillation was developed in seven patients (9.3%) in group I and in 24 patients (32%) in group II (P<0.001). Atrial flutter and other supraventricular tachyarrhythmia (SVT) prevalence was not statistically significant. Early pericardial effusion was developed 42.6% (32/75) and 10.6% (8/75), respectively, in group II and group I (P<0.0001), but no late pericardial effusion developed in group I despite seven (9.3%) late pericardial effusions developing in group II (P<0.013).

CONCLUSION

Posterior pericardiotomy is a simple, safe and effective technique for reducing not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.

Effects of diclofenac in the prevention of pericardial effusion after coronary artery bypass surgery. A prospective, randomized study

BACKGROUND

It is suggested that pericardial effusions after cardiac surgery can be managed with non-steroid anti-inflammatory drugs, but the efficacy of this therapy is not well established. This study was planned to evaluate the efficacy of the prophylactic use of diclofenac in the prevention of pericardial effusion after coronary artery bypass surgery.

METHODS

In a prospective, randomized study, diclofenac sodium 50 mg was administered orally every 8 hours to 22 patients in the postoperative period. The control group consisted of 19 patients who were not given postoperatively either steroids or non-steroid anti-inflammatory drugs.

RESULTS

Twelve patients of the diclofenac-treated group (54.5%) and 7 of the control group (36.8%) experienced supraventricular arrhythmias postoperatively. There was no statistically significant difference in the size of postoperative pericardial effusion as well as in the occurrence of pleural effusion in both groups. However, there was a higher rate of significant pericardial effusion (grade I-III) in the control group as compared with the diclofenac-treated group (52.6% vs 31.8%, p=ns). Based on chest X-ray findings, patients in the control group had higher incidence of pleural effusion either alone (42.1% vs 22.7%, p=ns) or combined with pericardial effusion (21.0% vs 13.6%, p=ns). Patients who received diclofenac had lower median C-reactive protein concentration (76.0+/-45.2 mg/L) than the patients of the control group (99.6+/-47.8 mg/L), (p=ns).

CONCLUSIONS

The results of the present study suggest that diclofenac, even if without a striking effect, may lessen the degree of inflammatory reaction after cardiac surgery and may be useful in the prevention and in the management of early pericardial effusion after cardiac surgery.

Preoperative prediction of pediatric patients with effusions and edema following cardiopulmonary bypass surgery by serological and routine laboratory data

AIM

Postoperative effusions and edema and capillary leak syndrome in children after cardiac surgery with cardiopulmonary bypass constitute considerable clinical problems. Overshooting immune response is held to be the cause. In a prospective study we investigated whether preoperative immune status differences exist in patients at risk for postsurgical effusions and edema, and to what extent these differences permit prediction of the postoperative outcome.

METHODS

One-day preoperative serum levels of immunoglobulins, complement, cytokines and chemokines, soluble adhesion molecules and receptors as well as clinical chemistry parameters such as differential counts, creatinine, blood coagulation status (altogether 56 parameters) were analyzed in peripheral blood samples of 75 children (aged 3-18 years) undergoing cardiopulmonary bypass surgery (29 with postoperative effusions and edema within the first postoperative week).

RESULTS

Preoperative elevation of the serum level of C3 and C5 complement components, tumor necrosis factor-alpha, percentage of leukocytes that are neutrophils, body weight and decreased percentage of lymphocytes (all P < 0.03) occurred in children developing postoperative effusions and edema. While single parameters did not predict individual outcome, >86% of the patients with postoperative effusions and oedema were correctly predicted using two different classification algorithms. Data mining by both methods selected nine partially overlapping parameters. The prediction quality was independent of the congenital heart defect.

CONCLUSION

Indicators of inflammation were selected as risk indicators by explorative data analysis. This suggests that preoperative differences in the immune system and capillary permeability status exist in patients at risk for postoperative effusions. These differences are suitable for preoperative risk assessment and may be used for the benefit of the patient and to improve cost effectiveness.

