Routine Thoracentesis in Acute Heart Failure: No Significant Clinical Benefit, Study Reports

"For patients with acute heart failure and pleural effusion, routine upfront thoracentesis offered no advantage over standard medical therapy alone in improving clinical outcomes at 90 days," the researchers reported in Circulation.

Pleural effusion is common in acute heart failure, with large effusions seen in about 20% of cases. Thoracentesis can provide immediate symptom relief but carries risks, and no randomized trials have assessed its benefits in heart-failure-related pleural effusion. With the increasing use of thoracentesis, there is a need for evidence. In the TAP-IT trial, Signe Glargaard, Department of Cardiology, Copenhagen University Hospital–Bispebjerg and Frederiksberg, Denmark, and colleagues examined the impact of adding therapeutic thoracentesis to standard medical therapy in patients with acute heart failure and significant pleural effusion.

For this purpose, the researchers conducted a multicenter, unblinded, randomized controlled trial between August 31, 2021, and March 22, 2024, involving patients with acute heart failure, left ventricular ejection fraction ≤45%, and notable pleural effusion. Those with very large effusions (over two-thirds of the hemithorax) were excluded. Participants were randomly assigned to either upfront ultrasound-guided pleural pigtail catheter thoracentesis with standard medical therapy or standard therapy alone.

The primary outcome was days alive out of the hospital over 90 days, while key secondary outcomes included length of hospital stay and 90-day all-cause mortality, analyzed using the intention-to-treat approach.

The study revealed the following findings:

• The trial included 135 patients with a median age of 81 years, 33% of whom were female.
• The median left ventricular ejection fraction was 25%.
• Patients were randomized into two groups: 68 received thoracentesis, while 67 received standard medical therapy.
• The thoracentesis group had a median of 84 days alive out of the hospital over 90 days, compared to 82 days in the control group.
• Mortality rates were identical at 13% in both groups, with no significant difference in survival probability.
• The median hospital stay was similar: 5 days in both groups.
• Major complications occurred in only 1% of thoracentesis procedures.

This trial, the first randomized study on thoracentesis for pleural effusion in heart failure, found that adding routine thoracentesis to standard medical therapy did not improve survival or reduce hospital stays over 90 days. The procedure was safe, with a low complication rate of 1%.

"While variability in outcomes may have affected statistical power, these findings provide a foundation for future research to further explore the role of thoracentesis in managing acute heart failure with pleural effusion," the authors concluded.

Reference: https://doi.org/10.1161/CIRCULATIONAHA.124.073521