Abstract
The aim of this study was to compare our experience between open and video-assisted thoracic surgery (VATS) approaches to the management of thoracic effusions in ventricular assist device (VAD) patients. This was a retrospective review of a prospectively collected database of VAD patients at a single institution. Patients who were operated on for pericardial and/or pleural effusions were included. Primary outcomes included operative mortality and morbidity as well as effusion recurrence. From 1993 to 2009, 360 adult patients underwent VAD placement. Twenty-three patients (11.9%) required operative management of pleural (n = 24), pericardial (n = 13) or both pleural and pericardial (n = 6) effusions [open = 20 (47%); VATS = 23 (53%)]. Drainage with decortication was performed in five patients, with the remaining undergoing drainage alone. Open and VATS patients were similar in age, gender and indication for VAD support. Conversion from VATS to open was necessary in four patients (17%). There was no operative mortality and no difference in perioperative complications between approaches. The open and VATS approaches had similar rates of pleural (open = 63%; VATS = 41%; P = 0.42) and pericardial (open = 31%; VATS = 17%; P = 1) effusion recurrences. In spite of apparent challenges, the VATS approach may be as safe and effective as open surgery for the management of pleural and pericardial effusions in VAD patients in centres with significant minimally invasive thoracic experience.
Keywords: Minimally invasive surgery, Circulatory assist devices, Pleural effusion, Pericardium, Pleural drainage, Heart failure
INTRODUCTION
Major perioperative complications are frequent in patients with ventricular assist devices (VADs) and include bleeding, stroke, sepsis and multi-organ failure [1]. In addition, patients with VADs may develop pleural and pericardial effusions requiring operative drainage [2]. The outcomes of these procedures are not well established in this patient population. Video-assisted thoracoscopic surgery (VATS) is a recognized approach to the management of pleural and pericardial effusions [3]. Potential advantages of VATS over open thoracic surgery include decreased surgical trauma and easier recovery [4]. In the VAD patient, the presence of drivelines, hepatomegaly, cardiomegaly and inability to tolerate single-lung ventilation poses challenges to the surgical exposure of the pleural space and pericardium. These issues cast doubt on the appropriateness of the VATS approach in this patient population. The objective of this study was to compare the outcomes of VATS and open surgery for the management of pleural and pericardial effusions in VAD patients.
MATERIALS AND METHODS
After approval from the Institutional Review Board, the medical records of adult patients undergoing the operative drainage of pleural and/or pericardial effusions after VAD implantation were retrospectively reviewed. The study period extended from January 1993 to February 2009. Patients who underwent emergent or urgent re-exploration for post-operative bleeding were excluded. Primary outcomes included operative mortality and morbidity, as well as effusion recurrence. Recurrences were defined as having at least a moderate effusion on chest roentgenogram, computed tomography (CT) scan and/or echocardiogram that was performed based on the clinical suspicion. Secondary outcomes included reoperation rates for effusion recurrence as well as individual perioperative complication rates, including driveline infection. Driveline infection was defined according to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS): a positive culture from skin or tissue surrounding the driveline or the external housing of an implanted pump, with the need for treatment, when there is clinical evidence of infection (pain, fever, drainage and leukocytosis). The follow-up period extended from the time of VAD implantation to explantation, cardiac transplantation or death. Categorical variables were compared using Fisher's exact test. Continuous variables were compared using the unpaired t-test. Two-tailed P-values of <0.05 were considered statistically significant.
RESULTS
Patient characteristics
A total of 360 VADs were implanted at our institution over the study period. Forty-three (11.9%) of these patients required surgical intervention for pleural (n = 24), pericardial (n = 13) or both pleural and pericardial (n = 6) effusions while on VAD support. Pleural effusions were managed by an open approach in 7 patients and VATS in 17. Open surgery was used to manage a pericardial effusion in 12 patients, with 1 isolated pericardial effusion being drained by VATS. In patients with both pleural and pericardial effusions, open management was utilized in one patient and VATS in five. Age, gender and indication for VAD support were similar between those undergoing open and VATS management (Table 1). A smaller proportion of open patients were on biventricular support when compared with VATS patients (open 15%; VATS 57%; P = 0.01). The mean time between VAD insertion and operation for the effusion was significantly longer in the VATS group (open 14.3 days; VATS 26.7 days; P = 0.03). Pulmonary decortication was performed in addition to pleural drainage in two (10%) open and three (13%) VATS cases (P = 1).
Table 1.
