- Email: [email protected]
Decreased incidence of postoperative pericardial effusions after cardiac surgery for congenital heart disease
1. Ormiston JA, Shah PM, Tei C, Wong M. Size and motion of the mitral valve annulus in man: I. A two dimensional echocardiographic method and findings in nom&l subjects. Circulation 1980;64:113-120. 2. Ormiston JA, Shah PM, Tei C, Wong M. Size and motion of the mitral valve annulus in man: II. Abnormalities in mitral valve prolapse. Circulation 1981;65:713-719. 3. Perloff JK, Roberts WC. The mitral apparatus: fudctional anatomy of mitral regurgitation. Circulation 1972;46:227-239. 4. Davis PKB, Kinmonth JB. The movements of the annulus of the mitral valve. J Cardiovasc Surg 1963;4:427-431. 5. Tsakiris AG, Bemutb G, Rastelli GC, Bourgeois MJ, Titus JL, Wood EH. Size and motion of the mitral valve annulus in anesthetized intact dogs. JAppl Physiol 1971;30:611-618, 6. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenhaum H, Gutgesell H, Reichek N, Sahn D, Schnitgger I, Silverman NH, Tajik AJ. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Sot Echocardiogr 1989;2:358-367. 7. Vijayaraghavan G, Boltwood CM, Tei C, Wong M, Shah PM. Simplified ech+ cxdiogmphic measurement of mitral annulus. Am Heart J 1986;112:985-991. 8. Spain MG, Smith MD, Graybum PA, Harlamert EA, DeMaria AN, O’Brien M, Kwan OL. Quantitative assessment of mitral regurgitation by Doppler color flow imaging: angiographic and hemodynamic correlations. JAm Coil Cardiol 1989;13:585-590. 9. StatView Version 4.02 (1992-93), Abacus Concepts, Inc., Berkeley, California. 10. Sonnenblick EH, Napolitano LM, Daggett WM, Cooper T. An intxinsic neommuscular basis for mitral valve motion in tbe dog. Circ Res 1%7;21:9- 15.
1 I. Fenoglio JJ, Pham TD, Wit AL, Bassett AL, Wagner BM. Canine mitral complex: ultrastructure and electromechanical properties. Circ Res 1972;31: 417-430. 12. Zimmermann, Bailey CP. The surgical significance of the fibrous skeleton of the heart. J Thorac C’ardiovasc Surg 1962;44:701-712. 13. Chandraratna PAN, Aronow WS. Mitral valve ring in normal vs dilated left ventricle: cross-sectional echocardiographic study. Chest 1981;79: 151-155. 14. Yoran C, Yellin EL, Becker RM, Gabbay S, Frater RWM, Sonnenblick EH. Dynamic aspects of acute mitral regurgitation: effects of ventricular volume, pressure and contractility on effective regurgitant orifice area. Circulakm 1979;60:170-176. 15. Waller BF, Morrow AG, Maron BJ, De Negro AA, Kent KM, McGrath FJ, Wallace RB, McIntosh CL, Roberts WC. Etiology of clinically isolated, severe, chronic pure mitral regurgitation: analysis of 97 patients over 30 years of age having mitral valve replacement. Am Hean J 1982;104:276-288. 16. Sahbah HN, Rosman H, Kono T, Alam M, Kbaja F, Goldstein S. On the mechanisms of functional mitral regurgitation. Am J Cardiol 1993;72:10741076. 17. Sabbah HN, Kono T, Rosman H, Jafri S, Stein PD, Goldstein S. Left ventricular shape: a factor in tbe etiology of functional mitral regurgitation in heart failure. Am Hean J 1992;123:961-966. 18. Stoddard MF, Prince CR, Dillon S, Longaker RA, Morris GT, Liddell NE. Exercise-induced mitral regurgitation is a predictor of morbid events in subjects with mitral valve prolapse. J Am Coil Cardiol 1995;25:693699.
