Rare Presentation of Postpericardiotomy Syndrome After Left Atrial Myxoma Removal.

Postpericardiotomy syndrome (PPS) is a known complication of cardiac valve surgery, but it has not been commonly reported as a postoperative complication of cardiac myxoma removal. A 78-year-old female with hypertension and atrial fibrillation presenting with angina was found to have a large left atrial myxoma (7.5 cm × 4.4 cm). The myxoma was resected; however, 1-week postoperation hemoglobin and blood pressure decreased with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Limited transthoracic echocardiogram (TTE) showed moderate pericardial effusion, confirming the diagnosis of PPS. This case highlights the importance of monitoring patients postremoval of myxoma for symptoms of PPS.

Pericarditis aguda complicada con derrame pericárdico: Caso clínico pediátrico / Acute pericarditis, complicated by pericardial effusion in a pediatric patient: case report

La pericarditis aguda es la enfermedad más común del pericardio en la práctica clínica. Supone el 0,1% de todos los ingresos hospitalarios y hasta un 5% de aquellos por dolor torácico. En países desarrollados, la causa suele ser benigna, y son más frecuentes las idiopáticas e infecciosas que las secundarias a pericardiotomía quirúrgica y neoplasias. La tuberculosis es la causa más importante en países en vías de desarrollo. Los síntomas más comunes son el dolor torácico característico y la fiebre. Debido a su benignidad y buena evolución con reposo y tratamiento médico, se puede controlar de forma ambulatoria, teniendo presentes aquellos signos de alarma para vigilar o pacientes de riesgo para evitar complicaciones (derrames importantes, taponamiento cardíaco, recurrencias, etc.). Presentamos un caso clínico de un niño de 7 años con antecedentes de comunicación interauricular cerrada quirúrgicamente 9 meses antes, con un cuadro de pericarditis aguda de evolución favorable.

Acute pericarditis is the most common disease of the pericardium encountered in clinical practice. It is diagnosed in 0.1% of all admissions and 5% of emergency room admissions for chest pain. In developed countries, it is usually due to a benign cause. Idiopathic and infectious pericarditis are more common than secondary to surgical pericardiotomy or neoplastic causes, whereas tuberculosis is the dominant cause in developing countries. The most common symptoms of pericarditis are characteristic chest pain and fever. Since pericarditis presents a benign outcome because of self-limiting and good response to conventional anti-inflammatory therapy, it can be safely managed on outpatient basis unless a specific cause is suspected or the patient has high-risk features to avoid complications such as pericardial effusion, cardiac tamponade or recurrent pericarditis. We report a case of pericarditis, diagnosed 9 months after surgical closure of an atrial septal defect, in a 7-year-old boy with favorable evolution.

[Acute pericarditis, complicated by pericardial effusion in a pediatric patient: case report]. / Pericarditis aguda complicada con derrame pericárdico. Caso clínico pediátrico.

Acute pericarditis is the most common disease of the pericardium encountered in clinical practice. It is diagnosed in 0.1% of all admissions and 5% of emergency room admissions for chest pain. In developed countries, it is usually due to a benign cause. Idiopathic and infectious pericarditis are more common than secondary to surgical pericardiotomy or neoplastic causes, whereas tuberculosis is the dominant cause in developing countries. The most common symptoms of pericarditis are characteristic chest pain and fever. Since pericarditis presents a benign outcome because of self-limiting and good response to conventional anti-inflammatory therapy, it can be safely managed on outpatient basis unless a specific cause is suspected or the patient has high-risk features to avoid complications such as pericardial effusion, cardiac tamponade or recurrent pericarditis. We report a case of pericarditis, diagnosed 9 months after surgical closure of an atrial septal defect, in a 7-year-old boy with favorable evolution.

La pericarditis aguda es la enfermedad más común del pericardio en la práctica clínica. Supone el 0,1% de todos los ingresos hospitalarios y hasta un 5% de aquellos por dolor torácico. En países desarrollados, la causa suele ser benigna, y son más frecuentes las idiopáticas e infecciosas que las secundarias a pericardiotomía quirúrgica y neoplasias. La tuberculosis es la causa más importante en países en vías de desarrollo. Los síntomas más comunes son el dolor torácico característico y la fiebre. Debido a su benignidad y buena evolución con reposo y tratamiento médico, se puede controlar de forma ambulatoria, teniendo presentes aquellos signos de alarma para vigilar o pacientes de riesgo para evitar complicaciones (derrames importantes, taponamiento cardíaco, recurrencias, etc.). Presentamos un caso clínico de un niño de 7 años con antecedentes de comunicación interauricular cerrada quirúrgicamente 9 meses antes, con un cuadro de pericarditis aguda de evolución favorable.

