Post-pericardiotomy syndrome: insights into neglected postoperative issues.

ABSTRACT OBJECTIVES: Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge. METHODS: A literature review was performed that included relevant prospective and retrospective studies on the subject. RESULTS: PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention. CONCLUSIONS: Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies.

Postpericardiotomy syndrome after cardiac surgery.

Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.

Postpericardiotomy Syndrome after Cardiac Operations.

The postpericardiotomy syndrome (PPS) is an important cause of morbidity and mortality following heart operation. This systematic review reviewed the literature regarding PPS. It was found to occur on day 18.3 ±15.9 after cardiac operations, most often after coronary artery bypass grafting, and mitral valve replacement. The most common symptoms were new/worsening pericardial effusions, pleuritic chest pain, and fever. The inflammation markers, such as C-reactive protein and erythrocyte sedimentation rate, were found to increase significantly in each patient who had these parameters examined. The subjects were managed conservatively in 472 (83.5%) patients, by surgical pericardial drainage in 85 (15.0%) patients, by thora-/pericardio-centesis in 3 (0.5%) patients, and were under surveillance without being treated in 5 (0.9%) patients. Conservative treatment was likely to be associated with a higher recovery rate. Surgical trauma and cardiopulmonary bypass trigger the systemic inflammatory response, which results in antiheart autoantigen release, and the deposited immune complex could be found in the pericardial, pleural, and lung tissues, thereby provoking the occurrence of PPS. Therapeutic options for the refractory cases are long-term oral corticoids or pericardiectomy. Surgical intervention was warranted in 2.6% of the cases due to cardiac tamponade.

Postpericardiotomy syndrome incidence, diagnostic and treatment strategies: experience AT two collaborative centers.

Postpericardiotomy syndrome (PPS) is worsening or new formation of pericardial and/or pleural effusion mostly 1 to 6 weeks after cardiac surgery, as a result of autoimmune inflammatory reaction within pleural and pericardial space. Its incidence varies among different studies and registries (2% to 30%), as well as according to the type of cardiac surgery performed. We conducted this retrospective analysis of PPS incidence and diagnostic and treatment strategies in patients referred for cardiac surgery for revascularization, valvular and/or aortic surgery. We retrospectively analyzed 461 patients referred for an urgent or elective cardiac surgery procedure between 2009 and 2015. PPS diagnosis was established using well defined clinical criteria. Demographic and clinical characteristics were used in regression subanalysis among patients having undergone surgery of aortic valve and/or ascending aorta. Within 6 weeks after cardiac surgery, 47 (10.2%) patients had PPS. The median time from the procedure to PPS diagnosis was 14 days. The incidence of PPS was 26% after aortic valve and/or aorta surgery, and 7.9% and 8.3% after coronary bypass and mitral valve surgery, respectively. Among patients subjected to aortic valve and/or aortic surgery, regression analysis showed significant association of fever, C-reactive protein (CRP) elevation between 5 and 100 mg/L, urgent procedure and postoperative antibiotic use with PPS diagnosis, whereas younger age showed near-significant association. All patients had complete resolution of PPS, mostly after corticosteroid therapy, with only 2 cases of recurrent PPS that successfully resolved after colchicine therapy. Pleural drainage was indicated in 15 (32%) patients, whereas only one patient required pericardial drainage. In conclusion, PPS incidence in our retrospective analysis was similar to previous reports. Patients having undergone aortic valve and/or aortic surgery were most likely to develop PPS. The most relevant clinical criteria for diagnosis in these patients were fever, CRP elevation between 5 and 100 mg/L, and pericardial and/or pleural effusion formation or worsening 2 weeks after cardiac surgery.

Post-pericardiotomy Syndrome.

