Post-pericardiotomy Syndrome - Symptoms, Diagnosis, and Treatment

Introduction

Postpericardiotomy syndrome (PPS) was initially identified in 1953 in mitral valve surgery patients who developed fever and pleuritic pain. Patients typically appear with PPS a few days after surgery; however, clinical symptoms may arise as late as several weeks to months after surgery and may be accompanied by substantial morbidity. It is considered that post-cardiothoracic surgery-associated PPS is caused by a heightened immunological response to damage.

However, the post-pericardiotomy syndrome has also been described after myocardial infarction (Dressler syndrome) and as an uncommon complication following percutaneous procedures such as coronary stent implantation, after implantation of epicardial pacemaker leads and transvenous pacemaker leads, and after blunt trauma, stab wounds, and heart puncture.

Pericardial effusions frequently accompany the condition and can lead to early or late postoperative cardiac tamponade, as well as recurrent cardiac tamponade. In addition to pericardial or pleuritic pain, shortness of breath, friction rubs, pleural effusions, pneumonitis, and abnormal ECG and radiographic findings, the syndrome is also characterized by pericardial or pleuritic pain, shortness of breath, friction rubs, pleural effusions.

What Causes Post-pericardiotomy Syndrome?

Postpericardiotomy syndrome is often caused by the development of anti-heart antibodies, which cause the pericardial space to become inflamed. The post-pericardiotomy syndrome may have more than one cause. A systematic review found that the inflammatory response, as well as bleeding and clotting during surgery, may be involved. Some of the things that were linked to a higher risk of this condition were:

• Low interleukin 8, platelets, and hemoglobin before surgery.

• Higher complement conversion products after surgery.

• Younger age.

• Transfusions of red blood cells.

What Are the Signs and Symptoms of Post-pericardiotomy Syndrome?

Symptoms appear one to six weeks following cardiac surgery. In general, the disease is self-limiting, with modest symptoms and signs that resolve in two to three weeks. After the first postoperative week, the temperature normally reaches between 38 to 39 degrees Celcius orally, although it can exceed 40 degrees Celcius. Despite the fever, the patient may not appear to be ill. The fever normally goes away in two to three weeks.

Typical presenting symptoms include:

• Malaise.

• Chest discomfort.

• Irritability and a loss of appetite.

• Patients may also complain of dyspnea and arthralgia.

• Children may complain of chest pain that worsens with inspiration and while lying down but improves when sitting upright and leaning forward.

• Vomitings have also been recorded as the primary symptom in children with post-pericardiotomy syndrome and imminent cardiac tamponade.

What Diagnostic Tests Are Done for Postpericardiotomy Syndrome?

When at least two of the following five diagnostic criteria are met, the post-pericardiotomy syndrome is diagnosed:

• New or worsening pleural effusion.

• New or worsening pericardial effusion.

• Fever.

• Pleural chest discomfort.

• Pleural or pericardial rubbing.

Symptoms and History:

• Fever, chest discomfort, and dyspnea are common symptoms of postpericardiotomy syndrome. Malaise, decreased appetite, and arthralgia is the less severe symptoms of postpericardiotomy syndrome.

• Physical Examination of the vital signs.

• A cardiac pericardial friction rub is frequently present, as is an enlarged heart.

• Pleural effusion signs may be found in the lungs.

• Ruling out for pericardial constriction or effusion. There may be leg swelling.

The diagnostic tests include:

1. Electrocardiogram: The diagnosis of post-pericardiotomy syndrome may benefit from an ECG. Pericarditis-related ECG findings include ST-segment elevation, T-wave inversion, and PR depression in several leads.

2. Heart X-ray: The costophrenic angles are frequently blunted together with the presence of a pleural effusion. If there is a significant enough pericardial effusion, cardiomegaly may be observed.

3. Ultrasonography or Echocardiography: In order to properly diagnose post-pericardiotomy syndrome, echocardiography may be useful. Pericardial effusion is a finding on an echocardiogram of a post-pericardiotomy syndrome.

4. Computed Tomography (CT) Scan: The diagnosis of the pericardial effusion may benefit from a cardiac CT scan. Pericardial effusion is a finding on a CT scan that is suggestive of post-pericardiotomy syndrome, while pericardial thickening is a finding on a CT scan that is diagnostic of pericardial effusion.

5. Magnetic Resonance Imaging (MRI): When determining the cause of postpericardiotomy syn, cardiac MRI may be useful. Pericardial thickening is a finding on MRI that suggests pericardial effusion.

How Is Postpericardiotomy Syndrome Treated?

1. Medical Therapy:

• Patients who might have postpericardiotomy syndrome (PPS) are usually evaluated outside a hospital. If the patient's blood flow is not affected, the testing and treatment can continue outside the hospital, but they should be closely watched.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like Aspirin are used to treat it medically. They are given for four to six weeks and then lessened as the fluid level goes down. For people who do not get better with Aspirin, Ibuprofen, or Naproxen, corticosteroids like Prednisone may be given for one week, then tapered over the next four weeks. There is very little information, if any, about how well colchicine works to treat PPS in children.

• One person with recurrent pericardial effusion was treated successfully with a single high dose of intravenous immunoglobulin and another with a low dose of Methotrexate once a week. More recently, two children who had heart surgery and had recurrent pericarditis were treated successfully with high-dose (two grams per kilogram) intravenous immunoglobulin every three to five months until their pericardial effusions went away.

• When a person with PPS is very sick, like when they have symptoms and signs of tamponade, they need to stay in the hospital. When a person has a tamponade, they must go to the hospital for pericardial drainage.

• Most patients can be treated without staying in the hospital after the pericardial effusion is drained and their symptoms get better.

2. Surgery: Surgery is not advised for the treatment of postpericardiotomy syndrome.

3. Nutrition and Exercise:

• Patients with the post-pericardiotomy syndrome usually have less of an appetite, but they do not usually need to change what they eat.

• Patients who are thought to have or who have been diagnosed with the post-pericardiotomy syndrome should not do anything too hard. For mild cases, bed rest may be enough on its own. The person is seen to stay in bed until the fever is gone, and the chest x-ray and ECG show results that are close to normal.

Conclusion

PPS is a reaction to cardiothoracic surgery that causes inflammation. It is often marked by a new pericardial effusion and fever. Colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) may help treat PPS if they are given at the right time. Few studies have given a clear picture of the things that put people at risk for PPS. There is a need to find biomarkers that will allow patients who are at high risk of getting PPS after surgery to be treated in a more targeted way.