Although pericardial effusion (PE) is common after cardiac surgery, late and recurrent cardiac tamponade that occurs more than 5–7 days after coronary artery bypass grafting is an infrequent complication. Moreover, the treatment of PE resistant to medical therapy, percutaneous drainage and pleuro-pericardial window remains a therapeutic challenge. We report the case of a recalcitrant PE with high-daily volume outflow drainage, finally treated with success, with a transdiaphragmatic pleuro-peritoneal shunting by laparoscopic approach.
A 57-year-old man was admitted to the cardio-thoracic surgery department for a coronary artery bypass grafting (CABG). Previous history revealed a Child-Pugh class A liver cirrhosis, diabetes, arterial hypertension and hypertrophic cardiomyopathy. A complete arterial T-graft revascularization was performed. On the 10th postoperative day, the patient presented a cardiac tamponade (CT) treated by emergent percutaneous subxyphoidal drainage of 400 ml bloody fluid. The drain was withdrawn on Day 13. On Day 15, a new tamponade occurred. Percutaneous drainage retrieved 800 ml of serous fluid. Aspirin 1 g/day, methylprednisolone 32 mg/day and colchicine initiated at 2 × 1 mg/day were started. Because of a daily 500 ml exudate drain outflow and no evidence of medical therapy efficiency, a pleuro-pericardial window was performed by video-assisted thoracoscopy. Pericardial biopsy was negative for inflammatory or neoplastic disease. White blood cells count and CRP were normal. Connective tissue disorders were excluded.
The pleural drain continued to collect a daily average of 500 ml and was removed on the 33th postoperative day with the hope for a spontaneous regression. The patient was discharged home but came back 1 week later with an important pleural effusion (Fig. 1). He kept on coming back every 5 days with severe dyspnoea, treated by pleural evacuation of an average of 1500 ml serous fluid. After 6 weeks of repeated drainage, a multidisciplinary discussion led us to propose a transdiaphragmatic shunting. Informed consent was obtained.
The left diaphragm was exposed with care due to liver cirrhosis (Fig. 2A). Two incisions were performed by ultrasonic dissection and 2-10 Fr double pigtail stents (Amplatz ureteral stents, Cook Medical, Limerick, Ireland) were introduced through the diaphragm into the left pleura (Fig. 2B). The patient was discharged with a residual asymptomatic pleural effusion. He was kept on Colchicine 1 mg/day for 6 months. At 1-year follow-up, he was asymptomatic. Thoraco-abdominal computed tomography scan showed no ascites and trivial left pleural effusion (Fig. 2C).
Postpericardiotomy syndrome and pericardial effusion (PE) are different entities that are frequently confused. Postpericardiotomy syndrome is an inflammatory pericardial syndrome, with small volume PE, complicating 5–20% of cardiac surgery . This differs from persistent PE, without systemic inflammation, which frequently leads to CT .
Late postoperative CT is not rare and is well described in the literature, but late and recurrent CT is rather infrequent after isolated CABG. In a study of 8400 patients, incidence of late CT was 1% but only 0.1% after isolated CABG. The major risk factor of developing this complication was anticoagulant therapy as 80.5% of patients with late CT had mechanical valves. Recurrence rate was 6% and occurred only after valve replacement .
After a systematic review of the English literature, we found few cases of late, large and recurrent PE, with or without CT, occurring after isolated CABG. One of them, under Coumadin therapy, presented with a recurrent CT and a large amount of drain outflow, which resolved within 2 weeks after creation of a pleuro-pericardial window . None of those cases presented with such a long-term, continuous and high-volume fluid production as did our patient.
We initially treated our patient as a postpericardiotomy syndrome. Therefore, a treatment with methylprednisolone and colchicine was initiated. Failure of medical therapy prompted us to perform a pleuro-pericardial window that led to a chronic large pleural effusion. The use of a Denver pleuro-peritoneal shunt device is the classical technique to manage recalcitrant pleural effusions. Although it is efficient and safe for most patients, occlusion and infection of the device occur in 13.47% . To try to avoid such complications, we created a transdiaphragmatic shunt with 2 double pigtail catheters. The postoperative residual pleural effusion can be explained by the low pleuro-peritoneal pressure gradient.
This case constitutes a success of transdiaphragmatic pleuro-peritoneal shunting by laparoscopic approach to manage recurrent high-volume pleural effusions. This innovative technique seems to be efficient and safe but more cases and longer follow-up are needed to confirm the long-term safety and efficacy.
Conflict of interest: none declared.