Role of diclofenac in the prevention of postpericardiotomy syndrome after cardiac surgery.

OBJECTIVE: Postpericardiotomy syndrome (PPS), which is thought to be related to autoimmune phenomena, represents a common postoperative complication in cardiac surgery. Late pericardial effusions after cardiac surgery are usually related to PPS and can progress to cardiac tamponade. Preventive measures can reduce postoperative morbidity and mortality related to PPS. In a previous study, diclofenac was suggested to ameliorate autoimmune diseases. The aim of this study was to determine whether postoperative use of diclofenac is effective in preventing early PPS after cardiac surgery. METHODS: A total of 100 patients who were administered oral diclofenac for postoperative analgesia after cardiac surgery and until hospital discharge were included in this retrospective study. As well, 100 patients undergoing cardiac surgery who were not administered nonsteroidal anti-inflammatory drugs were included as the control group. The existence and severity of pericardial effusion were determined by echocardiography. The existence and severity of pleural effusion were determined by chest X-ray. RESULTS: PPS incidence was significantly lower in patients who received diclofenac (20% vs. 43%) (P<0.001). Patients given diclofenac had a significantly lower incidence of pericardial effusion (15% vs. 30%) (P=0.01). Although not statistically significant, pericardial and pleural effusion was more severe in the control group than in the diclofenac group. The mean duration of diclofenac treatment was 5.11±0.47 days in patients with PPS and 5.27±0.61 days in patients who did not have PPS (P=0.07). Logistic regression analysis demonstrated that diclofenac administration (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.18-0.65, P=0.001) was independently associated with PPS occurrence. CONCLUSION: Postoperative administration of diclofenac may have a protective role against the development of PPS after cardiac surgery.

Postcardiotomy syndrome: recurrent cardiac tamponade and an exquisite steroid response.

A 26-year-old woman presented moribund with fever and pleuritic chest pain 3 times in 4 months following elective aortic root surgery. She was admitted 41 days after surgery with cardiac tamponade requiring surgical drainage twice within 1 week. Despite this, she was re-admitted for a second time 4 days after discharge with persistent pericardial effusion. High fevers and an incidental regurgitant murmur were extensively investigated for and treated as possible endocarditis or graft infection without conclusive results. The patient spent a total of 61 days in hospital during this period, receiving seven different antibiotic courses. Her third admission, with most severe clinical features, nearly led to further surgery and removal of her aortic graft but instead culminated in a multidisciplinary team decision to initiate steroid therapy for postcardiotomy syndrome. A short course of oral prednisolone saw her pericardial effusion and symptoms resolve completely.

Right ventricular failure due to postpericardiotomy syndrome following transvenous dual chamber permanent pacemaker implantation.

"Pericardial effusion and tamponade are recognised complications of permanent transvenous pacemakers implantation. This is more common when active fixation leads are used. We describe a patient who developed right ventricular failure with significant pericardial effusion following permanent transvenous pacemaker implantation."

The changing aetiological spectrum of pericarditis in children.

The aetiologies, clinical features and follow-up data of 62 children with pericarditis admitted to a university hospital during a 6-year period were retrospectively assessed. Uraemic pericarditis was the most frequent and infections the second most frequent cause. In this series, the proportion of children with purulent pericarditis is less than in previous reports from developing countries. Familial Mediterranean fever, neoplasias, acute rheumatic fever and post-pericardiotomy syndrome were other important causes of pericarditis.

The postpericardiotomy syndrome as a cause of pleurisy in rehabilitation patients.

Pleuritic chest pain in patients on a rehabilitation unit may be caused by several conditions. We report 2 cases of postpericardiotomy syndrome (PPS) as a cause of pleuritic pain. PPS occurs in 10% to 40% of patients who have coronary bypass or valve replacement surgery. The syndrome is characterized by fever, chest pain, and a pericardial or pleural friction rub. Its etiology is believed to be viral or immunologic. The syndrome can be a diagnostic challenge, and an increase in length of hospitalization because of it has been documented. Identified risk factors for PPS include age, use of prednisone, and a history of pericarditis. A higher incidence has been reported from May through July. Many patients undergo a battery of expensive procedures before PPS is diagnosed. The pain is sharp, associated with deep inspiration, and changes with position. Pleural effusions may be present and tend to occur bilaterally. Pericardial effusions are a documented complication. A pericardial or pleural rub may be present and is often transient. Serial auscultation is important. Laboratory work provides clues with a mild leukocytosis and an elevated erythrocyte sedimentation rate. However, this does not provide the definitive diagnosis. Cardiac enzymes are not reliably related to the syndrome. An electrocardiogram will show changes similar to those associated with pericarditis. The patient may have a fever, but it is rarely higher than 102.5 degrees F. Complications include pericardial effusions, arrhythmias, premature bypass graft closure, and cardiac tamponade. Treatment consists of a 10-day course of nonsteroidal anti-inflammatory drugs.

