Acute Pericardial Effusion after Hematopoietic Cell Transplantation: Single Center Experience

Pediatric hematopoietic cell transplant (HCT) is associated with significant morbidity and mortality despite advances in management of HCT-related complications. Cardiac complications, including pericardial effusion (PEF), are an underestimated subset of complications post-HCT, reported in 5-17% of adult HCT recipients. Pediatric literature is limited but suggests a prognostic impact on survival. We report a retrospective review study evaluating incidence, associations, and clinical course of clinically significant PEF (cPEF) following HCT in a large cohort comprised of 703 allogeneic HCT recipients at a single tertiary pediatric institution between January 2010 and December 2020.We defined cPEF as: symptomatic with moderate-large effusion on echocardiogram, clinical or echocardiographic evidence of tamponade, necessity of medical interventions or pericardiocentesis, or a combination of these.PEF was diagnosed in 141 patients; 68 were excluded based on PEF diagnosis: pre-HCT, after relapse or after second HCT. PEF was diagnosed in 10% (73/703) of patients, while ∼6% (40/703) had cPEF. Median time to PEF development was 92 days post-HCT.Of 40 patients with cPEF, 58% (n=23) were male and median age at transplantation was 13 years. The indication for HCT was hematological malignancy in 68% (n=27). Myeloablative conditioning was used in 70% (n=28). We identified cPEF within 100 days post-HCT in 53% (n=21). Half of patients with cPEF (n=20) were managed with observation alone. Twelve patients were managed medically either with diuretics, corticosteroids, NSAIDs or other anti-inflammatory drugs. Pericardiocentesis was performed in 20% (n=8), six of whom were initially managed with medications. Pericardial fluid analysis was unrevealing except for positive CMV PCR in 1 patient with known CMV viremia. Acute GVHD was noted in 30% (n=12) and chronic GVHD in 5% (n=2). TA-TMA was present in 45% (n=18) and CMV infection in 43% (n=17). Ultimately, 24 patients (60%) had resolution of cPEF. At 1-year post-HCT, 19/40 of patients (48%) with cPEF were alive .Landmark analysis demonstrated that out of the patients that remained alive at day 92, the patients that had already developed clinically significant PEF had a significantly higher risk of death (HR=2.579, p=0.0167) compared to those that had not yet developed any PEF. Further analyses using a control cohort of 502 patients without PEF are ongoing.The incidence of PEF in our cohort was comparable to what has been reported, with around half of patients developing cPEF. Clinically significant PEF post pediatric HCT is multifactorial. TA-TMA, CMV infection, and aGVHD commonly co-occurred with cPEF, and cPEF development within 92 days post-HCT was associated with increased mortality. Prospective studies identifying optimal screening, associations, and management of cPEF after pediatric HCT are necessary.