Pericardial effusion as a cause of morbidity in patients on maintenance hemodialysis: is it preventable?

OBJECTIVE

Cardiovascular diseases are the cause for 45% mortality and 20% morbidity in hemodialysis (HD) patients. Pericardial effusion (PE) accounts for 03-04% of all deaths in HD patients as a result of tamponade, arrhythmias or heart failure. This study aims to find out the prevailance and precipitating factors for PE in hemodialysis patients.

PATIENTS AND METHODS

Fifty-five patients were identified for echo-cardiographic assessment on the basis of signs and symptoms suggestive of PE i.e., hypotension during dialysis, dyspnea, globular heart in chest x-ray, raised JVP, soft heart sounds and low voltage ECG. A matched controlled group of 55 patients for age, sex, dialysis schedule, cause of ESRD and dialysis bath, was also studied echocardiographically.

RESULTS

Pericardial Effusion was detected in 12 patients (10.9%), 10 (83.3%) were on 2/week and only two on 3/week dialysis. Of these 75% were non-compliant in fluid intake and 58.3% were irregular in treatment. The morbidity of PE in study group (18.2%) is significantly higher as compared to controls (3.6%) (P = < 0.05). No correlation was found between development of PE and high iPTH and low albumin levels. Ten patients with mild PE responded to vigorous dialysis. Two patients developed cardiac tamponade needing pericardiocentesis.

CONCLUSION

We have identified 2/week dialysis (inadequate dialysis dose), acetate bath and fluid and dialysis non-compliance as factors contributing to development of PE in HD patients.

Efficacy of an inactivated oil emulsion vaccine against hydropericardium syndrome in broilers

Two inactivated vaccines were prepared against hydropericardium syndrome. The vaccine prepared from liver homogenate extracted with chloroform, inactivated with formalin and adjuvanted with liquid paraffin was highly effective against challenge in chickens aged three, five and seven weeks. Seroconversion following vaccination and challenge was assessed by the agar gel immunodiffusion test. The inactivated oil emulsion vaccine was highly effective against the syndrome in both experimental trials and field trials.

Pulse methylprednisolone therapy for impending cardiac tamponade in immunoglobulin-resistant Kawasaki disease

We describe a boy with Kawasaki disease (KD) whose clinical course was marked by a rapid improvement upon treatment with intravenous immunoglobulin (IVIG) and oral aspirin, which - within 14 days - was followed by the development of a large pericardial effusion with symptoms of impending cardiac tamponade as part of a polyserositis syndrome (pleural effusions, ascites). Upon treatment with pulsed methylprednisolone, the pericardial and pleural effusions and ascites rapidly disappeared within 48 h. This is the first case reported with a polyserositis syndrome and impending cardiac tamponade during KD.

The venotonic drug hydroxyethylrutosiden does not prevent or reduce docetaxel-induced fluid retention: results of a comparative study

PURPOSE

Fluid retention, which includes peripheral edema, ascites, pleural or pericardial effusion, or a combination of these that is sometimes associated with significant weight gain, is one of the most troublesome cumulative side effects of docetaxel. A suggestive observation from the data base available at the manufacturer (Rhone-Poulenc Rorer) was that patients who received venotonic drugs appeared to tolerate more courses of docetaxel. This prompted a comparative study to investigate whether the venotonic drug hydroxyethylrutosiden could reduce or delay docetaxel-related fluid retention.

METHODS

A total of 85 patients with metastatic breast cancer who were treated with docetaxel at a dose of 100 mg/m2 with corticoid comedication were allocated to receive either 300 mg hydroxyethylrutosiden given orally four times daily (group A) or no hydroxyethylrutosiden (group B). The end point for analysis was the development of fluid retention of > or = grade 2.

