Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD
Synonyms and keywords:Postcommissurotomy syndrome; PCS; PPS; Dressler syn; Post cardiac injury syndrome; Post heart injury syndrome; Post pericardial injury syndrome
The postpericardiotomy syndrome is inflammation of the pericardium following cardiac surgery. Symptoms can occur from days to weeks after the operation. The syndrome is thought to have an autoimmune basis. Postcardiac injury was first discovered by soloff, in 1953. Later Itoh in 1958 ,was first discovered same syndrome and labelled it postpericardiotomy syndrome. In 1956, Dressler described PMIS, and therefore referred to as Dressler syndrome. It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma. Persistance of Various viral agents,such as coxsackie B, adenovirus, and cytomegalovirus ,suggesting autoimmune response associated with a viral infection. It is thought that postpericardiotomy syndrome is mediated by development of antibodies againts heart. The progression to postpericardiotomy syndrome usually secondary to cell-mediated immunity.
- Postcardiac injury was first discovered by Soloff, in 1953.
- Later Itoh in 1958, was first discovered the same syndrome and labeled it postpericardiotomy syndrome.
- In 1956, Dressler described PMIS, and therefore referred to as Dressler syndrome.
There is no established system for the classification of postpericardiotomy syndrome.
- It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma.
- Persistance of Various viral agents,such as coxsackie B, adenovirus, and cytomegalovirus ,suggesting autoimmune response associated with a viral infection.
- It is thought that postpericardiotomy syndrome is mediated by development of antibodies againts heart.
- The progression to postpericardiotomy syndrome usually secondary to cell-mediated immunity.
The most important causes of the postpericardiotomy syndrome:
- Pericardial and/or pleural bleeding
- Heart surgery
- Postpericardiotomy syndrome can be an unusual complication after percutaneous coronary intervention such as stent implantation or after implantation of epicardial pacemaker leads and transvenous pacemaker leads, following blunt trauma, stab wounds, and heart puncture.
Differentiating Postpericardiotomy Syndrome from other Conditions
Postpericardiotomy syndrome should be distinguished from Dressler's syndrome which is an autoimmune process that occurs 2-10 weeks following ST elevation MI. It should also be differentiated from the much more common post myocardial infarction pericarditis that occurs between days 2 and 4 after myocardial infarction. Postpericardiotomy syndrome should also be differentiated from pulmonary embolism, another cause of pleuritic chest pain in people who have been hospitalized and/or undergone surgical procedures within the preceding weeks.
Epidemiology and Demographics
It is estimated that anywhere from 2000-30,000 out of 100,000 of patients who undergo heart surgery who have had their pericardium opened will develop postpericardiotomy syndrome.
The risk of postpericardiotomy syndrome increases with age.
- Infants: Uncommon
- Children: Not uncommon
- Adults: Common, occurs in 30% of patients following surgery in which the pericardium is opened
- Postpericardiotomy syndrome occurs more frequently in patients who have undergone heart surgery that involves opening the pericardium.
- Many studies has been shown higher incidence of pps after AVR, MVR, and aortic surgery.
Natural History, Complications, Prognosis
The onset of symptoms is 1 to 6 weeks after cardiac surgery. In general the disease is self-limited and the symptoms and signs are mild and resolve in 2 to 3 weeks.
- Pericardial effusion may result from the accumulation of fluids as a result of inflammation in the pericardial sac.
- Cardiac tamponade can occur if the accumulation of fluids in the pericardium is large enough and rapid enough. This occurs in <1% of patients.
- Constrictive pericarditis can occur if there is a chronic inflammatory response.
Prognosis is generally good.
Diagnostic Study of Choice
The diagnosis of postpericardiotomy syndrome is made when at least two of the following five diagnostic criteria are met: New or worsening pleural effusion, new or worsening pericardial effusion, fever, pleural chestpain, pleural or pericardial rubbing.
History and Symptoms
Common symptoms of postpericardiotomy syndrome include fever, chest pain, dyspenea. Less symptoms of postpericardiotomy syndrome are malaise, decrease appetite, arthralgia.
Tachycardia may be present hypoxemia may be present.
Pericardial friction rub is often present, an enlarged heart may be present.
Signs of a pleural effusion may be present.
Hepatomegaly may be present.
Pedal edema may be present if pericardial constriction or a pericardial effusion is present.
- CBC will be elevated with a leukocytosis and a leftward shift.
- ESR will be elevated.
- CRP will be elevated.
- Given the presence of fever and the post-operative status of the patient, blood cultures should be obtained to rule out endocarditis.
- Antiheart antibodies are elevated.
