The role of video-assisted thoracoscopic surgery for management of symptomatic pleural effusion after coronary artery bypass surgery: a best evidence topic report

Abstract

A best evidence topic in thoracic surgery was written addressing whether video-assisted thoracoscopic surgery (VATS) talc pleurodesis could be justified in patients with pleural effusion (PE) after coronary artery bypass graft (CABG) surgery and no-responded to repeated thoracentesis. Ten papers were identified to answer the question. Of these, two were case-series study including ≥4 patients, 7 retrospective analytical studies, and one observational study but no randomized controlled trial (RCTs) was included in the analysis. The score of the level of evidence was low; only one study presented a level of evidence of 2, 7 studies a level of 3b; and two studies a level of evidence of 4. The incidence of symptomatic post-CABG PE ranged from 2% to 9.7%. Management strategies included medical management, thoracentesis, and/ or surgical drainage. Most of the authors treated early and late PE with thoracentesis or chest drainage, while VATS with pleurodesis was reserved only for selected patients with persistent effusion after repeating thoracentesis and/or chest drainage. All studies but one do not include follow-up, thus rendering it difficult to define the real role of thoracentesis or chest drainage as definitive treatments for effusion, given the incomplete data regarding how many patients' effusions recur. Conversely, with follow up reported, no case of recurrence was found after VATS procedure. In patients who underwent delayed VATS, it was common to identify the formation of tenacious peel that trapped the lung. In three cases conversion to thoracotomy was required to decorticate the inflammatory peel that covered the pleura and did not allow the lung reexpansion. However, only five papers showed that VATS for management of post-CABG PEs is safe and efficacious and its use could help to prevent trapped lung through the resection of adhesions and loculations sometimes associated with multiple previous thoracentesis or chest drainage. As the low grade of evidence from the present analysis, future randomized controlled studies are wanted to define the real effectiveness of VATS in this field. Clinical scenarioA 57-year-old man was referred to your attention for the management of a left-sided symptomatic pleural effusion (PE). He underwent coronary artery bypass graft (CABG) surgery with a left internal thoracic artery (LITA) graft for unstable angina three months earlier. During follow-up, he had received two thoracentesis for symptomatic left-sided PE. Despite clinical improvements, each time the effusion re-accumulated, leading to a recrudescence of the dyspnoea. In both circumstances, the effusion fluid appeared serous with lymphocyte predominance but without neoplastic cells. How should this patient be managed and treated? Should we apply chest drainage and performing through that a blind talc pleurodesis (talc slurry), leaving him at risk of pleural adhesions formation or we should directly perform a video-assisted thoracoscopic surgery (VATS) talc pleurodesis in order to reduce the risk of PE rec...

Video-Assisted Thoracoscopic Surgery Management of Subacute Retained Blood Syndrome after Cardiac Surgery

“…Data on the feasibility and benefits of VATS after cardiac procedures remain scarce. Fiorelli et al 11) performed a systematic review of VATS pleurodesis to manage pleural effusion after coronary bypass surgery, and no-responded to repeated thoracentesis. Fiorelli and colleagues 11) included seven retrospective, two observational studies, and four case series in their systematic review.…”

“…Fiorelli et al 11) performed a systematic review of VATS pleurodesis to manage pleural effusion after coronary bypass surgery, and no-responded to repeated thoracentesis. Fiorelli and colleagues 11) included seven retrospective, two observational studies, and four case series in their systematic review. They concluded that VATS is safe and effective, and its use could help prevent trapped lungs through the resection of adhesions and loculations.…”

Clinical Presentation of Pleural Effusion Among Patients after CABG and its Prevalence

“…However, some CABG patients develop moderate to severe effusions that sometimes cause symptoms. Major pleural effusions occur in the early postoperatively duration with a frequency of 0.6-8.7% [5][6] . There are 2 types of pleural effusions that are related directly to CABG after surgery: atelectasis effusion due to diaphragmatic dysfunction and haemorrhagic effusion from harvesting of internal mammary artery (IMA).…”