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

Predictors of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery

BACKGROUND

We aimed to determine the rate and impact of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery and the perioperative factors associated with its occurrence.

METHODS

All consecutive patients who underwent native valve-sparing aortic valve surgery (i.e., repair ± ascending aorta replacement, valve-sparing root replacement, Ross procedure ± ascending aorta replacement) at our institution between January 2021 and August 2023 served as our study population. Post-pericardiotomy syndrome was diagnosed if patients showed at least two of the following diagnostic criteria: evidence of (I) new/worsening pericardial effusion, or (II) new/worsening pleural effusions, (III) pleuritic chest pain, (IV) fever or (V) elevated inflammatory markers without alternative causes. A logistic regression model was calculated.

RESULTS

During the study period, 91 patients underwent native valve-sparing aortic valve surgery. A total of 21 patients (23%) developed post-pericardiotomy syndrome early after surgery (PPS group). The remaining 70 patients (77%) showed no signs of post-pericardiotomy syndrome (non-PPS group). Multivariate logistic regression revealed blood type O (OR: 3.15, 95% CI: 1.06-9.41, p = 0.040), valve-sparing root replacement (OR: 3.12, 95% CI: 1.01-9.59, p = 0.048) and peak C-reactive protein >15 mg/dl within 48 hours postoperatively (OR: 4.27, 95% CI: 1.05-17.29, p = 0.042) as independent risk factors. 73% (8/11) of patients displaying all three risk factors, 60% (9/15) of patients with blood type O and valve-sparing root replacement, 52% (11/21) of patients with blood type O and early postoperative peak C-reactive protein >15 mg/dl and 45% (13/29) of patients with early postoperative peak C-reactive protein >15 mg/dl and valve-sparing root replacement developed post-pericardiotomy syndrome.

CONCLUSION

In summary, blood type O, valve-sparing root replacement and peak C-reactive protein >15 mg/dl within 48 hours postoperatively are significantly associated with post-pericardiotomy syndrome after native valve-sparing aortic valve surgery. Particularly, the presence of all three risk factors is linked to a particularly high risk of post-pericardiotomy syndrome.

Early Post-operative ECG Changes as a Predictor of Post-pericardiotomy Syndrome Following Atrial Septal Defect Repair

To identify risk factors associated with post-pericardiotomy syndrome (PPS) in patients undergoing surgical repair of atrial septal defects (ASD). A single-center retrospective study. Tertiary academic hospital. Included were patients of all ages who underwent surgical ASD repair, while exclusion criteria included the absence of post-operative electrocardiogram (ECG), lack of follow-up post-discharge and factors hindering ECG interpretation. Demographic and clinical data, including ECG changes indicative of pericardial inflammation, were collected. The primary outcome measure was the development of PPS, determined based on the standardized European Society of Cardiology (ESC) criteria. Among 190 patients who underwent surgical ASD repair, 154 (81%) met the inclusion criteria. Of these, 25 (16%)in total developed PPS, of which 60% were ≥ 18 years of age and 56% female. Significant associations relating both early ECG changes and pre-discharge pericardial effusion with subsequent occurrence of PPS were found in both univariate and multivariate analyses. The study establishes correlations of both early post-operative ECG changes indicative of inflammation and pre-discharge pericardial effusion with subsequent occurrence of PPS in patients undergoing surgical ASD repair. Both utilizing the standardized ESC definition of PPS and incorporating a physician-validated ECG evaluation strengthened the methodologic approach in establishing these relationships. The results also highlight the importance of considering age as a potential risk factor for PPS. Further research is needed to validate these findings and explore additional risk factors predicting early identification and management of patients at high risk for PPS following surgical ASD repairs.

Posterior pericardial window: a simple and reproducible technique in order to prevent pericardial tamponade in paediatric cardiac surgery

OBJECTIVE

Pericardial tamponade, which increases postoperative mortality and morbidity, is still not uncommon after paediatric cardiac surgery. We considered that posterior pericardiotomy may be a useful and safe technique in order to reduce the incidence of early and late pericardial tamponade. Herein, we present our experience with creation of posterior pericardial window following congenital cardiac surgical procedures.

