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Pericardial Effusions After Cardiac Transplantation

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Pericardial Effusions After Cardiac Transplantation JACC Vol . 23. No . 7 1625 Jun, 1990:1625-9 Pericardial Effusions After Cardiac Transplantation PAUL J . HAUPTMAN, MD, GREGORY S . COUPER, MD, SARY F . ARANKI, MD, ALEX KARTASHOV, PHD, GILBERT H . MUDGE, JR . MD, FACC, EVAN LOH, MD, FACCe Boston, Massachusetts Objectives. The aim of this study was to determine the etiologic Results. Eighteen (8.9%) of 203 transplant recipients devet- factors in the formation of significant pericardial effusion after aped moderate to large pericardial effusions. Forty-four percent oethalopte heart transplantation and to determine the association of patients required perleardiocentesis, and 28% subsequently of pericardial effusion with survival . required pericardleetamy for management of the efinsioas. Mul. Background. The formation of pericardial effusions has been tivariate analysis identified the presence of a positive weight well described after ortiatopie heart transplantation, but the risk difference between recipient and dew (recipcent weight > donor factors for development of effusions remain unclear . Rejection weight) and the lack of previous median sMnotosgy as the most and cyciesporiae have been cited as possible causes, but anatomic powerful predictors of effusion formation . No significant associa- factors have not been studied, tion was found with rejection, There was no difference In actuarial Me". We conducted a retrospective review of medical survival rate between patients with and without effusleers . records and echocardiograms of 203 consecutive patients at one Conclusions. A positive mismatch in weight between recipient center, facilitating ischendc time, incidence and severity of rejec- and donor and the absence of previous cardiac surgery are tion, weight difference between donor and recipient and previous associated with the formation of significant pericardial effusions . cardiac surgical history. Multivariate analysis was performed, Closer monitoring of these patients at risk may be warranted, and actuarial survival rate curves were calculated according to the (J Am Coll Cordial 1994;23 :1625-9) Kaplaa-Meler method . The development of small to moderate pericardial effusions closporin A era of immunosuppression has increased com- after orthotopic heart transplantation has been well de- pared with the incidence seen before the use of cyclosporin scribed (1-4), and their incidence appears to be similar to A . However, studies to date have not addressed the role of that after other types of cardiac surgery (5,6). However, the anatomic factors, such as weight mismatch between recipi . development of clinically significant pericardial effusions is ent and donor, and have been limited by relatively small uncommon. The clinical characteristics and risk factors for sample sizes. the development of these pericardial effusions after cardiac Thus, the primary objective of this study was to identify transplantation remain unclear. the specific clinical characteristics of the donor and recipient Valentine et al . (3) have described an association between patients, which may predict the development of significant progressively enlarging pericardial effusions and the pres- pericardial effusions after orthotopic cardiac transplantation . ence of myocyte rejection. The majority of these pericardial A secondary objective was to elucidate the natural history of effusions were diagnosed in the early postoperative period . patients with these pericardial effusions after cardiac trans- No other significant clinical characteristics were associated plantation. with the development of small to moderate pericardial effu- sions in this particular series . Other smaller series have not demonstrated a clear association between ongoing myocyte Methods rejection and the development of pericardial effusions (2,4) . Study patients. A retrospective analysis of 202 consecu- Some investigators (1,2) have suggested that the frequency live patients who underwent orthotopic heart transplantation of significant posttransplant pericardial effusions in the cy- at the Brigham and Women's Hospital between 1984 and 1992 was performed. A single patient underwent retransplan. ration for graft arteriosclerosis . Thus, a total of 203 trans- From the Cardiovascular and Cardiac Surgery Divisions, Departments of plant recipients were included in the study. All patients Medicine and General Sanitary, Brigham and Women's Hospital, Boston . Massachusetts. received immunosuppressive therapy with cyclosporin A Manuscript received May 20 .1993; revised manuscript received famous and prednisone. After 1988, azathioprine was gradually 3.1994, accepted January 26.1994. included as part of the standard immunosuppression regi- 'Pr-ox address