Decreased incidence of Postoperative Pericardial Eff usions After Cardiac Surgery for Congenital Heart Disease Anuradha
S. Prabhu,
MD, Robert D. Ross, MD, Maya
and Mehdi
Hakimi,
R. Heinert,
MD, Henry
L. Walters
III, MD,
MD
1000 echocardiographic machine. Effusions were assessed in the short-axis and apical views, and measured using M-mode and 2-dimensional echocardimay result from these effusions include postpericar- ography (Figure 1) . A significant effusion was diotomy syndrome in up to 25% to 30% of patients ‘,* defined as a separation of pericardial layers by 25 and cardiac tamponade, which has been reported to mm that persisted throughout the cardiac cycle. occur in 0.7% to 3% of postoperative patients.3-8 The Smaller effusions were recorded as trace. A followclinical significance, natural history, and manage- up echocardiographic evaluation was performed in ment of postoperative per&r-dial effusions have re- all patients before discharge from the hospital. The ceived little attention in recent pediatric literature. seasonal distribution of the effusion cases was anaThe reported incidence of postoperative pericardial lyzed using &i-square analysis. In all, 212 patients were studied with the first effusions has ranged from 53% to 85%.3,5,7,9,10 Over the last few years, our clinical impression is that echocardiogram recorded a median of 2 days (range the number of these effusions has decreased. This 2 to 4) after operation. Their ages ranged from 4 study examines the current incidence of postoperative pericardial effusions after open-heart surgery in children. ... This was a prospective study of patients undergoing intracardiac surgery from January 1992 to March 1995. All patients underwent a pericardiotomy as part of their surgical procedure. Patients with delayed sternal closure were excluded. Echocardiographic evaluation was performed at 2 to 4 days postoperatively using an HP Sonos 100 or HP pericardial effusion often occurs after openheart surgery and may contribute to postoperA ative morbidity and mortality. Complications that
From the Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michi an. Dr. Ross’s address is: De partment of Pediatric Cardiology, C\. rldren’s Hospital of Michi an, 390 1 Beaubien, Detroit, Michigan 4820 1 Manuscri 8 t receiv e&Y 1 1, 1995; revised manuscript received and occepte November 7, 1995.
774
THE AMERICAN
jOURNAL
OF CARDIOLOGY@’
VOL.
77
FIGURE 1. Two-dimensiord ~~~~~~~~,~~~i~~~~~~~~ial
APRIL 1, 1996
echocardiogmm
in the pamsternal effusion (EFF).
months to 18 years (median age 2.4 years), There were 113 male (53%) and 99 female (47%) patients. Twenty-nine patients ( 13.6%) had significant effusion, and an additional 11 (5%) had trace effusion; 170 (80%) had no effusion. Eight additional patients (4%) had a significant effusion on the follow-up study after an initial negative echocardiogram. The time interval between studies in this group was a median of 3.5 days (range 2 to 20). The patients had a wide variety of cardiac diagnoses and types of surgical repair performed. Although the numbers are few, pericardial effusion occurred more often in patients who underwent the Ross procedure (3 of 5). Interestingly, 2 of these patients who underwent the Ross procedure also developed the postpericardiotomy syndrome. No other particular cardiac diagnosis or type of surgery was significantly associated with a higher incidence of pericardial effusion. There was a seasonal variation in the incidence of pericardial effusion (Figure 2)) with a higher incidence in the winter months. Twenty patients (69%) had effusion in the months of October to March compared with 9 (3 1% ) who had effusion in the months of April to September. This difference was statistically significant (p < 0.05). Large effusions were treated with anti-inflammatory medication and no episodes of tamponade occurred. Five patients (2.3%) returned to the hospital with postpericardiotomy syndrome that required steroid therapy. This led to complete resolution in all patients. Of these 5 patients, 3 had effusions in the early postoperative period, and 2 did not. ... Postoperative per&-dial effusions after openheart surgery are most likely a local reaction to opening the pericardium, and may relate in part to how much pericardium remains after surgery. The precise etiology of the postpericardiotomy syndrome remains unclear, although several studies have suggested a relation to viral infections, autoimmune processes, or myocardial injury.