, 2025-04-16 13:17:00
Use of routine thoracentesis in addition to medical therapy yielded no significant benefits for adults with heart failure and pleural effusions, according to a new study.
For patients with acute heart failure, “thoracentesis provides immediate symptom relief, but poses a risk of complications,” wrote Signe Glargaard, MD, of Copenhagen University Hospital, Copenhagen, Denmark, and colleagues in their recent study. In addition, no randomized trials have been conducted to support routine thoracentesis, and current guidelines provide no information on indications despite increasing use of the procedure, the researchers wrote.
In a study published in Circulation, the researchers randomized 135 adults with acute heart failure, pleural effusion, and left ventricular ejection fraction (LVEF) of 45% or less to ultrasound-guided thoracentesis plus standard medical care or standard care only. The patients came from 10 cardiology departments across Denmark; their median age was 81 years, and 33% were women. The median LVEF was 25%, and patients were randomized at a median of 21 hours after hospital admission. The thoracentesis group had a median of 1062 mL of fluid drained.
The primary outcome was the number of days alive out of the hospital (DAOH) during the 90 days from the start of the study. The DAOH was not significantly different between the thoracentesis group and the control group (84 days and 83 days, respectively), and the results persisted when stratified by site or anticoagulant therapy treatment status.
Measures of several secondary outcomes were similar in the two groups, including 90-day all-cause mortality (13% in both groups), in-hospital mortality (3% in each group), and survival probability (P = .90). The median number of days alive and not hospitalized because of heart failure was also similar between the thoracentesis and control groups (85 and 84 days, respectively), and 28 patients in each group experienced all-cause hospitalization during the first 90 days after treatment.
The overall complication rate for patients who underwent thoracentesis was 26%, including four cases of pneumothorax, one of which was several enough for intervention with a surgical drain, the researchers noted. Although no episodes of major bleeding, organ laceration, intrapleural infection, or reexpansion of pulmonary edema occurred, 25% of the patients who underwent thoracentesis reported minor discomfort during or after the procedure, the researchers noted.
The findings were limited by several factors including the unblinded design that contributed to the risk for bias, the researchers noted. Other limitations included the lack of data on completeness of decongestion or drainage and inability to draw conclusions from subgroup analyses because of the small sample size, they said.
However, the results suggest that guided medical therapy and reduction of filling pressures via diuretics should be the first-line treatment for acute heart failure patients with low LVEF and pleural effusion, the researchers concluded.
More research is needed to confirm the results and determine how thoracentesis might be useful in heart failure patients with pleural effusion, they added.
Study Supports Conservative Care
Decompensated heart failure is a common reason for hospitalization, and many patients present with pleural effusions, said Emily DuComb, DO, in an interview.
“It is important to determine whether rapidly resolving the pleural effusions with thoracenteses may expedite patient outcomes or whether conservative care is just as efficacious,” said DuComb, an interventional pulmonologist and clinical assistant professor of internal medicine at the University of Michigan, Ann Arbor, Michigan.
The findings of the study are not unexpected, said DuComb, who was not involved in the study. “Typically, small to moderate size effusions in the setting of heart failure improve with diuresis and do not require percutaneous drainage; pleural effusions often do not create marked symptoms until patients have very large effusions or have coexisting comorbidities which limit ability to tolerate diuresis,” she explained.
The current study confirms that most patients hospitalized with decompensated heart failure will improve with medical therapy alone, she said.
The takeaway for practice is that most patients have no reason to undergo therapeutic thoracenteses when hospitalized for heart failure, DuComb told Medscape Medical News.
Exceptions include patients who cannot tolerate diuresis, have massive effusions with hemodynamic compromise and/or intolerable symptoms, or have a suspected alternative cause of their pleural effusions, DuComb said.
“I agree with the authors that it would be worthwhile to evaluate the benefit of early therapeutic thoracenteses in select patient populations, such as those with limited tolerance of goal-directed medical therapy,” DuComb added.
The study was supported by the Independent Research Fund Denmark, the Hartmann Foundation, the Per Henriksen Fund, and the Research Foundation at Copenhagen University Hospital – Bispebjerg. Glargaard and DuComb had no financial conflicts to disclose.