and address for cnrtrmondeocu: Dr. Evan Loh. Cardio- -or. Division . Hospital of the University of Pennsylvania, Philadelphia, men . Preservation solutions and surgical technique remained Rnnsylvania 19109. essentially unchanged over the course of the study period. ®1994 by the American College of Cardiology 0735-1097/54157.00 1626 HAUPrMAN ET AL. JACC Vo1.23, No. 7 PERICARDIAL EFFUSION IN CARDIAC TRANSPLANT 10110 1994 :16219 Therapeutic pericardiocentesis was performed only in the exact test for discrete variables and the unpaired Student I event of clinical signs or symptoms of decreased cardiac test for continuous variables . Multivariate analysis was also output or echocardiographic signs suggestive of pericardial performed using a logistic stepwise regression model with tamponade, or both. Only the characteristics of the initial relation to the development of pericardial effusions . Actuar- presentation of pericardial effusion were considered in the ial survival rate comes were calculated according to the multivariate analysis . Kaplan-Meier method and were compared using the gener- The donor and recipient characteristics analyzed were the alized Wilcoxon test . A significant result was defined if the following : United Network for Organ Sharing (UNOS) sta- null hypothesis could be rejected at the 0 .05 level. tus at the time of transplantation ; etiology of cardiomyopa- thy leading to transplantation ; total ischemic time ; the tim- ing, frequency and severity of myocyte rejection episodes as Results they related to the appearance of pericardial effusions ; donor A total of 18 patients (14 men, 4 women) developed and recipient weight, age, gender and eytontegalovirus anti- pericardial effusions that were considered by echocardio- body status; presence or absence of azathioprine therapy; graphic criteria to be moderate or large (Table 1). The year of transplant ; recipient left ventricular end-systolic and ' verag time to detection of the pericardial effusion was 12 .6 end-diastolic dimensions by M-mode echocardiography ; use days (range 4 to 28) after cardiac transplantation. Eight of anticoagulation in the early postoperative period ; and patients required pericardiocentesis at a mean of 35 t 15 previous cardiac surgical history of the recipient. "Weight days (range 0 to 130) from the time of diagnosis of effusion. mismatch" was calculated as the recipient weight minus the In one patient, close surveillance was obtained over a period donor weight. Thus, a positive weight mismatch represents a of 130 days, when sudden hypotension developed with recipient weight greater than the donor weight . During the echocardiogrophic signs suggestive of tamponade requiring initial transplant experience at our center (1984 to 1988), a intervention . The laid from all of these patients was sero- maximal weight mismatch of ±25% was considered . Subse- sanguinous and without evidence of active infection . Five quently, in an attempt to increase the donor pool for poten- (27.9%) of 18 patients required surgical pericardiectomy for tial recipients, we accepted donors who were ±50% of ideal recurrent large and symptomatic pericardial effusion after body weight of the recipient in the absence of moderate to repeated pericardiocemeses. severe pulmonary hypertension . Data on recipient and donor None of the 18 patients with pericardial effusions lad weights were available in all patients with effusions and in cardiac surgery before transplantation compared with 67 of 179 of 185 patients without effusions . the 185 patients without pericardial effusions who had pre- Eehocardlosraphk criteria . All patients had at least one vious cardiac surgery (p < 0.05) (fable 2). In addition, echocardiographic study before hospital discharge after patients with a positive weight mismatch were much more transplantation and at routine 3- to 6-month posttransplant likely to develop effissionns (Table 2) . The mean positive intervals according to standard protocol . Interval echocar- difference between recipient and donor weights in the 18 diographic studies were obtained only at the discretion of the patients with pericardial effusions was 11 .9 s 4.1 versus transplant physicians. An independent observer, utilizing 2.2 t 1 .11* in the group of patients without significantly standard conventions in our echocardiography laboratory, large effusions (p = 0.01) . Using a logistic regression model, defined effusions as small, moderate and large . Only moder- the presence of a positive weight mismatch and the absence ate and large pericardial effusions were considered in this of previous cardiac surgery would have correctly predicted analysis. Any diagnosis of pericardial effusion within the 1st 83% of the patients who developed moderate or large peri- 24 h after transplantation was not included, given the likeli- cardial effusions
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