Patient characteristics and operative approach
| Open (n = 20) | VATS (n = 23) | Significance (P-value) | |
|---|---|---|---|
| Age (years) | |||
| Mean | 47.9 | 49.0 | 0.82 |
| Range | 21–68 | 18–63 | |
| Gender | 15M, 5F | 16M, 7F | 0.74 |
| Indication for VAD | |||
| Ischaemic cardiomyopathy | 9 (45%) | 10 (43%) | 0.65 |
| Idiopathic cardiomyopathy | 8 (40%) | 11 (48%) | |
| Post-partum cardiomyopathy | 1 (5%) | 1 (4%) | |
| Myocarditis | 0 | 1 (4%) | |
| Alcohol-induced cardiomyopathy | 1 (5%) | 0 | |
| Chemotherapy-induced cardiomyopathy | 1 (5%) | 0 | |
| Device | |||
| BiVAD | 3 (15%) | 13 (57%) | 0.01 |
| LVAD | 17 (85%) | 10 (43%) | |
| Type of effusion | |||
| Pleural | 7 (35%) | 17 (74%) | 0.01 |
| Pericardial | 12 (60%) | 1 (4%) | 0.0001 |
| Both | 1 (5%) | 5 (22%) | 0.19 |
| Time between VAD implant and operation for effusion (days) | |||
| Mean | 14.3 | 26.7 | 0.03 |
| Range | 1–52 | 5–103 | |
| Laterality | |||
| Right | 5 (25%) | 11 (48%) | 0.21 |
| Left | 2 (10%) | 12 (52%) | 0.004 |
| Median | 13 (65%) | – | |
| Sternotomy | 12 | – | |
| Subxyphoid | 1 | – | |
| Type of operation | |||
| Drainage | 18 (90%) | 20 (87%) | 1 |
| Decortication | 2 (10%) | 3 (13%) | |
| Conversion to open | – | 4 (17%) | – |
BiVAD, biventricular assist device; LVAD, left ventricular assist device.
Perioperative outcomes
There was no operative mortality, and both overall and individual perioperative complication rates were comparable (Table 2). The incidence of driveline infection was lower in the VATS cohort but the difference did not reach statistical significance (open 30%; VATS 9%; P = 0.12). A total of four (17%) patients undergoing VATS required conversion to open. Conversions were due to impaired visualization due to dense adhesions (n = 2), difficulty with port placement secondary to cardiomegaly and adhesions (n = 1) and an inability to control port site bleeding (n = 1).
Table 2.
Perioperative outcomes
| Open (n = 20) | VATS (n = 23) | Significance (P-value) | |
|---|---|---|---|
| Operative mortality | 0 | 0 | 1 |
| Perioperative complications | 5 (25%) | 6a (26%) | 1 |
| Pneumonia | 1 (5%) | 2 (9%) | 1 |
| Respiratory failure | 0 | 1 (4%) | 1 |
| Transient ischeamic attack | 0 | 1 (4%) | 1 |
| Subcapsular liver hematoma | 0 | 1 (4%) | 1 |
| Splenic capsule fracture | 0 | 1 (4%) | 1 |
| Acute renal failure | 1 (5%) | 1 (4%) | 1 |
| Respiratory failure | 1 (5%) | 0 | 0.47 |
| Cerebral haemorrhage | 1 (5%) | 0 | 0.47 |
| Ventricular tachycardia | 1 (5%) | 0 | 0.47 |
| Stroke | 0 | 1 (4%) | 1 |
| Driveline infection | 6 (30%) | 2 (9%) | 0.12 |
aSome patients had more than one complication.
Effusions
The median follow-up was similar between approaches (open 107.5 days, VATS 123 days, P = 0.38; Table 3). The overall rate of pleural effusion recurrence was comparable between groups (open 63%, VATS 41%, P = 0.42). There was a statistical trend towards a lower rate of pleural effusion recurrence requiring reoperation with VATS (open 50%, VATS 14%, P = 0.06). There were no differences in overall pericardial effusion recurrence rates (open 31%, VATS 17%, P = 1) or reoperations for pericardial effusion recurrence (open 23%, VATS 0%, P = 0.52) between open and VATS. Furthermore, the improvement in left ventricular flow following the operative drainage of the pericardial effusion was similar between approaches (open 0.75 l/min, VATS 0.75 l/min, P = 0.99).
Table 3.
Post-operative outcomes
| Open (n = 20) | VATS (n = 23) | Significance (P-value) | |
|---|---|---|---|
| Pleural effusion recurrence | 5/8 (63%)a | 9/22 (41%)a | 0.42 |
| Reoperation for recurrence | 4 (50%) | 3 (14%) | 0.06 |
| No reoperation | 1 (13%) | 6 (27%) | 0.64 |
| Pericardial effusion recurrence | 4/13 (31%)a | 1/6 (17%)a | 1 |
| Reoperation for recurrence | 3 (23%) | 0 | 0.52 |
| No reoperation | 1 (8%) | 1 (17%) | 1 |
| Pericardial effusion—Left ventricular flow (l/min) | |||
| Preoperative | 4.9 | 5.1 | 0.52 |
| Post-operative | 5.6 | 5.9 | 0.54 |
| Improvement | 0.75 | 0.75 | 0.99 |
| Median follow-up (days) | 107.5 | 123 | 0.38 |
aIncidence per number of procedures; includes patients with both pleural and pericardial effusions.
