eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Postpericardiotomy Syndrome: Differential Diagnoses & Workup

Author: M Silvana Horenstein, MD, Consulting Staff, Department of Pediatrics, University of Texas Medical School Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc
Contributor Information and Disclosures

Updated: Apr 30, 2009

Differential Diagnoses

Endocarditis, Bacterial
Heart Failure, Congestive
Myocarditis, Nonviral
Myocarditis, Viral
Pericarditis, Constrictive
Pericarditis, Viral

Other Problems to Be Considered

Chylous pericardial effusion
Chylous pleural effusion

Workup

Laboratory Studies

  • The expected CBC count findings in patients with postpericardiotomy syndrome (PPS) include leukocytosis with a leftward shift.
  • As with other patients with suspected inflammatory versus infectious conditions, obtain blood cultures early in the workup. The results of the blood cultures should be negative.
  • Acute phase reactants, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, are elevated.
  • Antiheart antibodies are usually present in high titers.
  • Cardiac enzyme testing is not usually helpful because the results vary. In addition, studies have reported no difference in enzyme levels compared with patients who underwent cardiopulmonary bypass that do not have clinical signs of postpericardiotomy syndrome.
  • If a pericardial drain is placed, fluid should be obtained for cell count, differential, cytology, culture, gram stain, triglyceride level, and total protein level.

Imaging Studies

  • Chest radiography may be helpful in diagnosing postpericardiotomy syndrome.
    • Chest radiography usually reveals blunting of the costophrenic angles due to a pleural effusion. A pericardial effusion enlarges the cardiac silhouette, as in the image below.

    • Upright chest radiograph in a 3-year-old child wi...

      Upright chest radiograph in a 3-year-old child with dyspnea and fever reveals a large opacity on the left, with obliteration of the left costophrenic angle and a fluid stripe. These findings indicate a pleural effusion.

      [ CLOSE WINDOW ]
      Upright chest radiograph in a 3-year-old child wi...

      Upright chest radiograph in a 3-year-old child with dyspnea and fever reveals a large opacity on the left, with obliteration of the left costophrenic angle and a fluid stripe. These findings indicate a pleural effusion.

    • The cardiac silhouette enlarges in proportion to the amount of fluid contained in the pericardial sac.
  • Echocardiography is the diagnostic standard. It is a much more sensitive imaging study than plain radiography.
    • In the early stages of postpericardiotomy syndrome, a small amount of fluid may be detected posterior to the left ventricle during systole.
    • With increasing fluid accumulation, detection using echocardiography becomes easier.
    • Echocardiography assists in differentiating suspected postpericardiotomy syndrome from congestive heart failure; cardiac output is reduced in both conditions. In postpericardiotomy syndrome with a large effusion, one or more cardiac chambers may be compressed by the pericardial fluid.
    • Echocardiography is particularly helpful in evaluating ventricular contractility.
  • Cardiac MRI has been used more frequently to evaluate cardiac dynamics and pericardial abnormalities. Cardiac MRI may be more helpful in identifying posterior pericardial fluid collections that may have become loculated and are not easily viewed with transthoracic echocardiography.

Other Tests

ECG findings are abnormal in postpericardiotomy syndrome and may include the following:

  • Initial findings may simulate pericarditis, with global ST segment elevation and T-wave inversion.
  • Subepicardial injury, resulting from myocardial inflammation, causes ST segment elevation.
  • The ECG may also reveal low QRS amplitude, especially with a large pericardial effusion.

Procedures

  • Tamponade is a life-threatening condition that can result from postpericardiotomy syndrome. The inflammatory changes seen in postpericardiotomy syndrome may cause pericardial adhesions that result in a localized collection of pericardial fluid.
  • Pericardiocentesis may be emergently required if cardiac tamponade is present.
  • The standard subxiphoid approach is recommended. Because of the possible localized nature of the tamponade, echocardiographic guidance is recommended. Echocardiography-guided pericardiocentesis with extended catheter drainage is considered the primary management for patients with clinically significant pericardial effusions. The drainage tube is usually left in place for 24-48 hours, during which anti-inflammatory treatment is initiated.