METHODS

This retrospective study evaluated 229 patients who underwent paediatric cardiac surgical procedures between June 2021 and January 2023. A posterior pericardial window was created in all of the patients. In neonates and infants, pericardial window was performed at a size of 2x2 cm, whereas a 3x3 cm connection was established in elder children and young adults. A curved chest tube was placed and positioned at the posterolateral pericardiophrenic sinus. An additional straight anterior mediastinal chest tube was also inserted in every patient. Transthoracic echocardiographic evaluations were performed daily to assess postoperative pericardial effusion.

RESULTS

A total of 229 (135 male, 94 female) patients were operated. Mean age and body weight were 24.2 ± 26.7 months and 10.2 ± 6.7 kg, respectively. Eight (3.5%) of the patients were neonates where 109 (47.6%) were infants and 112 (48.9%) were in childhood. Fifty-two (22.7%) re-do operations were performed. Six (2.6%) patients underwent postoperative surgical re-exploration due to surgical site bleeding. Any early or late pericardial tamponade was not encountered in the study group.

CONCLUSIONS

Posterior pericardial window is an effective and safe technique in order to prevent both the early and late pericardial tamponade after congenital cardiac surgery.

Preoperative initiation of peripheral veno-arterial extracorporeal membrane oxygenation for a complex case of cardiac tamponade

In this case report, we present an alternative approach to the anaesthetic management of patients presenting with delayed postoperative cardiac tamponade physiology. Given that pericardiocentesis was deemed unsafe, and a protracted surgical dissection was anticipated, peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was established prior to induction of anaesthesia to prevent catastrophic circulatory failure. To the best of our knowledge, this is the first reported case of planned preoperative commencement of peripheral VA-ECMO in a complex case of cardiac tamponade. We discuss the challenges associated with this case and the process for selecting this strategy. We also describe the role of transoesophageal echocardiography in planning the surgical approach. This report is completed by a discussion on the topic of delayed postoperative pericardial effusion and tamponade.

Safety and Efficacy of Cryoballoon Pulmonary Vein Isolation and Left Atrial Appendage Closure Combined Procedure and Half-Dose Rivaroxaban After Operation in Elderly Patients with Atrial Fibrillation

Background

To investigate the safety and effectiveness of cryo-balloon pulmonary vein isolation (PVI) and left atrial appendage closure (LAAC) combined procedure and half-dose rivaroxaban after operation in elderly patients with atrial fibrillation (AF).

Patients and Methods

A total of 203 AF patients presented for cryo-balloon PVI, and LAAC combined procedure was included from 2019 to 2021. Postoperative patients were anticoagulated with rivaroxaban with/without clopidogrel for 60 days, with oral rivaroxaban of 10 mg in the elderly group and 20 mg in the non-elderly group. Patients with AF ≥80 and <80 years were considered elderly and non-elderly groups, respectively. Scheduled follow-ups and transesophageal echocardiography were used to assess peri- and post-procedural safety and effectiveness.

Results

A total of 203 patients underwent the combined procedure, 83 in the elderly and 120 in the non-elderly groups. All patients successfully obtained PVI and satisfactory LAAC. During the perioperative period, one patient had puncture complications in the elderly group and one with thrombosis in the non-elderly group. Oral rivaroxaban was administered to 83.2% and 75% of patients in the elderly and non-elderly groups, respectively, and rivaroxaban was combined with clopidogrel anticoagulation in the remaining patients. The annual rates of composite clinical events were 8.4% and 9.2% in the elderly and non-elderly groups, respectively, with no statistically significant difference. Patients in both groups had complete sealing, and there was no displacement of devices, death and peripheral arterial thrombosis. Recurrence of AF occurred in 25 and 32 patients in the elderly and non-elderly groups, respectively, with no statistically significant difference. Besides, the two groups had no statistically significant difference in cerebral infarction/transient ischemic attack and device-related thrombosis (p > 0.05).

Conclusion

This study suggests that cryo-balloon PVI and LAAC combined procedure and half-dose rivaroxaban after the operation is safe and effective in treating elderly patients with AF.

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.

Impact of posterior pericardial drain and risk factors on late pericardial effusion after coronary artery bypass surgery

BACKGROUND

The blood retained in posterior pericardium can trigger an inflammatory response that increases postoperative atrial fibrillations (POAFs), and it can complicate postoperative course. We retrospectively investigated the impact of a posterior pericardial drain (PPD) in reducing late postoperative pericardial effusion (pPE) and POAFs during the first 30 postoperative days.