[Recurrent cardiac tamponade secondary to postpericardiotomy syndrome]. / Taponamiento cardíaco recidivante secundario a síndrome postpericardiotomía.

A 22-year-old woman underwent surgical repair of a secondary atrial septal defect. Thirty-five days after surgery, she developed fever, systemic venous congestion, and respiratory symptoms and chest pain. The echocardiogram demonstrated pericardial effusion (PE) quantified at approximately 3,500 cc, with signs of cardiac tamponade (CT). Pericardiocentesis was performed and symptomatology subsides when Prednisone 10 mg was administered every 24 h. Fourteen days after discharge, she was readmitted due to progressive dyspnea, orthopnea and fatigue. The echocardiogram showed the reappearance of PE and a mild CT. Prednisone 40 mg/day was given. After 10 days an echocardiogram showed are duction of the PE (600 cc) and the clinical condition of the patient improved. Three months later, PE disappeared in the echocardiogram and the patient remained asymptomatic.

[Postpericardiotomy syndrome as a cause of recurrent pleural effusion]. / Het postpericardiotomiesyndroom als oorzaak van recidiverend pleuravocht.

The postpericardiotomy syndrome occurs frequently after cardiac surgery, and shows a strong tendency to recur. It is characterized by febrile illness with an elevated erythrocyte sedimentation rate, leucocytosis, and symptoms of pulmonary and pleuro-pericardial inflammation. Pleural effusion is a common manifestation of this syndrome, and is usually left-sided. We describe a patient who shows a periodic left-sided pleural effusion with an interval of 5 to 6 weeks 18 months after cardiac surgery. This is the first description of a 'cyclic' pleural effusion due to the postpericardiotomy syndrome. On the basis of this case report and the literature, we discuss the pathogenesis, therapy and clinical outcome of this syndrome.

Lymphocytic pleural effusion in postpericardiotomy syndrome.

Postpericardiotomy syndrome has been recognized as a frequent complication following coronary artery bypass graft (CABG) surgery. We observed five cases of postpericardiotomy syndrome resulting in exudative pleural effusions with white blood cell differential counts greater than 80% lymphocytes. Tuberculosis, lymphoma, and other neoplasma have been major diseases associated with lymphocytic exudative pleural effusions. We feel postpericardiotomy syndrome is another important etiology that should be considered in post-CABG patients with lymphocytic pleural effusion.

Late cardiac tamponade after open heart surgery.

Delayed cardiac tamponade after open heart surgery is relatively uncommon, but constitutes a life-threatening condition that must be diagnosed and managed promptly. We report 21 patients who developed cardiac tamponade 5 to 53 days after open heart operations. Possible etiological factors included anticoagulant therapy (19 patients), excessive mediastinal drainage in the postoperative period (10 patients), postpericardiotomy syndrome (4 patients), and coagulation disorders (1 patient). The clinical presentation was insidious and the diagnosis was often difficult to establish at the outset. A high index of clinical suspicion and echocardiography were the most reliable means to reach an early diagnosis. Twenty patients in whom delayed tamponade was suspected were operated and all of them survived. In one patient tamponade was not diagnosed antemortem and he died; on autopsy left heart compression by a large loculated clot was found. Decompression of the pericardial space can be accomplished by pericardiocentesis or by surgical means (subxiphoid pericardiotomy, median sternotomy, or thoracotomy). Although pericardiocentesis alone may be effective, mainly when the postpericardiotomy syndrome is the suspected etiology, we recommend open procedures since the presence of blood clots and adhesions has been a frequent finding.

Cardiac tamponade complicating the postpericardiotomy syndrome.

Cardiac tamponade is a rare complication of the postpericardiotomy syndrome in the absence of anticoagulation therapy. Three cases are presented where cardiac tamponade developed as a result of the postpericardiotomy syndrome with normal coagulation parameters. The pericardial effusions were serous in two and serosanguinous in the third case. Pericardial fluid studies were consistent with an exudate. The effusion resolved following a single pericardial tap and short-term corticosteroid therapy in one case. Repeated pericardiocentesis and drainage via an indwelling catheter were required in the other two cases.

Constrictive pericarditis following cardiac surgery.

Five patients with constriction secondary to pericarditis or membrane formation following cardiac surgical procedures are reported. In 4 of the 5 patients, a postpericardiotomy syndrome developed after the original procedure. Constriction occurred from ten weeks to almost 6 years after the cardiac operation. Clinicians should watch carefully for the delayed onset of constriction in patients with a postpericardiotomy syndrome after cardiac operation.