- Cardiac biomarker testing is usually not helpful as it has not been shown to differ between those patients with and those without postpericardiotomy syndrome.
- Send pericardial fluid for CBC and differential, culture and sensitivity, gram stain, protein and triglyceride level (to rule out chylopericardium).
An ECG may be helpful in the diagnosis of postpericardiotomy syndrome. Findings on an ECG diagnostic of pericarditis include ST-segment elevation and T-wave inversion and PR depression in multiple leads.
Chest X Ray
- Often a pleural effusion is present with blunting of the costophrenic angles.
- Cardiomegaly may be present if there is a sufficient pericardial effusion.
Echocardiography or Ultrasound
- Echocardiography may be helpful in the diagnosis of postpericardiotomy syndrome.
- Finding on an echocardiography of postpericardiotomy syn include pericardial effusion.
- Cardiac CT scan may be helpful in the diagnosis of pericardial effusion.
- Findings on CT scan suggestive of postpericardiotomy syndrome include pericardial effusion and findings on CT scan diagnostic of pericardial effusion include pericardial thickening.
Cardiac MRI may be helpful in the diagnosis of postpericardiotomy syn. Findings on MRI suggestive of pericardial effusion is pericardial thickening.
Other Imaging Findings
There are no other imaging findings associated with postpericardiotomy syndrome.
Other Diagnostic Studies
There are no other diagnostic studies associated with postpericardiotomy syndrome.
- The mainstay of treatment for is nonsteroidal anti inflammatory drugs,such as Aspirin and Ibuprofen.
- Pharmacologic medical therapies for postpericardiotomy sydrome include NSAIDs, colchicine and golococorticoid.
- Surgical intervention is not recommended for the management of postpericardiotomy syndrome.
- In 2016, there was a case report who was treated by IPC(indwelling pleural catheter) because of recurrent pleural effusion due to pps.
- Effective measures for the primary prevention of postpericardiotomy syndrome is prophylactic administration of colchicine.
- Colchicine will be given to patients pre or post cardiac surgery.
There are no established measures for the secondary prevention of postpericardiotomy syndrome.
ACC/AHA Treatment Guidelines (DO NOT EDIT)
1. Aspirin is recommended for treatment of pericarditis after STEMI. Doses as high as 650 mg orally (entericcoated) every 4 to 6 hours may be needed. (Level of Evidence: B)
2. Anticoagulation should be immediately discontinued if pericardial effusion develops or increases. (Level of Evidence: C)
1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following:
1. Corticosteroids might be considered only as a last resort in patients with pericarditis refractory to aspirin or NSAIDs. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. (Level of Evidence: C)
2. Nonsteroidal anti-inflammatory drugs may be considered for pain relief; however, they should not be used for extended periods because of their effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion. (Level of Evidence: B)
1. Ibuprofen should not be used for pain relief because it blocks the antiplatelet effect of aspirin and it can cause myocardial scar thinning and infarct expansion. (Level of Evidence: B)
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction 
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction 
- ↑ Andreev DA, Giliarov MIu, Syrkin AL, Udovichenko AE, Gerok DV (2008). "[Postcardiotomy syndrome outside a cardiosurgical clinic]". Klin Med (Mosk). 86 (10): 67–71. PMID 19069464.
- ↑ Hazelrigg SR, Mack MJ, Landreneau RJ, Acuff TE, Seifert PE, Auer JE (1993). "Thoracoscopic pericardiectomy for effusive pericardial disease". Ann Thorac Surg. 56 (3): 792–5. PMID 8379795.
- ↑ Mott AR, Fraser CD, Kusnoor AV, Giesecke NM, Reul GJ, Drescher KL; et al. (2001). "The effect of short-term prophylactic methylprednisolone on the incidence and severity of postpericardiotomy syndrome in children undergoing cardiac surgery with cardiopulmonary bypass". J Am Coll Cardiol. 37 (6): 1700–6. doi:10.1016/s0735-1097(01)01223-2. PMID 11345387.
- ↑ Gungor B, Ucer E, Erdinler IC. Uncommon presentation of postcardiac injury syndrome: Acute pericarditis after percutaneous coronary intervention. Int J Cardiol. Aug 14 2007
- ↑ Peters RW, Scheinman MM, Raskin S, Thomas AN. Unusual complications of epicardial pacemakers. Recurrent pericarditis, cardiac tamponade and pericardial constriction. Am J Cardiol. May 1980;45(5):1088-94.
- ↑ Vinit J, Sagnol P, Buttard P, Laurent G, Wolf JE, Dellinger A. Recurrent delayed pericarditis after pacemaker implantation: a post-pericardiotomy-like syndrome?. Rev Med Interne. Feb 2007;28(2):137-40.