RESULTS

Fluid retention of > or = grade 2 was reported in 14 of 42 patients (33%) in group A and in 15 of 43 patients (35%) in group B and occurred after a median of 4 cycles of docetaxel in both groups. Weight gain was similar in groups A and B.

CONCLUSION

We conclude that hydroxyethylrutosiden does not reduce or delay the incidence and severity of docetaxel-related fluid retention.

Haemopericardium: a rare fatal complication of attempted subclavian vein cannulation. A report of two cases

This paper describes two otherwise unrelated cases of fatal haemopericardium resulting directly from attempted cannulation of the right subclavian vein. Although this is an extremely rare complication, it is essential that all physicians involved in establishing central venous access are aware of the danger of causing this condition, and how the use of a careful technique of insertion can minimize the risk.

Surgical management of hemorrhage from rupture of the aortic arch

BACKGROUND

Control of hemorrhage in patients with active bleeding from rupture of the aortic arch is difficult, because of the location of the bleeding and the impossibility of cross-clamping the aorta without interfering with cerebral perfusion. A precise and swift plan of management helped us salvage some patients and prompted us to review our experience.

METHODS

Six patients with active bleeding of the aortic arch in the mediastinum and pericardial cavity (5 patients) or left pleural cavity (1 patient), treated between 1992 and 1996, were reviewed. Bleeding was reduced by keeping the mediastinum under local tension (3 patients) or by applying compression on the bleeding site (2 patients), or both (1 patient) while circulatory support, retransfusion of aspirated blood, and hypothermia were established. The diseased aortic arch was replaced during deep hypothermic circulatory arrest, which ranged from 25 to 40 minutes. In 3 patients, the brain was further protected by retrograde (2 patients) or antegrade (1 patient) cerebral perfusion.

RESULTS

Hemorrhage from the aortic arch was controlled in all patients. Two patients died postoperatively, one of respiratory failure and the other of abdominal sepsis. Recovery of neurologic function was assessed and complete in all patients. The 4 survivors are well 8 to 49 months after operation.

CONCLUSIONS

An approach relying on local tamponade to reduce bleeding, rapid establishment of circulatory support and hypothermia, retransfusion of aspirated blood, and swift repair of the aortic arch under circulatory arrest allows salvage of patients with active bleeding from an aortic arch rupture.

Hydropericardium syndrome (HPS) in India: a preliminary study on the causative agent and control of the disease by inactivated autogenous vaccine

Hydropericardium syndrome (HPS) in broiler birds of 3 to 6 weeks of age was recorded for the first time in the Haldwani area of Nainital district (UP) in India in November, 1994. The overall mortality in 6 poultry farms was 61.62 per cent. The disease was experimentally transmitted by bacteria free infected liver homogenate extract passed through membrane filters of 0.22 and 0.1 mu APD. The aetiological agent was inactivated by heat treatment at 56 degrees C for one hour and 80 degrees C for 10 min. A precipitin band was demonstrated in agar gel immunodiffusion and counter immunoelectrophoresis using infected liver homogenate extract as antigen and homologous antisera raised in the laboratory. The disease was effectively controlled by formalinised and heat inactivated autogenous vaccine prepared from the infected livers of birds which died of natural infection.

[Use of a thin retrocardiac drain after open heart surgery. Description of the technique]

PURPOSE

To describe a technique with a thin drainage system placed behind the heart, avoiding reoperation caused by tamponade due to pericardial effusion in patients who undergo open heart surgery.

METHODS

We studied 59 patients, average age of 50 years. Twenty-six (44%) patients had undergone CABG, 25 (42%) valvar procedures and 8 (14%) different procedures. The control group were 20 patients, average age 44 years. Nine (45%) underwent CABG, 6 (30%) valvar procedures and 5 (25%) other procedures. Every patient was submitted to echocardiographic study to verify presence of pericardial effusion after operation.

RESULTS

There was one patient with pericardial effusion with 8mm in the study group. Six patients showed pericardial effusion in the control group. The control group had mean drainage flow of 320 +/- 110ml and average permanence time was 45 +/- 10h. The study group had mean drainage flow of 410 +/- 122ml, the average permanence time was 46 +/- 10h. There was statistic difference between both groups when we compared the frequency of pericardial effusion.

CONCLUSION

This drainage system reduces pericardial effusion comparing with the literature and causes little discomfort to the patient. The fixed rule to remove the drains did not present more discomfort to the patient and there were no complications related to its permanence.

Suppression of fluid accumulation following pericardial inflammation in a patient with primary chylopericardium

The patient was a 50-year-old woman with primary chylopericardium. Triglyceride rich chyloid fluid was continuously drained from the pericardial space through an indwelling catheter. A surgical procedure was scheduled since a medium chain triglyceride diet was insufficient to control the fluid accumulation. Before the operation, inflammatory signs were apparent around the indwelling catheter and the catheter was removed immediately. The inflammation was easily treated with antibiotics, and the pericardial effusion no longer accumulated during a follow-up period of 10 months. The inflammatory process may have caused fibrin production and tissue adhesion in the pericardial cavity, and these might have prevented an accumulation of chyloid fluid and occluded the connection between the thoracic duct and the pericardial cavity.

Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias following coronary artery bypass surgery

A prospective study of 100 patients undergoing coronary artery bypass surgery was performed to demonstrate the effectiveness of a posterior pericardiotomy in reducing the incidence of pericardial effusions and, consequently, reducing the incidence of supraventricular arrhythmias in the post-operative period. Pericardial effusion occurred in 4 of 50 patients following a posterior pericardiotomy, whereas effusion occurred in 20 of 50 patients in whom a pericardiotomy was not created (P < 0.0005). Supra-ventricular arrhythmias occurred in 4 patients in the pericardiotomy group and 18 in the group treated without pericardiotomy (P < 0.005). No complications resulted from this procedure. We conclude that pericardiotomy is a simple, safe and effective method for reducing the incidence or pericardial effusion and thereby post-operative supra-ventricular arrhythmias.

Fontan operation: influence of modifications on morbidity and mortality

The mortality rate of the Fontan operation for heart malformations with a single or dominant ventricle has been reduced by dividing the procedure into two stages. The hemi-Fontan procedure allows early reduction of the volume work of the single ventricle and remodeling of ventricular geometry before a completion Fontan operation. Despite the improvement of survival with this strategy (8% mortality for completion Fontan versus 16% mortality for primary Fontan operation), morbidity related to serous effusions remains substantial. Further technical modifications have been undertaken in an effort to reduce morbidity and further reduce mortality. From January 1990 through June 1993, 200 patients underwent completion Fontan procedures after previous hemi-Fontan operations. Mean age was 23 months, and 157 patients were less than 24 months of age. Diagnoses were hypoplastic left heart syndrome (127 patients), tricuspid atresia (19 patients), single left ventricle (17 patients), complex double-outlet right ventricle (16 patients), pulmonary atresia with intact ventricular septum (8 patients), and other (13 patients). Overall, early mortality rate was 8% (16 patients). In the last 112 patients, the procedure was modified technically by creating one or more fenestrations in the baffle used to separate systemic venous blood from pulmonary venous blood (36 patients), or by excluding one or more hepatic veins from the systemic venous pathway (76 patients). Early mortality for these 112 patients was reduced to 4.5% (5 patients). Substantial morbidity from serous effusions occurred at a rate of 45% (35 of 78 patients) among survivors who had received neither technical modification.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged suction drainage prevents serous wound discharge after cardiac surgery

A series of 180 patients was randomised to two groups after median sternotomy performed for cardiac surgery in order to evaluate the effect of suction drainage on serous wound discharge. In group A all wounds were drained using two conventional mediastinal drains, while in group B one suction drain and one conventional mediastinal drain were employed. Five patients developed serous wound discharge in group B compared with 14 in group A (chi 2, P < 0.02). There were no significant differences between the rates of major wound infection (group A, n = 1; group B, n = 1) or the incidence of postoperative pericardial effusion assessed by echocardiography (group A, n = 10; group B, n = 5).

