Pericardial Effusion After Heart Transplantation: A Host of Possibilities
A 61-year-old man with a history of obstructive sleep apnea, paroxysmal atrial fibrillation and dilated non-ischemic cardiomyopathy was admitted to the hospital for orthotopic heart transplantation. His preoperative left ventricular ejection fraction was 15% and left ventricular end-diastolic diameter was 7.2 cm. The patient's body mass index was 28 kg/m2. The body mass index of the donor was unknown. Serologies showed that both the donor and recipient were positive for prior cytomegalovirus and Epstein-Barr virus antibodies.
The patient underwent an uncomplicated heart transplant surgery with bicaval anastomosis technique. The donor heart's cold ischemic time was 201 minutes. Methylprednisolone and basiliximab were given for immunosuppression induction, followed by a maintenance immunosuppression regimen of mycophenolate mofetil 1g twice daily and prednisone 20mg once daily. Tacrolimus was added nine days after transplantation. Trimethoprim-sulfamethoxazole and valganciclovir were given for antimicrobial prophylaxis.
A surveillance endomyocardial biopsy performed ten days after transplantation showed evidence of moderate acute cellular rejection (grade 2R). An echocardiogram performed on the same day (prior to the endomyocardial biopsy) showed a large concentric pericardial effusion, with greatest dimension 2.1cm posterior to the left ventricle (Figure 1). There was no diastolic chamber collapse and no significant respiratory variation in the mitral and tricuspid inflow velocities (Figure 2A). The inferior vena cava diameter was 0.8cm with collapse >50% during inspiration (Figure 2B). Left and right ventricular size and function were normal. The patient was asymptomatic with temperature 97.9 °F, blood pressure 113/69 mmHg, heart rate 86 beats per minute, respiratory rate 16 breaths per minute, and peripheral oxygen saturation 98%. Electrocardiogram is shown in Figure 3. Laboratory studies were notable for creatinine 1.0, white blood cell count 6,000/mm3, hemoglobin 10.0 g/dL, platelet count 446,000/mm3, and international normalized ratio 1.2.
Which of the following is the best next step in management of this patient?