Post-pericardiotomy syndrome (PPS) occurs in a subgroup of patients who have undergone cardiothoracic surgery and is characterized by fever, pleuritic pain, pleural effusion, and pericardial effusion. It is associated with significant morbidity, and the leading complications include tamponade and constrictive pericarditis. Epidemiologic studies have found that PPS often occurs among younger patients; however, there is a lack of comprehensive risk stratification. It is therefore important to be able to identify patients who are at high risk for developing this disease. The diagnosis is made if patients present with 2 out of the following 5 criteria; fever, pericardial or pleuritic chest pain, pericardial or pleural friction rub, pericardial effusion, and pleural effusion with elevated C-reactive protein (CRP). Pericardial effusion associated with PPS is detected by echocardiography, and cardiac MRI is used for evaluation of pericardial thickening as well as inflammation associated with PPS. These imaging modalities have been invaluable for monitoring the efficacy of treatment in PPS. Aspirin, nonsteroidal anti-inflammatory agents (NSAID), and colchicine are the mainstay of the current treatment for PPS. Although steroids are used for refractory cases of PPS, they are associated with significant side effects when used for long-term treatment of this disease. It is important for future research to focus on identification of clinical, serologic, and genetic markers that may predispose patients to PPS. There is also a need for clinical trials to address the use of targeted immunomodulatory treatment for this disease.

Incidence and risk factors of postpericardiotomy syndrome requiring medical attention: The Finland postpericardiotomy syndrome study.

OBJECTIVES: Postpericardiotomy syndrome is a well-known complication after cardiac surgery. Nevertheless, little is known about the incidence and predictors of postpericardiotomy syndrome requiring medical attention or hospitalization in a contemporary set of patients undergoing isolated coronary bypass. METHODS: This retrospective analysis included 688 patients from 2008 to 2010. The median follow-up time was 5.3 [4.5-6.0] years. RESULTS: The incidence of postpericardiotomy syndrome was 61 of 688 patients (8.9%), and the median time to diagnosis was 21 [11-52] days, but only 13 patients (22%) required pleural drainage and 3 patients (4.9%) required pericardiocentesis. Patients with postpericardiotomy syndrome more often had 1 or more red blood cell units transfused (61% vs 43%, P = .008) after surgery and less often had diabetes (12% vs 31% P = .002) or metformin medication (3.3% vs 20%, P = .001) compared with those without postpericardiotomy syndrome. In multivariable Cox regression model, renal insufficiency and 1 or more red blood cell units transfused remained as independent predictors of postpericardiotomy syndrome and diabetes remained as a protective factor. Incidence of recurrences was high (38%), and increasing body mass index was the only predictor of relapse. CONCLUSIONS: The incidence of symptomatic postpericardiotomy syndrome leading to medical care contact was markedly lower compared with that reported in older clinical studies. Postpericardiotomy syndrome was associated with the use of red blood cell units and was less common in patients with medically treated diabetes.

Postpericardiotomy syndrome: a proposal for diagnostic criteria.

The post-pericardiotomy syndrome (PPS) affects 10-40% of patients after cardiac surgery, depending on the adopted diagnostic criteria, institution and type of surgery. On this basis, there is a need for standardized criteria for epidemiological and clinical purposes, which we propose on the basis of the largest published clinical trials on PPS prevention. Proposed diagnostic criteria for the PPS include: fever without alternative causes, pleuritic chest pain, friction rub, evidence of new or worsening pleural effusion, and evidence of new or worsening pericardial effusion. At least two of these criteria should be present for the diagnosis. These criteria may be adopted in future clinical trials and studies on the PPS.

Postpericardiotomy syndrome - post-cardiac injury syndrome.