‘~“~‘* The incidence of postoperative pericardial effusions was 13.6% in this study, which is much less than has been previously reported. In pediatric literature, Clapp et aL9 in 1980, studied a group of 40 children during postoperative days 0 to 10, and found a 53% incidence of pericardial effusions. Beland et al lo reported in 1990 a 65% incidence of pericardial effusions in 74 patients from postoperative days 4 to 28. Several adult studies have shown similar results with an effusion incidence of 56% by Stevenson et al in 1984,5 77% by Ikaheimo et al in 1988,3 and 85% by Weitzman et al in 1984.’ This apparent decrease in the number of postoperative pericardial effusions is likely to be related to many factors. These include improved surgical and anesthetic techniques, which over the last decade have led to better myocardial protection and improved postoperative hemodynamics. At the same time, the ability to quantitate accurately the presence and size of these effusions has substantially increased. False-positive pericardial effusions should not occur using current 2-dimensional echocardio-
+oPcAsEs so t&EFF
pta HITOTALpta
” JAN RB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTHS OF THE YEAR FIGURE 2. Seasonal dishibution of effusion cases. X-axis shows the months of the year; y-axis shows the number of cases studied. EFF = effusion.
graphic techniques, whereas the presence of the descending aorta in a posterior location may have been confused with pericardial effusion on the older Mmode studies.‘v9The addition of color flow Doppler can enhance sensitivity by identifying vascular structures. False-negative studies should also be minimal in that trace effusions may now be detected, which in the past may not have been seen before the availability of higher resolution transducers and zooming capabilities. No particular surgical procedure has been reported to be more commonly associated with pericardial effusions.3-6 Preliminary experience with the Ross procedure suggests a higher incidence of pericardial effusion and postpericardiotomy syndrome. This could relate to the extensive surgical dissection involved in this operation. Further monitoring of these patients should be performed to determine if this association persists over time. Engle et al ’ reported a seasonal variation in the incidence of postpericardiotomy syndrome, with more cases reported between February and July than between August and January, suggesting a relation to the changing seasonal patterns of viral illness. We observed a higher incidence of per&u-dial effusions in the winter months, which also suggests a possible association with a concurrent viral process. The development of postpericardiotomy syndrome in 2 patients who did not have pericardial effusions in the early postoperative period indicates that this development does not require the presence of a significant pericardial effusion in the immediate postoperative period. These patients would be more likely to have an autoimmune etiology for the late onset of pericardial effusion. This study does not directly compare the incidence of postoperative per&u-dial effusion in the same institution over 2 different time periods, but compares the recent incidence with reported studies from 1980 to 1990. As such, it can only suggest that the incidence of postoperative pericardial effusion is BRIEF REPORTS 775
decreasing. However, the striking difference in the reported incidence from 53% to 85% down to 13.6% in this study, and the low incidence of subsequent postpericardiotomy syndrome (2.3% ) are compelling evidence that there has been a true decrease in the occurrence of such effusions.
This study documents a decreasein the incidence of postoperativepericardial effusiousfollowing open heart surgery in children from 53% to 85% in published reports to 13.6% in this study. The incidence of postpericardiotomy syndrome has also decreased from a reported 25% to 30% to 2.3% in this study. These tidings may reflect improvement in surgical and myocardial protection techniques. Acknowledgment: We express our gratitude to James Pollock, RDMS, and Joellyn Gurczynski, ASCVT, for their assistance with performing the echocardiographic studies.