METHODS

Two hundred and fifty coronary artery bypass grafting patients were divided into two groups according to the presence of a PPD in addition to the anterior one. Perioperative data and the incidence of POAF were compared. Risk factor analysis was used to determine the predictors of pPE and postpericardiotomy syndrome.

RESULTS

Late pPE was present in 16% of all patients. It proved to be much more frequent in patients with a posterior drain (odds ratio 2.58; 95% confidence interval 1.23-5.79; P = 0.015) where it seemed to be almost mild and anterior. 'Anterior Drain' patients showed an increased rate of moderate (P < 0.001) and posterior effusions (P < 0.001). POAF was much more frequent in patients without a PPD (25.2 vs. 6.3%; P < 0.001). Univariate risk factor analysis revealed a significant association between late pPE and lower preoperative weight (P = 0.003), lower preoperative and postoperative serum albumin (P < 0.001) and a greater amount of blood transfusion (P = 0.02).

CONCLUSION

Even if a PPD is associated with a higher rate of pPE, the patients with only anterior drains were shown to have a greater amount of pericardial effusion and an increased risk of POAFs. Therefore, a PPD should be considered to improve postoperative course.

Pericardial effusion after congenital heart surgery

Objective

Pericardial effusion after cardiac surgery remains an important cause of morbidity and mortality. We describe the risk factors of pericardial effusion after congenital heart surgery through analyzing data from a nationwide, multi-institutional registry.

Methods

The Japan Congenital Cardiovascular Surgery Database, which reflects routine clinical care in Japan, was used for this retrospective cohort study. Multivariable regression analysis was done after univariable comparison of patients with pericardial effusion and no pericardial effusion.

Results

The study enrolled 64,777 patients registered with the Japan Congenital Cardiovascular Surgery Database between 2008 and 2016; 909 of these had postoperative pericardial effusion (1.4%) and were analyzed along with 63,868 patients without pericardial effusion. Univariable analysis found no difference between the groups in terms of gender, early delivery, or preoperative mechanical ventilatory support. In the pericardial effusion group, cardiopulmonary bypass use was lower (58.4% vs 62.1%), whereas the cardiopulmonary bypass time (176.9 vs 139.9 minutes) and aortic crossclamp time (75.1 vs 62.2 minutes) were longer, and 30-day mortality was higher (4.1% vs 2.2%). Multivariable analysis identified trisomy 21 (odds ratio, 1.54), 22q.11 deletion (odds ratio, 2.17), first-time cardiac surgery (odds ratio, 2.01), and blood transfusion (odds ratio, 1.43) as independent risk factors of postoperative pericardial effusion. In contrast, neonates, infants, ventricular septal defect, atrial septal defect, tetralogy of Fallot repair, and arterial switch operation were correlated with a low risk of pericardial effusion development.

Conclusions

The incidence of postoperative pericardial effusion in congenital cardiac surgery was 1.4%. Trisomy 21, 22q.11 deletion, first-time cardiac surgery, and blood transfusion were identified as the principal factors predicting the need for pericardial effusion drainage.

Incidence and predictors of pericardial effusion following surgical closure of atrial septal defect in children: A single center experience

OBJECTIVES

To evaluate the incidence of pericardial effusion (PE) after surgical atrial septal defect (ASD) closure and to investigate the presence of predictive risk factors for its development.

METHODS

We collected data from 203 patients followed at Bambino Gesù Children's Hospital of Rome who underwent cardiac surgery for ASD repair between January 2015 and September 2019.

RESULTS

A total of 200/203 patients with different types of ASD were included. Patients were divided into two groups: Group 1) 38 (19%) who developed PE and Group 2) 162 (81%) without PE. No differences were noted between the two groups with regard to gender or age at the surgery. Fever in the 48 h after surgery was significantly more frequent in group 1 than in group 2 (23.7 vs. 2.5%; p < 0.0001). ECG at discharge showed significant ST-segment elevation in children who developed PE, 24.3 vs. 2.0% in those who did not (p < 0.0001). Group 1 patients were divided into two subgroups on the basis of the severity of PE, namely, 31 (81.6%) with mild and 7 (18.4%) with moderate/severe PE. Patients with moderate/severe PE had a significantly higher BMI value (median 19.1 Kg/m²) (range 15.9-23.4, p = 0.004).