INTRODUCTION: Postpericardiotomy syndrome is a non specific belated reaction of pericardium, epicardium and pleural cavity after cardiac or pericardial injury. It is considered to be a common complication in cardiosurgery with occurrence of 3 to 30 percent. Most likely, the primary cause is a common immunopathic process. It develops within days or even up to six months after either cardiac or pericardial injury or both. AIM: Echocardiography is the leading method in determination of postpericardiotomy syndrome due to the frequency of occurrence, non- specific clinical symptoms (fever, chest pain, cough, dizziness), inaccurate interpretation of examination methods (ECG, X-ray, laboratory tests). We would like to show how to determine the exactly diagnose, how to treat it and what is prognosis of this illness. RESULTS: We have performed a retrospective analysis of 1344 patients, who underwent cardiac surgery in the year 2009. The incidence of post- cardiac surgery syndrome was 12.4 %. In 2.6 % of the studied cases, surgical intervention was needed due to a cardiac tamponade. Int other cases similar to acute pericarditis, symptomatic treatment in duration of several weeks or months with non-steroid antireumatics, salicylic acid or colchicine is sufficient. Therapeutic options in refractory forms are long term oral corticoids or pericardiectomy. During our follow-up, pericardiectomy was necessary to perform in one patient. CONCLUSION: Postpericardiotomy syndrome, which occurs in early postoperative period, prolongs hospitalisation. In spite of non specific symptoms huge pericardial effusion might be present and can cause cardiac tamponade with haemodynamic failure in later periods. Transthoracic echocardiography is the golden standard in determination of accurate diagnosis (Fig. 6, Ref. 15).

Postpericardiotomy syndrome after thymothymectomy: report of two cases.

Two cases of postpericardiotomy syndrome (PPS) after thymothymectomy associated with pericardiotomy are described. The incidence of PPS in cardiac operations is reportedly 10-30%. Although no reports have been described in the English literature, our retrospective analysis revealed similar incidents following mediastinal tumor operation associated with pericardiotomy in cardiac surgery. Clinicians should thus be aware of this syndrome.

Pericardial diseases.

The pericardium provides an enclosed lubricated space for the beating heart and functions to fix the heart in the chest cavity relative to adjacent organs. Pericardial pathophysiology is often manifested in a spectrum of distinct cardiac and systemic disease states. The pericardial response to injury typically involves a spectrum of inflammation with both acute and chronic features and/or fluid accumulation. Recent advances in imaging methods have refined the diagnosis and therapy of pericardial disease. This article presents the anatomy and physiology of pericardial disease and the clinical approach for diagnosis and treatment.

El síndrome postpericardiotomía tras la implantación de marcapasos: presentación de un caso y revisión / The postpericardiotomy syndrome following endove-nous pacemaker insertion: case report and review

Presentamos un caso de síndrome postpericardiotomía tras la implantación de un marcapasos endovenoso (SPIV) en una mujer de 78 años y revisamos la experiencia publicada. Desde 1975 se han publicado en la literatura médica diez casos más de SPIV. La escasez de casos publicados y la alta tasa de complicaciones contrastan con la elevada prevalencia (4.6%) y el curso benigno de las pericarditis agudas tras la inserción de marcapasos endovenosos en una serie de 126 pacientes consecutivos. Esta clase de SPIV está probablemente infradiagnosticada y los casos publicados probablemente representan solo las formas clínicas más graves. Un alto índice de sospecha debería mejorar su diagnóstico y tratamiento

We report a postpericardiotomy syndrome (PS) following the implantation of endovenous pacemaker in a 78-year-old woman. Ten more single cases were reported in the medical literature since 1975. The infrequent single reports and the high complication rate are in contrast with the 4,6% occurrence and the benign course of acute pericarditis following the insertion of endovenous pacemakers in 126 consecutive patients. This sort of PS is probably underdiagnosed and the cases reported represent the more severe clinical presentations. A higher suspicion index would improve the diagnosis and management

Postpericardiotomy syndrome after permanent pacemaker implantation in children and young adults.