3. Ikaheimo MJ, Huikuri HV, Airaksinen J, Korhonen UR, Linnaluoto MK, Tarkka MR, Takkunen JT. Pericardial effusion after cardiac surgery: incidence, relation to the type of surgery, antitbrombotic therapy, and early coronary bypass graft patency. Am Heart J 1988;116:97-102. 4. Angelini GD, Penny WJ, El-Ghamary F, West RR, Butchart EG, Armistead SH, Breckemidge IM, Henderson AH. The incidence and significance of early pericardial effusion after open heart surgery. Eur J Cardiothorac Surg 1987;1:165-168. 5. Stevenson LW, Child JS, Laks H, Kern L. Incidence and significance of early pericardial effusions after cardiac surgery. Am J Cardiol 1984;54: 848-851. 6. Borkon MA, Schaff HV, Gardner TJ, Merrill WH, Brawley RK, Donahoo JS, Watkins L Jr, Weiss JL, Gott VL. Diagnosis and managementof postoperative pericardial effosions and late cardiac tamponadefollowing open heart surgery. Ann Thorac Surg 1981;31:512-519. 7. Weitzman LB, Tinker WP, Konzon I, Cohen ML, Glassman E, Spencer FC. The incidence and natural history of pericardial effusion after cardiac surgery-an echocardiographic study. Circulation 1984;69:506511. 8. Solem JO, Kugelberg J, Stahl E, Olim C. Late cardiac tamponadefollowing open heart surgery: diagnosis and treatment. Stand .I Thorac Cardiovasc Surg 1986;20:129-131. 9. Clapp SK, Garson A Jr, Gutgesell HP, Cooley DA, McNamara DG. Postoperative pericardial effusion and its relation to postpericardiotomy syndrome. Pediatrics 1980;66:585-588. 10. Beland MJ, Paquet M, Gibbons JE, Tchervenkov CI, Dobell ARC. Per-
cardial effusion after cardiac surgery in children and effects of aspirin for prevention. Am J Cardiol 1990;65:1238-1241. 11. Engle MA, Ehlers KH, O’Loughlin JE, Lindlay LA, Fried R. The postpericardiotomy syndrome: iatrogenic illness with immunologic and virologic com1. Engle MA, Zabriskie JB, Senterfit LB, Gay WA Jr, O’Loughlin JE Jr, Ehlers ponents. Cardiovasc Clin 1981;11:381-391. KH. Viral illness and the postpericardiotomy syndrome: a prospective study in 12. Nomura Y, Haraguchi YT, Oku S, Noda T, Miyata K, UmebayashiY, Taira children. Circtdation 1980;62:1151- 1158. A. Relationship between the degree of injury at operation and the change in 2. Dmsin LM, Engle MA, Hagstim JWC, SchwartzMS. The postpericardiotomy antimyosin antibody titer in the postpericardiotomy syndrome.Pediatr Cardiol syndrome:a six-year epidemiologicstudy.N Engl J Med 1965;272:597-602. 1994;15:116-120.
Comparison of Hospital Charges for Closure of Patent Ductus Arteriosus by Surgery and by Transcatheter Coil Occlusion Raymond
T. Fedderly, Edward
MD, Robert H. Beekman III, MD, Ralph S. Mosca, L. Bove, MD, and Thomas R. Lloyd, MD
r
anscatbeter occlusion by Gianturco coils is a recently described alternative”’ to traditional surgical closure of patent ductus arteriosus (PDA). It is clear that economic considerations are important in the adoption of novel medical treatments, joining the more traditional issues of efficacy, safety, and patient acceptance. A recent multi-institutional study of resource utilization for the Rashkind PDA Oc.eluder@ concluded that surgical closure of isolated PDA was more effective and less costly than transcatheter closure.3 This study compares contemporaneous hospital charges at a single institution for closure of PDA by surgery and by transcatheter occlusion using Gianturco coils. ... All patients who underwent elective closure of a PDA at C.S. Mott Children’s Hospital between July 1992 and November 1993 were identified by From the Division of Pediatric Cardiology, Department of Pediatrics, C.S. Mott Children’s Hospital, The University of Michigan Medical Center, Ann Arbor, Michigan 48 109-0204. Dr. Fedderly’s address is: Children’s Hospital of Wisconsin, Department of Pediatric Cardiology, 9000 West Wisconsin Avenue, Milwaukee, Wisconsin 53226-35 18. Manuscript received July 2 1, 1995; revised manuscript received and accepted November 8, 1995.
776
THE AMERICAN
JOURNAL
OF CARDIOLOGY@
VOL.