CONCLUSION

The presence of fever and ST-segment elevation after surgery predicts subsequent development of PE suggesting a closer follow-up for these categories of patients. A higher BMI appears to be associated with a higher risk of moderate/severe PE.

Refractory Recurrent Pericarditis After Pericardiectomy in a Young Woman

Pericardiectomy is the recommended treatment for patients with recurrent pericarditis and refractory symptoms despite optimal anti-inflammatory therapy. We present a case of a 40-year-old woman who underwent total pericardiectomy after multiple episodes of pericarditis that was refractory to optimal guideline-derived medical therapy, including anti-inflammatory and biologic agents, who continued to have relapsing symptoms even after pericardiectomy. (Level of Difficulty: Intermediate.)

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.

An overview of human pericardial space and pericardial fluid

The pericardium is a double-layered fibro-serous sac that envelops the majority of the surface of the heart as well as the great vessels. Pericardial fluid is also contained within the pericardial space. Together, the pericardium and pericardial fluid contribute to a homeostatic environment that facilitates normal cardiac function. Different diseases and procedural interventions may disrupt this homeostatic space causing an imbalance in the composition of immune mediators or by mechanical stress. Inflammatory cells, cytokines, and chemokines are present in the pericardial space. How these specific mediators contribute to different diseases is the subject of debate and research. With the advent of highly specialized assays that can identify and quantify various mediators we can potentially establish specific and sensitive biomarkers that can be used to differentiate pathologies, and aid clinicians in improving clinical outcomes for patients.

Peculiarity of clinical course of postpericardiotomy syndrome in different methods of surgery and postoperative antithrombotic therapy

Aim    To compare features of the disease course and the effectiveness of nonsteroidal anti-inflammatory drug (NSAID) treatment of postpericardiotomy syndrome (PPS) in patients after coronary bypass (CB) surgery who were treated with antiplatelet drugs and in patients after surgical correction of heart valve disease (CHVD) who received the anticoagulant warfarin for prevention of thrombotic complications. Material and methods    This study included 89 patients of whom 53 patients had underwent CB and 36 patients had underwent CHVD. At 15 [13; 15] days after surgery, the severity of inflammatory response, the state of coagulation hemostasis, and hematocrit were studied. At 5 days after the first test, blood count and measurement of C-reactive protein were repeated. Echocardiography was used to determine the presence and volume of pleural effusion. For prevention of thrombotic complications, antiplatelet drugs were administered after CB and warfarin was administered after CHVD. PPS was detected in 35 (66 %) patients after CB and 18 (50 %) patients after CHVD. The ibuprofen treatment (600 mg twice a day) was administered to all patients with PPS. If positive changes in inflammatory markers were absent during the NSAID treatment, ibuprofen was replaced with prednisolone 0.5 mg/kg body weight with subsequent laboratory and instrumental monitoring. Results    Patients after CHVD treated with warfarin had higher values of international normalized ratio (INR) and activated partial thromboplastin time (aPPT) and lower values of prothrombin index (PTI), fibrinogen (p&lt;0.001 for all), hemoglobin (p=0.0016), and hematocrit (p=0,0032) than patients after CB treated with antiplatelet drugs. 21 (40 %) patients with PPS required changing the anti-inflammatory therapy from ibuprofen to prednisolone. These patients displayed hypocoagulation, which was evident as reduced PTI (p=0.0023) and fibrinogen (p=0.0209), increased INR (p=0.0291) and aPPT (p=0.0416), and a higher incidence of pericardial effusion (p=0.0080). The insufficient effectivity of NSAIDs that required administration of prednisolone was more frequently observed in patients after CHVD (61 % vs. 29 %, р=0.037).Conclusion    Hypocoagulation observed in patients after CHVD due to the anticoagulant treatment with warfarin was associated with more severe course of PPS and lower effectiveness of the NSAID treatment compared to patients after CB. This results in more frequent replacement of NSAIDs with glucocorticoids in the treatment of patients after CHVD.

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.

