The postpericardiotomy syndrome then and now

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.

The Spectrum of Pleural Effusions After Coronary Artery Bypass Grafting Surgery

Pleural effusions are common after coronary artery bypass grafting (CABG) surgery and can be categorized by time intervals: perioperative (within the first week), early (within 1 month), late (2-12 months), or persistent (after 6 months). The perioperative effusions are usually attributable to diaphragm dysfunction or internal mammary artery harvesting and are typically self-limited. Early effusions are usually attributable to postcardiac injury syndrome and may require corticosteroid treatment. Although late effusions can have multiple causes, persistent effusions are attributable to trapped lung and often require decortication. Diagnostic thoracentesis should be performed for patients with large symptomatic pleural effusions or fever after CABG surgery. The range of management includes observation, therapeutic thoracentesis, corticosteroids, or decortication depending on the cause and course of the effusion.

Relationship between the degree of injury at operation and the change in antimyosin antibody titer in the postpericardiotomy syndrome

Successive measurements of cardiac myosin light chain I (MLC), creatine kinase isoenzyme MB (CKMB), and the titer of antimyosin antibody (AMA) were performed prospectively in 19 patients following open heart surgery. Seven of these patients showed the postpericardiotomy syndrome (PPS). No differences in serum concentrations of MLC or CKMB were observed between the patients with and without PPS, and all patients in both groups had abnormal MLC values after surgery. However, only patients with PPS had significantly elevated AMA titers. The maximum AMA titer was significantly correlated with the severity of the effusion. These data suggest that PPS is unrelated to the severity of myocardial injury during operation. Furthermore, the AMA titer may be useful as one of the indicators for determining the patient's clinical condition.

Pericarditis

Pericarditis is a common but frequently subclinical entity. There are a number of causes, including infection, systemic illness, cardiac disease, trauma, and neoplasm. Iatrogenic causes include surgery, cardiac instrumentation, irradiation, and medications. The clinical presentation varies, depending on the cause. Chest pain and dyspnea are characteristic complaints. A typical progression of ECG changes occurs during the course of acute pericarditis. These changes occasionally require differentiation from those of acute myocardial infarction or normal variant ST segment elevation. Echocardiography is the most sensitive technique for detecting the presence of pericardial effusion. In addition, a number of echocardiographic findings are characteristic of larger effusions and cardiac tamponade. Any form of pericarditis may lead to the development of cardiac tamponade. Malignant effusion is probably the most common single cause.

Postpericardiotomy syndrome

Postpericardiotomy syndrome, a frequent complication of open-heart surgery, is characterized by fever, chest pain, and pericardial and pleural effusions. These signs may develop 1 to 12 weeks after intracardiac surgery in approximately 30 percent of patients. Although the etiology of the syndrome is unknown, evidence points to a viral and/or autoimmune cause. Postpericardiotomy syndrome is diagnosed after excluding other conditions such as endocarditis and pneumonia. In many cases, the syndrome is self-limiting and occurs only once, but in other cases the symptoms have recurred as many as eight times. When the symptoms recur, management is more difficult because optimal pharmacologic treatment is not known. Antiinflammatory agents, such as salicylates and steroids, represent the drugs most commonly used. Although analgesics with codeine or oxycodone are important for the patients' symptomatic relief, early recognition of the syndrome is the key to limiting the discomfort and possible complications associated with this condition.

Viral illness and the postpericardiotomy syndrome. A prospective study in children

Postoperative fever and pericardial-pleural reaction, designated postpericardiotomy syndrome (PPS), is a common complication of cardiac surgery involving entry into the pericardium. To determine whether the etiology of PPS is viral or immunologic, we undertook a prospective, triple-blind study of consecutive long-term survivors of intrapericardial surgery in the pediatric age group. We evaluated clinical evidence of syndrome and concurrent appearance of antiheart antibody (AHA) by indirect immunofluorescence and antiviral antibody (AVA) by complement fixation in sera preoperatively and serially postoperatively. Incidence of PPS was 27% overall in 400 subjects, but only 3.5% in infants younger than 2 years of age. AHA in high titer appeared in all patients with PPS. A fourfold or greater rise in titer to AVA was found in 70% of these but in only 5% of those with negative AHA and no PPS. AVA rise, tested in 280 consecutive patients, was to no single one of the eight viruses studied (adenovirus, cytomegalovirus, and coxsackievirus B 1-6). Instead, the rise and fall, consistent with antiviral response to a recent infection, was exhibited usually to one but occasionally to two or more viruses, and the viral prevalence changed from year to year, as did that in the community. The study suggests that concurrent fresh or reactivated viral illness plays a role in triggering the immunologic response that characterizes the PPS.