77
MD,
review of cardiac catheterization and surgical records. To reduce confounding by charges of treating coexisting cardiac disease or neonatal conditions, patients aged <6 months at the time of ductus closure and patients with significant associated heart disease were excluded. Hospital bills for the remaining 44 patients were reviewed and total hospital charges ascertained. These charges included room rates and nursing care, operating room or catheterization laboratory charges, anesthesia supplies and recovery room charges, pharmacy, clinical laboratory, and radiology charges, and miscellaneous charges. Professional fees (i.e., cardiologists, surgeons, anesthesiologists, radiologists) were not included. Patients were assigned to coil occlusion or to surgery based on the preference of the referring physician or of the patient or family. Patients in the coil occlusion group were divided into 3 subgroups based on the clinical protocol in use at the time of their coil procedure. Patients in the original coil protocol had coils implanted under general anesthesia, and were observed overnight as hospital inpatients after their procedures. Right-sided cardiac catheterization was performed before coil implantation, and repeated APRll
1, 1996
1 I. Fenoglio JJ, Pham TD, Wit AL, Bassett AL, Wagner BM. Canine mitral complex: ultrastructure and electromechanical properties. Circ Res 1972;31: 417-430. 12. Zimmermann, Bailey CP. The surgical significance of the fibrous skeleton of the heart. J Thorac C’ardiovasc Surg 1962;44:701-712. 13. Chandraratna PAN, Aronow WS. Mitral valve ring in normal vs dilated left ventricle: cross-sectional echocardiographic study. Chest 1981;79: 151-155. 14. Yoran C, Yellin EL, Becker RM, Gabbay S, Frater RWM, Sonnenblick EH. Dynamic aspects of acute mitral regurgitation: effects of ventricular volume, pressure and contractility on effective regurgitant orifice area. Circulakm 1979;60:170-176. 15. Waller BF, Morrow AG, Maron BJ, De Negro AA, Kent KM, McGrath FJ, Wallace RB, McIntosh CL, Roberts WC. Etiology of clinically isolated, severe, chronic pure mitral regurgitation: analysis of 97 patients over 30 years of age having mitral valve replacement. Am Hean J 1982;104:276-288. 16. Sahbah HN, Rosman H, Kono T, Alam M, Kbaja F, Goldstein S. On the mechanisms of functional mitral regurgitation. Am J Cardiol 1993;72:10741076. 17. Sabbah HN, Kono T, Rosman H, Jafri S, Stein PD, Goldstein S. Left ventricular shape: a factor in tbe etiology of functional mitral regurgitation in heart failure. Am Hean J 1992;123:961-966. 18. Stoddard MF, Prince CR, Dillon S, Longaker RA, Morris GT, Liddell NE. Exercise-induced mitral regurgitation is a predictor of morbid events in subjects with mitral valve prolapse. J Am Coil Cardiol 1995;25:693699.
Decreased incidence of Postoperative Pericardial Eff usions After Cardiac Surgery for Congenital Heart Disease Anuradha
S. Prabhu,
MD, Robert D. Ross, MD, Maya
and Mehdi
Hakimi,
R. Heinert,
MD, Henry
L. Walters
III, MD,
MD
1000 echocardiographic machine. Effusions were assessed in the short-axis and apical views, and measured using M-mode and 2-dimensional echocardimay result from these effusions include postpericar- ography (Figure 1) . A significant effusion was diotomy syndrome in up to 25% to 30% of patients ‘,* defined as a separation of pericardial layers by 25 and cardiac tamponade, which has been reported to mm that persisted throughout the cardiac cycle. occur in 0.7% to 3% of postoperative patients.3-8 The Smaller effusions were recorded as trace. A followclinical significance, natural history, and manage- up echocardiographic evaluation was performed in ment of postoperative per&r-dial effusions have re- all patients before discharge from the hospital. The ceived little attention in recent pediatric literature. seasonal distribution of the effusion cases was anaThe reported incidence of postoperative pericardial lyzed using &i-square analysis. In all, 212 patients were studied with the first effusions has ranged from 53% to 85%.3,5,7,9,10 Over the last few years, our clinical impression is that echocardiogram recorded a median of 2 days (range the number of these effusions has decreased. This 2 to 4) after operation. Their ages ranged from 4 study examines the current incidence of postoperative pericardial effusions after open-heart surgery in children. ... This was a prospective study of patients undergoing intracardiac surgery from January 1992 to March 1995. All patients underwent a pericardiotomy as part of their surgical procedure. Patients with delayed sternal closure were excluded. Echocardiographic evaluation was performed at 2 to 4 days postoperatively using an HP Sonos 100 or HP pericardial effusion often occurs after openheart surgery and may contribute to postoperA ative morbidity and mortality. Complications that
From the Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michi an. Dr. Ross’s address is: De partment of Pediatric Cardiology, C\. rldren’s Hospital of Michi an, 390 1 Beaubien, Detroit, Michigan 4820 1 Manuscri 8 t receiv e&Y 1 1, 1995; revised manuscript received and occepte November 7, 1995.