Multimodality imaging in patients with post-cardiac injury syndrome

This review article is focused on the role of echocardiography, cardiac CT and cardiac magnetic resonance (CMR) imaging in diagnosing and managing patients with post-cardiac injury syndrome (PCIS). Clinically, the spectrum of pericardial diseases under PCIS varies not only in form and severity of presentation but also in the timing varying from weeks to months, thus making it difficult to diagnose. Pericarditis developing after recent or remote myocardial infarction, cardiac surgery or ablation if left untreated or under-treated could worsen into complicated pericarditis which can lead to decreased quality of life and increased morbidity. Colchicine in combination with other anti-inflammatory agents (non-steroidal anti-inflammatory drugs) is proven to prevent and treat acute pericarditis as well as its relapses under various scenarios. Imaging modalities such as echocardiography, CT and CMR play a pivotal role in diagnosing PCIS especially in difficult cases or when clinical suspicion is low. Echocardiography is the tool of choice for emergent bedside evaluation for cardiac tamponade and to electively study the haemodynamics impact of constrictive pericarditis. CT can provide information on pericardial thickening, calcification, effusions and lead perforations. CMR can provide pericardial tissue characterisation, haemodynamics changes and guide long-term treatment course with anti-inflammatory agents. It is important to be familiar with the indications as well as findings from these multimodality imaging tools for clinical decision-making.

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.

Delayed diagnosis of postcardiac injury syndrome

Postcardiac injury syndrome (PCIS) is a rare condition that is considered to have a trauma-induced autoimmune mechanism triggered by damage to pericardial and/or pleural tissues. We report a case of PCIS accompanied by systemic oedema after thymectomy. A 73-year-old woman was referred to our hospital for dyspnoea and oedema, 9 months after thymectomy. Evaluation revealed the presence of pericardial effusion, pleural effusion and systemic oedema. Differential diagnosis included constrictive pericarditis (secondary to tuberculosis), serositis caused by collagen disease and malignancy. Detailed investigations led to the diagnosis of PCIS, which was successfully treated with prednisolone. This report focuses on the diagnostic approach to PCIS. Since it took time to make a final diagnosis in our patient, we analysed several past case reports and series to determine the cause of the delay in diagnosis.

Post-Pericardiotomy Syndrome: Beware or Just Be Aware?

See Article by https://doi.org/10.1161/JAHA.118.010269.

Occurrence of Postpericardiotomy Syndrome: Association With Operation Type and Postoperative Mortality After Open-Heart Operations

Background Postpericardiotomy syndrome ( PPS ) is a common complication after cardiac surgery. However, large-scale epidemiological studies about the effect of procedure type on the occurrence of PPS and mortality of patients with PPS have not yet been performed. Methods and Results We studied the association of PPS occurrence with operation type and postoperative mortality in a nationwide follow-up analysis of 28 761 consecutive patients entering coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or ascending aortic surgery. Only PPS episodes severe enough to result in hospital admission or to contribute as a cause of death were included. Data were collected from mandatory Finnish national registries between 2005 and 2014. Of all the patients included, 493 developed PPS during the study period. The occurrence of PPS was significantly higher after aortic valve replacement (hazard ratio, 1.97; 95% confidence interval, 1.58-2.46; P<0.001), mitral valve replacement (hazard ratio, 1.62; 95% confidence interval, 1.22-2.15; P<0.001), and aortic surgery (hazard ratio, 3.06; 95% confidence interval, 2.24-4.16; P<0.001), when compared with coronary artery bypass grafting in both univariable and multivariable analyses. The occurrence of PPS decreased significantly with aging ( P<0.001). The occurrence of PPS was associated with an increased risk of mortality within the first year after the surgery (adjusted hazard ratio, 1.78; 95% confidence interval, 1.12-2.81; P=0.014). Conclusions The occurrence of PPS was higher after aortic valve replacement, mitral valve replacement, and aortic surgery when compared with the coronary artery bypass grafting procedure. Aging decreased the risk of PPS . The development of PPS was associated with higher mortality within the first year after cardiac or ascending aortic surgery.

Predictors of Pericardial Effusion in Patients Undergoing Pulmonary Artery Banding

BACKGROUND

Although pulmonary artery banding (PAB) is a common palliative procedure for pediatric heart malformation, there are concerns of pressure overload and concomitant immune reactions in the right ventricle causing postsurgical complications such as pericardial effusion. At this time, no clear guidelines as to potential risk factors or procedural contraindications have been widely disseminated. Therefore, a study was undertaken to examine wide-ranging factors to find potential biomarkers for postsurgical pericardial effusion formation risk.

METHODS

A retrospective study was conducted on all cardiac surgeries performed over an eight-year period, and the main inclusion criterion was pericardial effusion development after PAB that required surgical drainage. Nine cases were then analyzed against a control group of 45 cases with respect to body measurements, concomitant surgeries, genetic screens, laboratory tests results, and cardiac function parameters.

