Postpericardiotomy syndrome: Difference between revisions
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Revision as of 13:37, 24 October 2012
| Postpericardiotomy syndrome | |
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| Fibrinous pericarditis: Gross, natural color, excellent external view of typical fibrinous pericarditis (After mitral valve replacement). Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology |
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Pericarditis Microchapters |
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Diagnosis |
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Treatment |
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Surgery |
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Case Studies |
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Postpericardiotomy syndrome On the Web |
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American Roentgen Ray Society Images of Postpericardiotomy syndrome |
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Risk calculators and risk factors for Postpericardiotomy syndrome |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and Related Keywords: Postcommissurotomy syndrome; PCS; PPS
Overview
The postpericardiotomy syndrome is inflammation of the pericardium (the sac surrounding the heart) following cardiac surgery. Symptoms can occur from days to weeks after the operation. The syndrome is thought to have an autoimmune basis.
Pathophysiology
It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma. Various viral agents, including coxsackie B, adenovirus, and cytomegalovirus, are identified in approximately two thirds of patients with postpericardiotomy syndrome, suggesting that postpericardiotomy syndrome is an autoimmune response that may be associated with a coincident viral infection.[1][2]
Causes
- 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. [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]
Conditions that Postpericardiotomy Syndrome should be Distinguished From
Postpericardiotomy syndrome should be distinguished from Dressler's syndrome which is an autoimmune process that occurs 2-10 weeks following ST elevation MI [13]. 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.
Risk Factors
Postpericardiotomy syndrome occurs more frequently in patients who have undergone heart surgery that involves opening the pericardium.
Epidemiology and Demographics
It is estimated that anywhere from 2% to 30% of patients who undergo heart surgery who have had their pericardium opened will develop postpericardiotomy syndrome.
Age
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
Natural History, Complications, Prognosis
Natural History
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.
Complications
- 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
In general the prognosis is good.
Diagnosis
Symptoms
Symptoms usually become manifest several (1 to 6) weeks after heart surgery and may include:
- Anorexia
- Arthralgias
- Chest pain
- Dyspnea
- Emesis in children
- Fever
- Irritability
- Joint pain
- Malaise
- Muscle pain
- Palpitation
- Poor appetite
- Shortness of breath
Physical Examination
Vital signs
Tachycardia may be present Hypoxemia may be present
Cardiac
Pericardial friction rub is often present, an enlarged heart may be present
Lungs
Signs of a pleural effusion may be present
Abdominal Exam
Hepatomegaly may be present
Extremities
Pedal edema may be present if pericardial constriction or a pericardial effusion is present
Laboratory Studies
- 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
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
Treatment
Postpericardiotomy syndrome is typically treated similar to Dressler's syndrome with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin. Acetominophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion.
NSAIDs such as ibuprofen should be avoided in the peri-infarct period as they:
- Increase the risk of reinfarction
- Adversely impact left ventricular remodeling.
- Block the effectiveness of aspirin
- May cause increased bleeding
ACC/AHA Treatment Guidelines (DO NOT EDIT)[14]
| “ |
Class I1. 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) Class IIa1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following:
Class IIb1. 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) Class III1. 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) |
” |
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [14]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [15]
References
- ↑ 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.
- ↑ 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.
- ↑ 14.0 14.1 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
|month=ignored (help) - ↑ 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
|month=ignored (help)