More on Postpericardiotomy Syndrome

Overview: Postpericardiotomy Syndrome
Differential Diagnoses & Workup: Postpericardiotomy Syndrome
Treatment & Medication: Postpericardiotomy Syndrome
Follow-up: Postpericardiotomy Syndrome
Multimedia: Postpericardiotomy Syndrome
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Andreev DA, Giliarov MIu, Syrkin AL, Udovichenko AE, Gerok DV. [Postcardiotomy syndrome outside a cardiosurgical clinic]. Klin Med (Mosk). 2008;86(10):67-71. [Medline].

  2. Gungor B, Ucer E, Erdinler IC. Uncommon presentation of postcardiac injury syndrome: Acute pericarditis after percutaneous coronary intervention. Int J Cardiol. Aug 14 2007;[Medline].

  3. 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. [Medline].

  4. 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. [Medline].

  5. 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. [Medline].

  6. 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. [Medline].

  7. 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. [Medline].

  8. Hargreaves M, Bashir Y. Postcardiotomy syndrome following transvenous pacemaker insertion. Eur Heart J. Jul 1994;15(7):1005-7. [Medline].

  9. 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. [Medline].

  10. Tabatznik B, Isaacs JP. Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiol. Jan 1961;7:83-96. [Medline].

  11. 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. [Medline].

  12. Russo AM, O'Connor WH, Waxman HL. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest. Jul 1993;104(1):71-8. [Medline].

  13. Herrera-Franco R, Narvaez-Rivera JL, Benitez-Perez C, et al. Recurrent cardiac tamponade secondary to postpericardiotomy syndrome. Gac Med Mex. Nov-Dec 1999;135(6):593-7. [Medline].

  14. Wessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J. Mar 2006;99(3):309-14. [Medline].

  15. Webber SA, Wilson NJ, Junker AK, et al. Postpericardiotomy syndrome: no evidence for a viral etiology. Cardiol Young. Jan 2001;11(1):67-74. [Medline].

  16. Scarfone RJ, Donoghue AJ, Alessandrini EA. Cardiac tamponade complicating postpericardiotomy syndrome. Pediatr Emerg Care. Aug 2003;19(4):268-71. [Medline].

  17. Cabalka AK, Rosenblatt HM, Towbin JA, et al. Postpericardiotomy syndrome in pediatric heart transplant recipients. Immunologic characteristics. Tex Heart Inst J. 1995;22(2):170-6. [Medline].

  18. Wendelin G, Fandl A, Beitzke A. High-Dose Intravenous Immunoglobulin in Recurrent Postpericardiotomy Syndrome. Pediatr Cardiol. Aug 3 2007;[Medline].

  19. Zucker N, Levitas A, Zalzstein E. Methotrexate in recurrent postpericardiotomy syndrome. Cardiol Young. Apr 2003;13(2):206-8. [Medline].

  20. Little AG, Kremser PC, Wade JL, Levett JM, DeMeester TR, Skinner DB. Operation for diagnosis and treatment of pericardial effusions. Surgery. Oct 1984;96(4):738-44. [Medline].

  21. Naunheim KS, Kesler KA, Fiore AC, Turrentine M, Hammell LM, Brown JW. Pericardial drainage: subxiphoid vs. transthoracic approach. Eur J Cardiothorac Surg. 1991;5(2):99-103; discussion 104. [Medline].

  22. Moores DW, Allen KB, Faber LP, et al. Subxiphoid pericardial drainage for pericardial tamponade. J Thorac Cardiovasc Surg. Mar 1995;109(3):546-51; discussion 551-2. [Medline].

  23. Hazelrigg SR, Mack MJ, Landreneau RJ, Acuff TE, Seifert PE, Auer JE. Thoracoscopic pericardiectomy for effusive pericardial disease. Ann Thorac Surg. Sep 1993;56(3):792-5. [Medline].

  24. Forbes TJ, Horenstein MS, Vincent JA. Balloon pericardiotomy for recurrent pericardial effusions following fontan revision. Pediatr Cardiol. Nov-Dec 2001;22(6):527-9. [Medline].

  25. Ziskind AA, Pearce AC, Lemmon CC, Burstein S, Gimple LW, Herrmann HC. Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. J Am Coll Cardiol. Jan 1993;21(1):1-5. [Medline].

  26. Hajduczok ZD, Ferguson DW. Percutaneous balloon pericardiostomy for non-surgical management of recurrent pericardial tamponade: a case report. Intensive Care Med. 1991;17(5):299-301. [Medline].