RESULTS

Trisomy 21 was strongly associated with the development of severe pericardial effusion after PAB, and postoperative serum albumin levels in patients with trisomy 21 were associated with pericardial effusion development. Other parameters showed no significant correlation with pericardial effusion development.

CONCLUSIONS

Our data indicate a strong association between trisomy 21 and pericardial effusion requiring drainage after PAB, which is in line with translational research findings. Pressure overload from PAB may play a role in the formation of severe pericardial effusion that is exacerbated by cardiac structural defects commonly associated with trisomy 21. Surgical teams should therefore use caution and plan to implement drainage in PAB cases, and postoperative serum albumin may serve as a useful biomarker for pericardial effusion formation.

Incidence, presentation and risk factors of late postoperative pericardial effusions requiring invasive treatment after cardiac surgery

OBJECTIVES

Occurrence and risk factors of late postoperative pericardial effusions requiring invasive treatment, i.e. pretamponade and tamponade, following cardiac surgery are incompletely described in current literature. The purpose of this study was to define the incidence and presentation of late pretamponade and tamponade as well as to outline significant predisposing factors.

METHODS

A cohort of 1356 consecutive cardiac surgery patients treated in a tertiary academic centre between January 2013 and December 2014 was followed up for 6 months after surgery. Pericardial effusion was considered late when presenting after the 7th postoperative day. The incidence, timing and risk factors, as well as symptoms and clinical findings associated with late pretamponade and tamponade in patients surviving at least 7 days was analysed.

RESULTS

Of 1308 patients included in the analysis, 81 (6.2%) underwent invasive treatment for late postoperative pericardial effusion, 27 (2.1%) for pretamponade and 54 (4.1%) for tamponade, respectively, with a median delay of 11 (range 8-87) days after the primary operation. Haemodynamic instability was present in 34.6%, signs of cardiac chamber compression in 54.3% and subjective symptoms, mostly dyspnoea, in 56.8% of patients, respectively. Treated patients were younger, had lower EuroSCORE-II rating, less coronary disease, better cardiac function, higher preoperative haemoglobin values and had mostly undergone elective surgery involving cardiac valves. In multivariable analysis, independent risk factors were single valve surgery and high preoperative haemoglobin level, whereas age 60-69 years was associated with lower risk.

CONCLUSIONS

Younger, generally healthier patients undergoing valve surgery are at greatest risk for developing late tamponade or pretamponade.

Determinants of the postpericardiotomy syndrome: a systematic review

BACKGROUND

Postpericardiotomy syndrome (PPS) is a common complication following cardiac surgery; however, the exact pathogenesis remains uncertain. Identifying risk factors of PPS might help to better understand the syndrome. The aim of this study was to provide an overview of existing literature around determinants of PPS in adult cardiac surgery patients.

MATERIAL AND METHODS

Two independent investigators performed a systematic search in MEDLINE, EMBASE and the Cochrane Central Register. The search aimed to identify studies published between January 1950 and December 2015, in which determinants of PPS were reported.

RESULTS

A total of 19 studies met the selection criteria. In these studies, 14 different definitions of PPS were used. The median incidence of PPS was 16%. After quality assessment, seven studies were considered eligible for this review. Lower preoperative interleukin-8 levels and higher postoperative complement conversion products were associated with a higher risk of PPS. Among other clinical factors, a lower age, transfusion of red blood cells and lower preoperative platelet and haemoglobin levels were associated with a higher risk of PPS. Colchicine use decreased the risk of PPS.

CONCLUSION

We found that both the inflammatory response and perioperative bleeding and coagulation may play a role in the development of PPS, suggesting a multifactorial aetiology of the syndrome. Due to a lack of a uniform definition of PPS in the past, study comparability was poor across the studies.