BACKGROUND: Postpericardiotomy syndrome (PPS) occurs in 10% to 50% of pediatric patients after cardiac surgery. The incidence and outcome of PPS after permanent pacemaker implantation in children is not described. METHODS: A retrospective analysis was performed of all pediatric patients who underwent isolated placement of a pacemaker between January 1984 and December 2002. Patients who underwent congenital heart surgery at the time of pacemaker implantation were excluded. PPS was diagnosed on the basis of clinical symptoms with echocardiographic confirmation of a pericardial effusion. RESULTS: Four hundred and forty-three pacemakers (237 epicardial, 206 transvenous) were implanted in 370 patients (median age 10 years, range 2 months to 24 years). Eight (2%) episodes of PPS (6 epicardial, 2 transvenous) occurred in 7 patients. The median time from implantation to PPS was 12.5 days (range 8 to 22 days). Six (75%) episodes followed primary pacemaker implantation, two occurred after subsequent lead revision. Three patients were initially treated with medical therapy (1 nonsteroidal agents, 2 steroids), and 1 required subsequent pericardiocentesis. Five patients underwent initial pericardiocentesis followed by medication. One patient had echocardiographic recurrence of a pericardial effusion 3 weeks after a nonsteroidal taper, with resolution after nonsteroidal agents were reinitiated. One patient required a pericardial window for a persistent effusion. No pacemaker was explanted. CONCLUSIONS: PPS occurred in 2% of children undergoing isolated pacemaker implantation of both epicardial and transvenous systems. PPS is usually managed successfully with medical therapy. Patients with medical treatment failure were successfully treated with pericardiocentesis or the surgical creation of a pericardial window.

Postpericardiotomy syndrome following temporary and permanent transvenous pacing.

The postpericardiotomy syndrome may occur as a complication of temporary and permanent pacing. Physicians involved in procedures which may be complicated by this condition therefore need to be aware of its diagnosis and management.

Postpericardiotomy syndrome: its diagnosis and treatment after muscle flap closure of an infected sternal wound.

After nearly any form of cardiac surgery, an acute febrile illness characterized by leukocytosis, pericarditis with pericardial effusion, and pleural effusion may occur. In some instances, this postpericardiotomy syndrome may suggest the presence of mediastinal infection. Treatment of postpericardiotomy syndrome is conservative, and symptoms typically resolve with nonsteroidal antiinflammatory medication. We report a case of postpericardiotomy syndrome that mimicked recurrent mediastinal infection and developed after muscle flap closure of an infected sternal wound. Pericardial, pleural, and periflap fluid accumulated postmuscle flap closure and was sterile on culture. A diagnosis of postpericardiotomy syndrome was made, and the patient improved while receiving oral indomethacin. She has remained free of infection as of the 2-year follow-up.

The postcardiac injury syndromes.

Late pericarditis following myocardial infarction, cardiac surgery, or trauma is referred to as postmyocardial infarction syndrome (PMIS) or postcardiotomy syndrome (PCS), respectively. The term postcardiac injury syndrome (PCIS) is used to encompass both these entities. PCIS is characterized by fever, pleuropericardial pain, pericarditis, and pulmonary involvement. Abnormal laboratory findings include leukocytosis, high sedimentation rate, and chest x-ray abnormalities of pleural effusion with or without pulmonary infiltrates. Evidence supports an immunopathic etiology; viruses may play a contributing role. The course is benign but rare complications include tamponade, constriction, anemia, and coronary bypass graft occlusion. Anti-inflammatory agents are helpful; indo-methacin and steroids are preferably avoided. Rarely, PMIS-like syndrome may occur following pulmonary embolism. Anticoagulation and steroids have been used successfully in the latter situation.

Postpericardiotomy syndrome: etiology, manifestations, and interventions.

Postpericardiotomy syndrome (PPS) is a complication of any cardiac surgery or procedure involving entry into the pericardium. The syndrome presents as a delayed pleural or pericardial reaction, characterized by fever, chest pain, and a friction rub. Although symptoms often identify PPS, diagnosis may be aided by the use of radiography, echocardiography, electrocardiography, and laboratory analysis. PPS can cause considerable discomfort and anxiety. Furthermore, patients are at risk of pericardial effusion and cardiac tamponade. For these reasons and because the complication often extends hospitalization, health care professionals must familiarize themselves with the syndrome, recognize signs and symptoms early, and plan interventions accordingly.