774
THE AMERICAN
jOURNAL
OF CARDIOLOGY@’
VOL.
77
FIGURE 1. Two-dimensiord ~~~~~~~~,~~~i~~~~~~~~ial
APRIL 1, 1996
echocardiogmm
in the pamsternal effusion (EFF).
months to 18 years (median age 2.4 years), There were 113 male (53%) and 99 female (47%) patients. Twenty-nine patients ( 13.6%) had significant effusion, and an additional 11 (5%) had trace effusion; 170 (80%) had no effusion. Eight additional patients (4%) had a significant effusion on the follow-up study after an initial negative echocardiogram. The time interval between studies in this group was a median of 3.5 days (range 2 to 20). The patients had a wide variety of cardiac diagnoses and types of surgical repair performed. Although the numbers are few, pericardial effusion occurred more often in patients who underwent the Ross procedure (3 of 5). Interestingly, 2 of these patients who underwent the Ross procedure also developed the postpericardiotomy syndrome. No other particular cardiac diagnosis or type of surgery was significantly associated with a higher incidence of pericardial effusion. There was a seasonal variation in the incidence of pericardial effusion (Figure 2)) with a higher incidence in the winter months. Twenty patients (69%) had effusion in the months of October to March compared with 9 (3 1% ) who had effusion in the months of April to September. This difference was statistically significant (p < 0.05). Large effusions were treated with anti-inflammatory medication and no episodes of tamponade occurred. Five patients (2.3%) returned to the hospital with postpericardiotomy syndrome that required steroid therapy. This led to complete resolution in all patients. Of these 5 patients, 3 had effusions in the early postoperative period, and 2 did not. ... Postoperative per&-dial effusions after openheart surgery are most likely a local reaction to opening the pericardium, and may relate in part to how much pericardium remains after surgery. The precise etiology of the postpericardiotomy syndrome remains unclear, although several studies have suggested a relation to viral infections, autoimmune processes, or myocardial injury.‘~“~‘* The incidence of postoperative pericardial effusions was 13.6% in this study, which is much less than has been previously reported. In pediatric literature, Clapp et aL9 in 1980, studied a group of 40 children during postoperative days 0 to 10, and found a 53% incidence of pericardial effusions. Beland et al lo reported in 1990 a 65% incidence of pericardial effusions in 74 patients from postoperative days 4 to 28. Several adult studies have shown similar results with an effusion incidence of 56% by Stevenson et al in 1984,5 77% by Ikaheimo et al in 1988,3 and 85% by Weitzman et al in 1984.’ This apparent decrease in the number of postoperative pericardial effusions is likely to be related to many factors. These include improved surgical and anesthetic techniques, which over the last decade have led to better myocardial protection and improved postoperative hemodynamics. At the same time, the ability to quantitate accurately the presence and size of these effusions has substantially increased. False-positive pericardial effusions should not occur using current 2-dimensional echocardio-
+oPcAsEs so t&EFF
pta HITOTALpta
” JAN RB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC MONTHS OF THE YEAR FIGURE 2. Seasonal dishibution of effusion cases. X-axis shows the months of the year; y-axis shows the number of cases studied. EFF = effusion.