Prevalence and Risk Factors for Pericardial Effusions Requiring Readmission After Pediatric Cardiac Surgery

Pericardial effusion (PE) may require readmission after cardiac surgery and has been associated with postoperative morbidity and mortality. We sought to identify the prevalence and risk factors for postoperative PE requiring readmission in children. A retrospective analysis of the Pediatric Health Information System database was performed between January 1, 2003, and September 30, 2014. All patients ≤18 years old who underwent cardiac surgery were identified by ICD-9 codes. Those readmitted within 1 year with an ICD-9 code for PE were identified. Logistic regression analysis was performed to determine risk factors for PE readmissions. Of the 142,633 surgical admissions, 1535 (1.1%) were readmitted with PE. In multivariable analysis, older age at the initial surgical admission [odds ratio (OR) 1.17, p < 0.001], trisomy 21 (OR 1.24, p = 0.015), geographic region (OR 1.33-1.48, p ≤ 0.001), and specific surgical procedures [heart transplant (OR 1.82, p < 0.001), systemic-pulmonary artery shunt (OR 2.23, p < 0.001), and atrial septal defect surgical repair (OR 1.34, p < 0.001)] were independent risk factors for readmission with PE. Of readmitted patients, 44.2% underwent an interventional PE procedure. Factors associated with interventions included shorter length of stay (LOS) for the initial surgical admission (OR 0.85, p = 0.008), longer LOS for the readmission (OR 1.37, p < 0.001), and atrial septal defect surgery (OR 1.40, p = 0.005). In this administrative database of children undergoing cardiac surgery, readmissions for PE occurred after 1.1% of cardiac surgery admissions. The risk factors identified for readmissions and interventions may allow for improved risk stratification, family counseling, and earlier recognition of PE for children undergoing cardiac surgery.

Risk factors and prognosis of postpericardiotomy syndrome in patients undergoing valve surgery

OBJECTIVE

The study aim was to investigate the long-term prognosis and risk factors of postpericardiotomy syndrome (PPS).

METHODS

We performed a single-center cohort study in 822 patients undergoing nonemergent valve surgery. Risk factors of PPS were evaluated using multivariable logistic regression analysis. We also compared the incidence of reoperation for tamponade at 1 year between patients with and without PPS. Main secondary outcomes were hospital stay and mortality.

RESULTS

Of the 822 patients, 119 (14.5%) developed PPS. A higher body mass index (odds ratio (OR) per point increase, 0.94; 95% confidence interval (CI), 0.89-0.99) was associated with a lower risk of PPS, whereas preoperative treatment for pulmonary disease without corticosteroids (OR, 2.55; 95% CI, 1.25-5.20) was associated with a higher risk of PPS. The incidence of reoperation for tamponade at 1 year in PPS versus no PPS was 20.9% versus 2.5% (OR, 15.49; 95% CI, 7.14-33.58). One-year mortality in PPS versus no PPS was 4.2% versus 5.5% (OR, 0.68; 95% CI, 0.22-2.08). Median hospital stay was 13 days (interquartile range, 9-18 days) versus 11 days (interquartile range, 8-15 days) (P = .001), respectively.

CONCLUSIONS

Despite longer hospital stays and more short-term reoperations for tamponade, patients with PPS had an excellent 1-year prognosis.

Predictors of tamponade and constriction in patients with pericardial disease undergoing interventional and surgical treatment

OBJECTIVE

The aim of our study was to define predictors of cardiac compression development including clinical, electrocardiographic, echocardiographic, chest-X-ray and perioperative parameters and their diagnostic value.

METHODS

Overall 243 patients with pericardial disease, among them 123 with compression (tamponade, constriction) and 120 without signs of compression were included in the study. Clinical, laboratory, electrocardiographic, chest-X-Ray, echocardiographic and perioperative data were included in the logistic regression analysis to define predictors of tamponade/constriction development.

RESULTS

Logistic regression analysis demonstrated large effusion (> 20 mm) (OR 5.393, 95%CI 1.202-24.199, p = 0.028), cardiac chamber collapse (OR 31.426, 95%CI 1.609-613-914, p = 0.023) and NYHA class > 3 (OR 8.671, 95%CI 1.730-43.451, p = 0.009) were multivariable predictors of compression development. The model including these three variables allowed predicting compression in 91.7% of cases. ROC analyses demonstrated that all three variables had significant diagnostic value with sensitivity of 75.6% and specificity of 74.2% for large effusion, low sensitivity and high specificity for cardiac chamber collapse (35% and 92%) and NYHA class (32.5% and 94.2%).

CONCLUSION

The independent predictors of compression development are presence of large effusion > 20 mm, cardiac chamber collapse and high NYHA class. The model including all three parameters allows correctly predicting compression in 91.4% of cases. The diagnostic accuracy of each parameter is characterized by high sensitivity and specificity of large effusion, high specificity of cardiac chamber collapse and NYHA class.