  27. Finkelstein Y, Shemesh J, Mahlab K, Abramov D, Bar-El Y, Sagie A. Colchicine for the prevention of postpericardiotomy syndrome. Herz. Dec 2002;27(8):791-4. [Medline].

  28. Imazio M, Cecchi E, Demichelis B, et al. Rationale and design of the COPPS trial: a randomised, placebo-controlled, multicentre study on the use of colchicine for the primary prevention of postpericardiotomy syndrome. J Cardiovasc Med (Hagerstown). Dec 2007;8(12):1044-8. [Medline].

  29. Bartels C, Honig R, Burger G, et al. The significance of anticardiolipin antibodies and anti-heart muscle antibodies for the diagnosis of postpericardiotomy syndrome. Eur Heart J. Nov 1994;15(11):1494-9. [Medline].

  30. Cheung EW, Ho SA, Tang KK, et al. Pericardial effusion after open heart surgery for congenital heart disease. Heart. Jul 2003;89(7):780-3. [Medline].

  31. De Biase L, Di Renzi P, Piccioni F, et al. Cardiac magnetic resonance imaging diagnosis of a loculated pericardial effusion in a patient with a postpericardiotomy syndrome. Ital Heart J. Jul 2002;3(7):435-6. [Medline].

  32. Dressler W. The post-myocardial-infarction syndrome: a report on forty-four cases. AMA Arch Intern Med. Jan 1959;103(1):28-42. [Medline].

  33. Engle MA, Zabriskie JB, Senterfit LB, et al. Viral illness and the postpericardiotomy syndrome. A prospective study in children. Circulation. Dec 1980;62(6):1151-8. [Medline].

  34. Hoffman JIE, Stanger P. Diseases of pericardium. In: Rudolph's Pediatrics. 1996:1530-1.

  35. Horneffer PJ, Miller RH, Pearson TA, et al. The effective treatment of postpericardiotomy syndrome after cardiac operations. A randomized placebo-controlled trial. J Thorac Cardiovasc Surg. Aug 1990;100(2):292-6. [Medline].

  36. Kim BJ, Ma JS. Constrictive pericarditis after surgical closure of atrial septal defect in a child. J Korean Med Sci. Dec 1998;13(6):658-61. [Medline].

  37. Kronick-Mest C. Postpericardiotomy syndrome: etiology, manifestations, and interventions. Heart Lung. Mar 1989;18(2):192-8. [Medline].

  38. Prabhu AS, Ross RD, Heinert MR, et al. Decreased incidence of postoperative pericardial effusions after cardiac surgery for congenital heart disease. Am J Cardiol. Apr 1 1996;77(9):774-6. [Medline].

  39. Prince SE, Cunha BA. Postpericardiotomy syndrome. Heart Lung. Mar-Apr 1997;26(2):165-8. [Medline].

  40. Takata M, Robotham JL. Pericardial effusion and tamponade. In: Critical Heart Disease in Infants, Children, and Adolescents. 1995:255-71.

  41. Tsang TS, Barnes ME, Hayes SN, et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998. Chest. Aug 1999;116(2):322-31. [Medline].

  42. Tsang TS, El-Najdawi EK, Seward JB, et al. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy. J Am Soc Echocardiogr. Nov 1998;11(11):1072-7. [Medline].

  43. Wilson NJ, Webber SA, Patterson MW, et al. Double-blind placebo-controlled trial of corticosteroids in children with postpericardiotomy syndrome. Pediatr Cardiol. Mar-Apr 1994;15(2):62-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

The European Society of Cardiology have established guidelines for the diagnosis and management of pericardial diseases.

[ CLOSE WINDOW ]

Keywords

postpericardiotomy syndrome, PPS, postcardiac injury syndrome, cardiac tamponade, pericardium surgery, pericardial effusion, pleural effusion, pneumonitis, friction rubs, pleuritic pain, myocardial infarction, Dressler syndrome, coronary stent implantation, epicardial pacemaker leads, transvenous pacemaker leads, blunt trauma, stab wounds, heart puncture, tamponade cardiac tamponade, coxsackie B, adenovirus, cytomegalovirus, pericardial rub, hepatomegaly

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

M Silvana Horenstein, MD, Consulting Staff, Department of Pediatrics, University of Texas Medical School Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc
M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Hugh D Allen, MD, Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine
Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.