Use of a thin retrocardial drain to prevent pericardial effusion

A thin (3.125 mm) drain was placed retrocardially in 21 patients undergoing cardiac surgical procedures and its efficacy in the prevention of the formation of pericardial effusions was determined with two-dimensional echocardiography. Some 29 patients without such a drain acted as controls. No effusions developed in patients with a retrocardial drain. Nine of 29 (31%) patients without a retrocardial drain had an effusion of 7-18 mm. The effusions were most commonly found behind the left ventricle. Using Fisher's exact test as a contingency table, the results were significant (P = 0.05). Insertion of a thin retrocardial drain may prevent the incidence of pericardial effusions in the early postoperative period and is not associated with local complications.

Studies on the aetiology of hydropericardium syndrome (Angara disease) in broilers

The study was carried out to determine the aetiological agent(s) associated with hydropericardium syndrome (Angara disease) in broilers in Pakistan. The results indicate that in addition to adenovirus some other agent is involved in causing the disease but that this agent requires co-infection by an adenovirus for the reproduction of the typical signs of the syndrome. The nature of this agent remains unknown because no discrete virus or virus-like particle could be seen by electron microscopy.

[No consequences of prolonged drainage following open heart surgery on the incidence of postoperative pericardial effusion]

Pericardial effusion (PE) frequently occurs after cardiac surgery and, in some cases, complicates the postoperative course. This study was performed in order to assess if prolongation of the postoperative drainage period may result in a decreased incidence of PE. For this purpose we studied 100 patients, randomised into two groups. In group I (50 patients) standard drainage of the thorax was performed. In group II (50 patients) the drainage period was prolonged by 24 hours. The amount of fluid drained during the additional period did not correlate with preceding fluid production. Echocardiography performed on the sixth postoperative day revealed a virtually equal incidence of PE in both groups: 26 patients in group I, 29 patients in group II. None of the observed effusions resulted in clinical signs of cardiac tamponade. PE occurred more frequently in patients with more than 60 ml of additional drainage volume (p less than 0.01). We conclude that: (1) prolonging the duration of postoperative drainage does not result in a lower incidence of postoperative PE and (2) the aetiological process causing PE in a number of patients is probably already active during the early postoperative course.

Pericardial effusion after cardiac surgery in children and effects of aspirin for prevention

Seventy-four children aged 0.3 to 21.4 years (median 4.0) were followed echocardiographically on days 4, 7, 14 and 28 (+/- 2 days) after cardiac surgery to evaluate the incidence of postoperative pericardial effusion, to identify the patients at greatest risk of developing an effusion and to evaluate the use of aspirin as prophylaxis against pericardial effusion. Pericardial effusion was graded relative to the size of the aortic root from grade 0 (no effusion) to grade 5 (larger than the aortic root dimension). Patients were randomly divided into 2 groups: group 1 (32 patients) received aspirin 60 mg/kg/day for 7 days starting on the third postoperative day; group 2 (42 patients) received no aspirin. Forty-eight patients (65%) developed an effusion during the study period, 3 required pericardiocentesis and 1 died of tamponade. All patients with tamponade had a grade 4 effusion. Age or type of operation did not alter the cumulative incidence of significant effusion. No patient with a grade 0 effusion on the first echocardiogram developed a grade 4 or 5 effusion. Results in groups 1 and 2 were similar. Pericardial effusions are common in the first month after cardiac surgery. Patients with no effusion in the immediate postoperative period appear to be at lesser risk of developing a grade 4 effusion in the first month after operation. Finally, aspirin prophylaxis against postoperative pericardial effusions did not significantly alter the outcome in this small series of patients.