DISCUSSION
Despite encouraging survival data in VAD recipients, many of these patients experience significant post-operative complications, including pleural and/or pericardial effusions [1, 2]. There is limited scientific literature on the outcomes of the operative drainage of pleural and pericardial effusions after VAD implantation [5–8]. This review provides details on pre- and post-operative outcomes on a relatively large group of VAD patients who had effusions drained operatively. When percutaneous drainage fails or cannot be safely performed, open surgery via thoracotomy, sternotomy or subxyphoid pericardial window, has been the standard approach to the management of patients with pleural space or pericardial complications. Our collective interest in developing safe, minimally invasive alternatives to open surgery has resulted in an increased number of VAD patients undergoing thoracoscopic pleural and pericardial evacuation. The perioperative outcome data suggest that pleural and pericardial effusions can be safely approached by VATS in patients on VAD support. Indeed, the morbidity and mortality rates were similar between VATS and open cases. In addition, the majority of the planned VATS procedures (83%) were successfully accomplished without the need for open conversion.
Cardiomegaly and hepatomegaly are common findings in the VAD population. Hepatomegaly may lead to upward shift of the right hemidiaphragm and, as a result, hinder visualization during VATS. In contrast to VATS performed for the same indications in other patients, the location of the port site used for initial access to the pleural cavity may need to be displaced cranially, in order to avoid injury to the diaphragm, liver and/or spleen. In addition, diaphragmatic traction sutures may need to be used to retract the dome of the diaphragm caudally and thereby improve the visualization of the pleural space and pericardium. Injury to the liver capsule may occur if diaphragmatic sutures are placed too deep, or excessive traction is applied. Proper preoperative planning and careful surgical technique are likely to prevent these problems. Moreover, special attention must be paid to reviewing the preoperative CT scan to aid in optimal port placement given the altered anatomy in many of these patients. In patients with a clinically significant pericardial effusion, the presence of a concurrent pleural effusion and the echocardiographic characteristics of the effusion can help the surgeon to decide between a left- or right-sided approach. Although pericardial effusions may be preferentially approached through a left VATS, hemodynamically significant, right-sided pericardial fluid collections may be best approached through the right pleural space. The pericardial sac is monitored intra-operatively using a transoesophageal echocardiogram (TEE) probe. The TEE aids in optimizing the location of the pericardial entry point and provides confirmation of the complete drainage of the pericardial effusion.
In the present study, drainage by VATS appeared to be as effective as the open surgical approach. Indeed, the rate of recurrence of pleural effusions was similar between groups. In addition, there was a statistical trend towards a lower probability of requiring additional surgical intervention after VATS pleural drainage when compared with open. In patients with pericardial effusions, overall recurrences and recurrences requiring reoperation were also equally distributed between the VATS and open groups. These findings lend support to the hypothesis that VATS is as effective as open surgery in the operative management of pleural and pericardial effusions in this patient population.
In the current study, patients undergoing VATS drainage experienced a lower driveline infection rate (9%) compared with the open cohort (30%). Although the difference may appear clinically relevant, it did not reach statistically significance. Driveline infection in VAD recipients represents a major complication and may be life-threatening, requiring intravenous antibiotics and/or exchanging of the device [9]. Serious infections can also lead to lengthier hospitalization and increased costs. The adverse effects of driveline infections underscore the importance of prevention. Over recent years, we have implemented protocols for the assessment and care of driveline incisions. The use of minimally invasive surgery to address symptomatic pleural and pericardial effusions has also been a part of attempts to prevent driveline infection. Potential advantages of VATS over open surgery include decreased exposure of the drivelines to the ambient environment (10 mm port sites versus larger open incision) and decreased immunosuppression as a result of diminished surgical trauma [2, 10, 11].
Aside from its retrospective nature, the present study has a few potential limitations. Standardized assessment (e.g. CT scan and TEE measurements) of the size of a given pericardial or pleural effusion was not uniformly available. Also, specific criteria for operative drainage, other than the clinical judgement of the surgeon, were not established a priori. Finally, the retrospective review of the clinical data did not allow for meaningful comparisons of post-operative pain or length of hospital stay between approaches, both of which have been shown to be improved with VATS [12–15]. Length of hospitalization after the initiation of VAD support likely depends on a multitude of factors beyond the potential impact of using minimally invasive surgery.
Retrospective study designs are associated with several shortcomings which limit the generalization of the results. It is clear that additional prospective data with larger patient cohorts are needed to further define the role of VATS in managing thoracic effusions in VAD patients. Meanwhile, our results indicate that VATS appears to be a suitable, safe and effective approach to manage pleural space and pericardial complications after VAD implantation.
Funding
Departmental Funds from the Heart, Lung, and Esophageal Surgery Institute of the University of Pittsburgh Medical Center.
Conflicts of interest: none declared.
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