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

Postpericardiotomy Syndrome

Author: M Silvana Horenstein, MD, Consultant, Pediatric and Fetal Cardiac Diagnostic, Diagnostico Gineco-Obstetrico, PC; Associate Medical Director, Legacy Department, Best Doctors, Inc
Contributor Information and Disclosures

Updated: Apr 30, 2009

Introduction

Background

Postpericardiotomy syndrome (PPS) is a febrile illness secondary to an inflammatory reaction involving the pleura and pericardium.1  It is more common in patients who have undergone surgery that involves opening the pericardium. However, postpericardiotomy syndrome has also been described following myocardial infarction (Dressler syndrome) and as an unusual complication after percutaneous procedures such as coronary stent implantation,2 after implantation of epicardial pacemaker leads3  and transvenous pacemaker leads,4,5,6,7,8 and following blunt trauma,9 stab wounds,10 and heart puncture.11

Pericardial effusions often accompany the syndrome and may develop into early or late postoperative cardiac tamponade12 and even recurrent cardiac tamponade.13  The syndrome is also characterized by pericardial or pleuritic pain, friction rubs, pleural effusions, pneumonitis, and abnormal ECG and radiography findings (see Workup).

Pathophysiology

Postpericardiotomy syndrome is often associated with the development of antiheart antibodies.14 Various viral agents, including coxsackie B, adenovirus, and cytomegalovirus, have been present in approximately two thirds of patients with postpericardiotomy syndrome, suggesting an autoimmune response associated with a viral infection. However, a prospective study found no evidence to support a viral etiology for postpericardiotomy syndrome.15  This study suggested that the use of viral titers in the setting of cardiopulmonary bypass and recent blood transfusions is unreliable.

Frequency

United States

Estimated frequencies vary from 2-30% of patients undergoing surgery that involves opening of the pericardium.

Mortality/Morbidity

Postpericardiotomy syndrome usually manifests as a mild, self-limited inflammatory illness. Life-threatening pericardial tamponade can develop due to a progressively increasing pericardial effusion. Tamponade occurs in less than 1% of patients with postpericardiotomy syndrome. Elevation of cardiac filling pressures, progressive limitation of ventricular diastolic filling, and reduction of stroke volume and cardiac output characterize cardiac tamponade.

Age

Postpericardiotomy syndrome is uncommon in infants, but frequency increases in children and adults to as much as 30%.

Clinical

History

Symptoms of postpericardiotomy syndrome (PPS) usually develop within 1-6 weeks after surgery involving pericardiotomy. Temperature after the first postoperative week usually reaches 38-39°C orally but may spike as high as 40°C. Despite a high temperature, the patient may not appear ill. The fever usually subsides within 2-3 weeks. Malaise, chest pain, irritability, and decreased appetite are typical presenting symptoms. Patients may also report dyspnea and arthralgias. Children may report chest pain that worsens with inspiration and when in the supine position. Emesis has also been reported as the main symptom in 2 children with impending cardiac tamponade secondary to postpericardiotomy syndrome.16

Physical

Patients often demonstrate tachycardia and a pericardial friction rub. The pericardial rub disappears either with improvement or with further accumulation of pericardial fluid. Systemic fluid retention and hepatomegaly can also occur. Pleural friction rubs are common. Signs of pneumonitis, including cough, fever, and decreased oxygen saturation, may also be present.

Causes

The precise etiology of postpericardiotomy syndrome is not known. Postpericardiotomy syndrome is postulated to be an autoimmune response involving autoantibodies which target antigens exposed after the percardium has been damaged.14   

In a study of patients who had developed postpericardiotomy syndrome after transplantation, an increased proportion of activated helper T cells (CD4+/25+) and cytotoxic T cells (Leu-7+/CD8+) was found. This led to conclude that, in this population, postpericardiotomy syndrome was possibly secondary to cell-mediated immunity.17

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, Consultant, Pediatric and Fetal Cardiac Diagnostic, Diagnostico Gineco-Obstetrico, PC; Associate Medical Director, 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.