Therapeutic Thoracentesis Adds No Benefit Over Diuretics in Acute Heart Failure with Pleural Effusion: Study

A new study published in the journal of Circulation found that left ventricular ejection fraction <=45%, and moderate pleural effusion, diuretics and guideline-directed medical therapy should remain the primary approach for patients with acute heart failure. Adding therapeutic thoracentesis does not improve hospital stay duration or 90-day outcomes. Therefore among patients with acute heart failure, reduced ejection fraction (≤45%), and moderate pleural effusion, targeting filling pressure reduction with diuretics and guideline-directed therapy should be prioritized.

More than half of patients with acute decompensated heart failure who are admitted to the hospital have pleural effusion. The effusion takes up more than one-third of the hemithorax in about 20% of individuals. The patients with sizable effusions may benefit from invasive drainage with therapeutic thoracentesis to alleviate dyspnea. Thus, TAP-IT (Thoracentesis to Alleviate Cardiac Pleural Effusion–Interventional Trial) examined the impact of therapeutic thoracentesis together with conventional medical treatment in patients who had a significant pleural effusion and acute heart failure.

The patients with non-negligible pleural effusion, acute heart failure, and a left ventricular ejection fraction ≤45% were enrolled in this study, which ran from August 31, 2021, to March 22, 2024. Individuals who had effusions that covered more than two-thirds of their hemithorax were not included. The participants were randomized 1:1 to receive regular medical therapy with upfront ultrasound-guided pleural pigtail catheter thoracentesis, or standard medical therapy only. Days alive out of the hospital over the next 90 days were the main outcome, the length of hospital stay and 90-day all-cause mortality were important secondary outcomes. 

Either thoracentesis (n=68) or normal medical therapy (n=67) were randomly assigned to 135 patients (median age, 81 years [25th; 75th percentile, 75; 83]; 33% female; median left ventricular ejection fraction, 25% [25th; 75th percentile, 20%; 35%]). Over the next 90 days, the median time out of the hospital for the thoracentesis group was 84 days (77; 86), whereas the control group's was 82 days (73; 86) (P=0.42). There was no difference in the survival probability between the two groups, and the death rate was 13% (P=0.90).

The median length of the index hospitalization was 5 days [3; 8] for the control group and 5 days [3; 7] for the thoracentesis group (P=0.69). Major complications occurred in 1% of thoracenteses done during the research period. Overall, the number of days that participants were living and out of the hospital in the next 90 days was not increased by referring patients with heart failure who were hospitalized with a lower ejection fraction and pleural effusion to regular thoracentesis. 

Source:

Glargaard, S., Thomsen, J. H., Tuxen, C., Lindholm, M. G., Bang, C. A., Schou, M., Iversen, K., Rasmussen, R. V., Løgstrup, B. B., Vraa, S., Stride, N., Seven, E., Barasa, A., Tofterup, M., Høfsten, D. E., Rossing, K., Køber, L., Gustafsson, F., & Thune, J. J. (2025). A randomized controlled trial of thoracentesis in acute heart failure. Circulation, 151(16), 1150–1161. https://doi.org/10.1161/CIRCULATIONAHA.124.073521