Myocardial hydroxyproline reduced by early administration of methylprednisolone or ibuprofen to rabbits with radiation-induced heart disease

The ability of methylprednisolone (MP) and ibuprofen (IB) to reduce the severity of the late state of radiation-induced heart disease was assessed in 57 New Zealand white rabbits. Before and shortly after cardiac irradiation, 15 rabbits received i.v. MP, 30 mg/kg twice daily for 3 days, and 15 others received IB, 12.5 mg/kg twice daily for 2 days. No drug was administered to 14 irradiated rabbits, and neither irradiation nor drugs were administered to 13 rabbits that served as controls, All 15 rabbits treated with MP and 13 of the 15 treated with IB lived for 100 days. Only seven of the untreated, irradiated rabbits lived that long. Longevity of each treated group of rabbits was better (p less than 0.01 and 0.05) than that of the untreated, irradiated rabbits. Surviving rabbits were killed 100 days after irradiation. Pericarditis (p less than 0.05) and pericardial effusion (p less than 0.01) were less frequent in the treated, irradiated groups than in the untreated, irradiated rabbits. At least some rabbits in each irradiated group had microscopic evidence of myocardial fibrosis. The fibrosis was quantitated by determination of myocardial hydroxyproline concentrations (MHP). MHP concentration in the untreated, irradiated rabbits was greater than in those treated with MP (p less than 0.05) or IB (p less than 0.01) and in the untreated, unirradiated rabbits (p less than 0.01). Early administration of MP or IB retarded the development of myocardial fibrosis, pericarditis and pericardial effusion, and improved survival in this experimental model of radiation-induced heart disease.

Limitatoins of surgical methods of pericardial drainage. Echocardiographic observations

To assess the efficacy of surgical methods of pericardial drainage in preventing the accumulation of pericardial effusion, we performed M-mode and cross-sectional echocardiograms in 26 patients before and one week after the creation of a pericardial window or leaving the pericardium open after cardiac surgery. A pericardial window was created in six patients (group 1) who had pericardial effusions. Group 2 consisted of 20 patients who had heart surgery. Echocardiography disclosed moderate or large pericardial effusions preoperatively in all group 1 patients but in one of the group 2 patients. Following operation, three of the group 1 patients had complete clearing of pericardial effusion, while three showed reaccumulation. In group 2, thirteen patients had either no effusion or a small effusion. Seven patients had moderate or large pericardial effusions that were located posterior to the heart; only one had an anterior pericardial effusion. Cross-sectional echocardiography showed posterior loculation of effusion in six of the seven patients. Pericardial drainage is not always effective in preventing accumulation of pericardial effusions.

Influence of primary closure of the pericardium after open-heart surgery on the frequency of tamponade, postcardiotomy syndrome, and pulmonary complications

Experiences with primary closure of the pericardium in a series of 100 patients undergoing open-heart operations are described. The pericardium was kept under tension during the operation to minimize shrinkage and permit closure at the end of the procedure. In 28 patients one pleural space was opened for drainage, whereas in 72 patients intra- and extrapericardial sumps alone were used for drainage. Measurements of sump drainage revealed that most postoperative bleeding originates from outside the pericardium. There were no instances of cardiac tamponade although 19 patients lost more than 1 L. of blood after operation and 5 required reoperation for hemorrhage. Transpleural drainage tubes were shown to be ineffective and in addition were associated with a fourfold increase in postcardiotomy syndrome and a significantly greater frequency of pleural effusion and atelectasis when compared to the use of mediastinal sump drainage alone. We have concluded that closing the pericardium and using mediastinal sump drainage minimizes the risk of cardiac tamponade and allows early localization of the site of postoperative bledding. Another advantage of pericardial closure and drainage is that postoperative adhesions and postcardiotomy syndrome will be less significant. As a consequence the danger of injuring the heart in a subsequent operation is lessened.