graphic techniques, whereas the presence of the descending aorta in a posterior location may have been confused with pericardial effusion on the older Mmode studies.‘v9The addition of color flow Doppler can enhance sensitivity by identifying vascular structures. False-negative studies should also be minimal in that trace effusions may now be detected, which in the past may not have been seen before the availability of higher resolution transducers and zooming capabilities. No particular surgical procedure has been reported to be more commonly associated with pericardial effusions.3-6 Preliminary experience with the Ross procedure suggests a higher incidence of pericardial effusion and postpericardiotomy syndrome. This could relate to the extensive surgical dissection involved in this operation. Further monitoring of these patients should be performed to determine if this association persists over time. Engle et al ’ reported a seasonal variation in the incidence of postpericardiotomy syndrome, with more cases reported between February and July than between August and January, suggesting a relation to the changing seasonal patterns of viral illness. We observed a higher incidence of per&u-dial effusions in the winter months, which also suggests a possible association with a concurrent viral process. The development of postpericardiotomy syndrome in 2 patients who did not have pericardial effusions in the early postoperative period indicates that this development does not require the presence of a significant pericardial effusion in the immediate postoperative period. These patients would be more likely to have an autoimmune etiology for the late onset of pericardial effusion. This study does not directly compare the incidence of postoperative per&u-dial effusion in the same institution over 2 different time periods, but compares the recent incidence with reported studies from 1980 to 1990. As such, it can only suggest that the incidence of postoperative pericardial effusion is BRIEF REPORTS 775
decreasing. However, the striking difference in the reported incidence from 53% to 85% down to 13.6% in this study, and the low incidence of subsequent postpericardiotomy syndrome (2.3% ) are compelling evidence that there has been a true decrease in the occurrence of such effusions.
This study documents a decreasein the incidence of postoperativepericardial effusiousfollowing open heart surgery in children from 53% to 85% in published reports to 13.6% in this study. The incidence of postpericardiotomy syndrome has also decreased from a reported 25% to 30% to 2.3% in this study. These tidings may reflect improvement in surgical and myocardial protection techniques. Acknowledgment: We express our gratitude to James Pollock, RDMS, and Joellyn Gurczynski, ASCVT, for their assistance with performing the echocardiographic studies.
3. Ikaheimo MJ, Huikuri HV, Airaksinen J, Korhonen UR, Linnaluoto MK, Tarkka MR, Takkunen JT. Pericardial effusion after cardiac surgery: incidence, relation to the type of surgery, antitbrombotic therapy, and early coronary bypass graft patency. Am Heart J 1988;116:97-102. 4. Angelini GD, Penny WJ, El-Ghamary F, West RR, Butchart EG, Armistead SH, Breckemidge IM, Henderson AH. The incidence and significance of early pericardial effusion after open heart surgery. Eur J Cardiothorac Surg 1987;1:165-168. 5. Stevenson LW, Child JS, Laks H, Kern L. Incidence and significance of early pericardial effusions after cardiac surgery. Am J Cardiol 1984;54: 848-851. 6. Borkon MA, Schaff HV, Gardner TJ, Merrill WH, Brawley RK, Donahoo JS, Watkins L Jr, Weiss JL, Gott VL. Diagnosis and managementof postoperative pericardial effosions and late cardiac tamponadefollowing open heart surgery. Ann Thorac Surg 1981;31:512-519. 7. Weitzman LB, Tinker WP, Konzon I, Cohen ML, Glassman E, Spencer FC. The incidence and natural history of pericardial effusion after cardiac surgery-an echocardiographic study. Circulation 1984;69:506511. 8. Solem JO, Kugelberg J, Stahl E, Olim C. Late cardiac tamponadefollowing open heart surgery: diagnosis and treatment. Stand .I Thorac Cardiovasc Surg 1986;20:129-131. 9. Clapp SK, Garson A Jr, Gutgesell HP, Cooley DA, McNamara DG. Postoperative pericardial effusion and its relation to postpericardiotomy syndrome. Pediatrics 1980;66:585-588. 10. Beland MJ, Paquet M, Gibbons JE, Tchervenkov CI, Dobell ARC. Per-