- ↑ Zeltser I, Rhodes LA, Tanel RE, Vetter VL, Gaynor JW, Spray TL. Postpericardiotomy syndrome after permanent pacemaker implantation in children and young adults. Ann Thorac Surg. Nov 2004;78(5):1684-7.
- ↑ Sasaki A, Kobayashi H, Okubo T, Namatame Y, Yamashina A. Repeated postpericardiotomy syndrome following a temporary transvenous pacemaker insertion, a permanent transvenous pacemaker insertion and surgical pericardiotomy. Jpn Circ J. Apr 2001;65(4):343-4.
- ↑ Goutal H, Baur F, Bonnevie L, Monnier G, Le Blainvaux M, Brion R. Postpericardiotomy syndrome; a rare complication of transcavitary cardiac pacing: apropos of a case. Arch Mal Coeur Vaiss. Dec 1995;88(12):1901-3.
- ↑ Hargreaves M, Bashir Y. Postcardiotomy syndrome following transvenous pacemaker insertion. Eur Heart J. Jul 1994;15(7):1005-7.
- ↑ Goodkind MJ, Bloomer WE, Goodyer AV. Recurrent pericardial effusion after nonpenetrating chest trauma: report of two cases treated with adrenocortical steroids. N Engl J Med. Nov 3 1960;263:874-81.
- ↑ Tabatznik B, Isaacs JP. Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiol. Jan 1961;7:83-96.
- ↑ Peter RH, Whalen RE, Orgain ES, McIntosh HD. Postpericardiotomy syndrome as a complication of percutaneous left ventricular puncture. Am J Cardiol. Jan 1966;17(1):86-90.
- ↑ Krainin F, Flessas A, Spodick D (1984). "Infarction-associated pericarditis. Rarity of diagnostic electrocardiogram". N Engl J Med. 311 (19): 1211–4. PMID 6493274.
- ↑ Imazio M, Hoit BD (2013). "Post-cardiac injury syndromes. An emerging cause of pericardial diseases". Int J Cardiol. 168 (2): 648–52. doi:10.1016/j.ijcard.2012.09.052. PMID 23040075.
- ↑ 16.0 16.1 van Osch D, Nathoe HM, Jacob KA, Doevendans PA, van Dijk D, Suyker WJ; et al. (2017). "Determinants of the postpericardiotomy syndrome: a systematic review". Eur J Clin Invest. 47 (6): 456–467. doi:10.1111/eci.12764. PMID 28425090.
- ↑ Bucekova E, Simkova I, Hulman M (2012). "Postpericardiotomy syndrome - post-cardiac injury syndrome". Bratisl Lek Listy. 113 (8): 481–5. doi:10.4149/bll_2012_106. PMID 22897372.
- ↑ 18.0 18.1 Tamarappoo BK, Klein AL (2016). "Post-pericardiotomy Syndrome". Curr Cardiol Rep. 18 (11): 116. doi:10.1007/s11886-016-0791-0. PMID 27761786.
- ↑ Ünal E, Karcaaltincaba M, Akpinar E, Ariyurek OM (2019). "The imaging appearances of various pericardial disorders". Insights Imaging. 10 (1): 42. doi:10.1186/s13244-019-0728-4. PMC 6441059. PMID 30927107.
- ↑ Çetin MS, Özcan Çetin EH, Özdemir M, Topaloğlu S, Aras D, Temizhan A; et al. (2017). "Effectiveness of computed tomography attenuation values in characterization of pericardial effusion". Anatol J Cardiol. 17 (4): 322–327. doi:10.14744/AnatolJCardiol.2016.7353. PMC 5469113. PMID 28100899.
- ↑ Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J; et al. (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)". Eur Heart J. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. PMID 26320112.
- ↑ Bujarski S, Guy E (2016). "Use of Indwelling Pleural Catheter for Recurrent Pleural Effusion Due to Postpericardiotomy Syndrome: A Case Report". J Bronchology Interv Pulmonol. 23 (2): 160–2. doi:10.1097/LBR.0000000000000196. PMID 26905442.
- ↑ 23.0 23.1 Imazio M, Trinchero R, Brucato A, Rovere ME, Gandino A, Cemin R; et al. (2010). "COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial". Eur Heart J. 31 (22): 2749–54. doi:10.1093/eurheartj/ehq319. PMID 20805112. Review in: Ann Intern Med. 2011 Feb 15;154(4):JC2-10
- ↑ 24.0 24.1 Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter
- ↑ Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter