Post-Pericardiotomy Syndrome

Joy Baysa, MD, PGY-4 May 22, 2013

Lets Meet the Patient

11 yo previously healthy male who initially presented with fever of unknown origin and non-tender rash on his hands and feet Echocardiogram revealed endocarditis of his mitral valve with a mobile vegetation Subsequently went to the OR for removal of infected valve and implantation of 25 mm St Judes valve in the mitral position PCR positive for hemophilus paraphrophiilus Discharged home on POD# 13 on IV Rocephin and anti-coagulation with Coumadin

 About 6 weeks post-operatively, patient presented in cardiology clinic for follow-up Had complaints of cough, decreased appetite, and increased fatigue for the past few days Noted in clinic to be tachycardic to the 110s-120s No fevers or chest pain

Labwork
12.1 12.6 135 100 3.9 26 10 128 0.4

275 34.9

77N/13L/10M

INR: 2.37 PT: 26.7 PTT 55.9

ESR: 33 CRP: 10

CXR

Admission CXR

CXR 6 weeks prior

Echocardiogram

Management & Hospital Course

Patient was admitted to the CICU The next morning, he was taken to the cath lab for pericardiocentesis About 100 ml of bloody fluid was drained & sent down to the laboratory for further evaluation and testing A pericardial drain was left in place for <24 hours Evaluation of pericardial fluid showed no evidence of bacterial infection Serial echocardiograms showed improvement in the amount of effusion He was sent home on HD#6 with a diagnosis of post-pericardiotomy syndrome

Post-Pericardiotomy Syndrome
An inflammatory process affecting the pleural and pericardial space in 10-40% of patients after surgical trauma involving the pleura and/or pericardium Also associated with other kinds of interventions that may lead to pericardial bleeding, such as pacemaker implantation, percutaneous coronary interventions, and radiofrequency ablations

Pathogenesis Historical Perspectives

First described by Janton in 1952 and Soloff in 1953 after mitral commissurotomy Was thought to be reactivation of rheumatic fever, involving the mitral valve In 1958, Ito and colleagues noted the same process, following surgical repair for congenital heart disease Because the common feature of these patients was incision of the pericardium, they suggested the name postpericardiotomy syndrome In the 1960s, several investigators noted that elevated autoantibodies to the heart seemed to be correlated with the manifestation of the syndrome

Pathogenesis Contemporary Perspectives

Pathogenesis is still not well-understood Presumed to be an immune-mediated response after damage to the pericardium or pleura, especially with bleeding into the pericardial sac

However, PPS can also occur in immunosuppressed transplanted patients Viral infections may play a causative or provocative role The role of antiheart antibodies remains controversial
There are seasonal variations in the syndrome, similar to seasonal variations in viral prevalence

Supported by the fact that there is usually a latent period of several weeks after initial insult (surgery) before symptoms appear Also appears to respond to anti-inflammatory drugs

Clinical Manifestations
80% occur in the first month Pleuritic chest pain (56%) Fever (50%) Elevation of inflammatory markers (>70%) Pericardial or pleural friction rub (1/3) Pericardial or pleural effusion (~90%) Other manifestations: dyspnea, non-productive cough, fatigue, myalgia/arthralgia

Evaluation & Diagnosis

No standardized guidelines for diagnosis, which probably leads to underestimation The largest clinical trials use the following criteria (2 of the 5 are required to make the clinical diagnosis):
Fever beyond the first post-operative week with no evidence of infection Pleuritic chest pain Pleural or pericardial friction rub Pleural effusion New or worsening pericardial effusion

 Laboratory studies show non-specific markers of increased inflammation

CBC may show leukocytosis with predominance of neutrophils ESR/CRP may be elevated

Blood and fluid cultures important in ruling out bacterial infection as cause rather than postpericardiotomy syndrome CXR may show cardiomegaly and/or evidence of pleural effusions Echocardiography good for evaluating for the presence of pericardial effusion

Differential Diagnosis
Bacterial Pericarditis Idiopathic/Viral Pericarditis Hemopericardium Bacterial Endocarditis Incisional Pain Pneumonia

Treatment
Treatment is mostly aimed at patient comfort, as the illness is usually self-limited Thoracentesis or pericardiocentesis not usually required, unless fluid is causing hemodynamic compromise, severe symptoms, or is refractory to medical treatment Medical treatment is empiric, and involves the use of antiinflammatory agents, such as NSAIDs or corticosteroids Aspirin, at anti-inflammatory doses, usually used first line If ASA is contraindicated, can used ibuprofen Corticosteroids, at low-medium doses, may be useful in refractory cases or if the patient is on anti-coagulant therapy Colchicine is emerging as an adjunct therapy as well as in prevention of PPS

Prognosis
Generally good prognosis, comparable to or better than that for idiopathic pericarditis <4% risk of recurrence <2% risk of cardiac tamponade Longer hospital stays and more readmissions Risk of subsequently developing constrictive pericarditis low, unless patient also has connective tissue disease

Conclusion
Post-pericardiotomy syndrome is a relatively common complication of heart surgery Occurs after pericardial or pleural incision, with bleeding into the pericardial space Pathogenesis is not well understood but is thought to be an immune mediated process Patients present with chest pain, fever, friction rub, and evidence of pericardial or pleural effusions May treat empirically with anti-inflammatory agents, but illness is self-limited with generally good prognosis

References
Imazio M, Brucato A, Rovere ME, et al. Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. Am J Cardiol 2011; 108:1183-1187 Imazio M. The post-pericardiotomy syndrome. Curr Opin Pulm Med 2012, 18: 366-374. Ito T, Engle MA, Goldberg H. Postpericardiotomy syndrome following surgery for nonrheumatic heart disease. Circulation 1953; 17: 549-556. Kahn AH. The postcardiac injury syndromes. Clin Cardiol 1992; 15: 67-72. Kirsh MM, McInotish K, Kahn DR, Sloan H. Postpericardiotomy syndromes. Ann Thor Surg 1970; 9: 158-179. Maisch B, Seferovic PM, Ristic AD, et al. Task Force of the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and magament of pericardial diseases exective summary; the task force of the diagnosis and management of pericardial diseases of the European Society of Cardiology. Eur Heart J 2004; 25: 587610.