cardial effusion after cardiac surgery in children and effects of aspirin for prevention. Am J Cardiol 1990;65:1238-1241. 11. Engle MA, Ehlers KH, O’Loughlin JE, Lindlay LA, Fried R. The postpericardiotomy syndrome: iatrogenic illness with immunologic and virologic com1. Engle MA, Zabriskie JB, Senterfit LB, Gay WA Jr, O’Loughlin JE Jr, Ehlers ponents. Cardiovasc Clin 1981;11:381-391. KH. Viral illness and the postpericardiotomy syndrome: a prospective study in 12. Nomura Y, Haraguchi YT, Oku S, Noda T, Miyata K, UmebayashiY, Taira children. Circtdation 1980;62:1151- 1158. A. Relationship between the degree of injury at operation and the change in 2. Dmsin LM, Engle MA, Hagstim JWC, SchwartzMS. The postpericardiotomy antimyosin antibody titer in the postpericardiotomy syndrome.Pediatr Cardiol syndrome:a six-year epidemiologicstudy.N Engl J Med 1965;272:597-602. 1994;15:116-120.
Comparison of Hospital Charges for Closure of Patent Ductus Arteriosus by Surgery and by Transcatheter Coil Occlusion Raymond
T. Fedderly, Edward
MD, Robert H. Beekman III, MD, Ralph S. Mosca, L. Bove, MD, and Thomas R. Lloyd, MD
r
anscatbeter occlusion by Gianturco coils is a recently described alternative”’ to traditional surgical closure of patent ductus arteriosus (PDA). It is clear that economic considerations are important in the adoption of novel medical treatments, joining the more traditional issues of efficacy, safety, and patient acceptance. A recent multi-institutional study of resource utilization for the Rashkind PDA Oc.eluder@ concluded that surgical closure of isolated PDA was more effective and less costly than transcatheter closure.3 This study compares contemporaneous hospital charges at a single institution for closure of PDA by surgery and by transcatheter occlusion using Gianturco coils. ... All patients who underwent elective closure of a PDA at C.S. Mott Children’s Hospital between July 1992 and November 1993 were identified by From the Division of Pediatric Cardiology, Department of Pediatrics, C.S. Mott Children’s Hospital, The University of Michigan Medical Center, Ann Arbor, Michigan 48 109-0204. Dr. Fedderly’s address is: Children’s Hospital of Wisconsin, Department of Pediatric Cardiology, 9000 West Wisconsin Avenue, Milwaukee, Wisconsin 53226-35 18. Manuscript received July 2 1, 1995; revised manuscript received and accepted November 8, 1995.
776
THE AMERICAN
JOURNAL
OF CARDIOLOGY@
VOL.
77
MD,
review of cardiac catheterization and surgical records. To reduce confounding by charges of treating coexisting cardiac disease or neonatal conditions, patients aged <6 months at the time of ductus closure and patients with significant associated heart disease were excluded. Hospital bills for the remaining 44 patients were reviewed and total hospital charges ascertained. These charges included room rates and nursing care, operating room or catheterization laboratory charges, anesthesia supplies and recovery room charges, pharmacy, clinical laboratory, and radiology charges, and miscellaneous charges. Professional fees (i.e., cardiologists, surgeons, anesthesiologists, radiologists) were not included. Patients were assigned to coil occlusion or to surgery based on the preference of the referring physician or of the patient or family. Patients in the coil occlusion group were divided into 3 subgroups based on the clinical protocol in use at the time of their coil procedure. Patients in the original coil protocol had coils implanted under general anesthesia, and were observed overnight as hospital inpatients after their procedures. Right-sided cardiac catheterization was performed before coil implantation, and repeated APRll
1, 1996