Excessive intravenous fluid therapy in head and neck cancer surgery

BACKGROUND

The purpose of this retrospective study was to present our assessment of modifiable perioperative factors for major cardiac and cerebrovascular events (MACCE).

METHODS

This study included an unselected cohort of patients with head and neck cancer (n = 456) treated in Turku University Hospital between 1999 and 2008.

RESULTS

Perioperative and postoperative univariate predictors of MACCE at 30-day follow-up were: total amount of fluids (during 24 hours) over 4000 mL, any red blood cell (RBC) infusion, treatment in the intensive care unit (ICU), tracheostomy, and microvascular reconstruction surgery. Median time from operation to MACCE was 3 days. Patients receiving >4000 mL of fluids had MACCE more often compared with those receiving <4000 mL (10.8% vs 2.4%; p < .001, respectively). Moreover, every RBC unit transfused or every liter of fluid administered over 4000 mL/24h increased the risk of MACCE 18% per unit/liter, respectively.

CONCLUSION

Patients with head and neck cancer receiving excessive intravenous fluid administration perioperatively and postoperatively are at high risk for cardiac complications, especially heart failure. © 2016 Wiley Periodicals, Inc. Head Neck 39: 37-41, 2017.

Impact of retained blood requiring reintervention on outcomes after cardiac surgery

OBJECTIVES

Evacuation of shed blood from around the heart and lungs is a critical requirement for patients in early recovery after cardiac surgery. Incomplete evacuation of shed blood can result in retained blood, which may require subsequent reinterventions to facilitate recovery. The purpose of this study was to determine the incidence of retained blood requiring reintervention and examine the impact on outcomes.

METHODS

We performed a cross-sectional, observational study of all adult patients undergoing cardiac surgery between 2006 and 2013. Subjects who required an intervention to remove blood, blood clot, or bloodily fluid were attributed to the retained blood group. These patients were compared with those not presenting with any of the defined criteria for retained blood. Multivariate regression was performed to account for confounders.

RESULTS

Of 6909 adult patients who underwent cardiac surgery, 1316 (19%) presented with a retained blood-related condition. Retained blood was associated with increased in-hospital mortality (odds ratio [OR], 4.041; 95% confidence interval [CI], 2.589-6.351, P < .001) and a length of stay more than 13 days in the hospital (OR, 3.853; 95% CI, 2.882-5.206; P < .001) and 5 days in the intensive care unit (OR, 4.602; 95% CI, 3.449-6.183; P < .001). The OR for a time of ventilation greater than 23 hours was 3.596 (95% CI, 2.690-4.851; P < .001) and for incidence of renal replacement therapy was 4.449 (95% CI, 3.188-6.226; P < .001).

CONCLUSIONS

Postoperative retained blood is a common outcome and associated with higher in-hospital mortality, longer intensive care unit and hospital stay, and higher incidence of renal replacement therapy. Further research is needed to validate these results and explore interventions to reduce these complications.

Occurrence of postpericardiotomy syndrome admissions: A population-based registry study

BACKGROUND

Postpericardiotomy syndrome (PPS) is a common complication after cardiac surgery. Previous epidemiological descriptions of the syndrome, however, are scarce.

MATERIAL AND METHODS

This retrospective analysis included all patients hospital admission due to PPS in patients aged 20-79 years. Data were collected from the Finnish national registry that included data on all cardiovascular hospital admissions (n = 51 7669) during 9.5 years in 29 Finnish hospitals nationwide.

RESULTS

There were 760 hospital admissions due to PPS during the study period. The patients were more likely male than female (67.8% versus 32.2%) with an age-adjusted RR of 2.37 (95% CI 1.85-3.02) for men (p < 0.0001). When evaluating the rate of PPS in relation to cardiac surgeries, female gender was associated with a higher incidence of PPS (RR 1.78; 95% CI 1.45-2.19; p < 0.001). The rate of PPS in relation to the number of cardiac surgery was highest in youngest patients followed by a gradual decrease (RR 0.59; 95% CI 0.55-0.65; p < 0.0001 per 10-year increment in age) with aging.

CONCLUSIONS

Hospital admission due to PPS was most common in men in their sixties. When stratified by the total number of performed cardiac operations the incidence of PPS was higher among women and younger patients.