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

Postpericardiotomy Syndrome: Treatment & Medication

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

Treatment

Medical Care

Evaluation of patients with suspected postpericardiotomy syndrome (PPS) is usually performed in an outpatient setting. The workup and treatment may continue on an outpatient basis if the patient is not hemodynamically affected. Medical management includes the use of nonsteroidal anti-inflammatory agents and corticosteroids. Pericardial drainage is indicated in patients with symptoms consistent with tamponade. Patients with tamponade must be admitted to the hospital for definitive care.

Anecdotally, successful treatment of recurrent pericardial effusion has been described using a single high dose of intravenous immunoglobulin in one patient18  and a low weekly dose of methotrexate in one other.19

Surgical Care

Immediate pericardiocentesis is necessary to relieve life-threatening cardiac tamponade.

A surgically created pericardial window may be necessary in patients with persistent symptoms or relapse after medical therapy. This may be achieved through an open thoracotomy20,21,22 or through a video-assisted thoracoscopic technique.23

Percutaneous balloon pericardiotomy (PBP) may be another alternative for these patients. This is a less invasive procedure in which a pericardial window is created in the catheterization laboratory using a balloon catheter under fluoroscopic guidance.24,25,26

Consultations

Consult a pediatric cardiologist to diagnose and treat as well as to follow care of patients with postpericardiotomy syndrome. Consult a pediatric cardiothoracic surgeon in cases of patients with persistent symptoms or relapse after medical therapy. These patients may require a pericardial window.

Diet

Patients usually have decreased appetite; however, special dietary restrictions are usually not required in patients with postpericardiotomy syndrome.

Activity

Patients with suspected or confirmed postpericardiotomy syndrome should avoid strenuous activity. Bed rest alone may be adequate to treat mild cases. Enforce strict bed rest until the fever has resolved and chest radiography and ECG reveal near baseline findings.

Medication

The mainstay of medical therapy is use of anti-inflammatory agents. Various drugs are available; all have similar efficacy. Corticosteroids are often used in more severe or refractory cases. Corticosteroids have resulted in rapid improvement in clinical symptoms and decrease in antiheart antibodies.

No evidence suggests that steroids administered prior to cardiopulmonary bypass reduce the risk of developing postpericardiotomy syndrome.14 One case has been reported of low-dose methotrexate used in postpericardiotomy syndrome refractory to standard therapy;19 however, this has not been further supported.

Anti-inflammatory agents

These agents decrease inflammatory responses and interfere with systemic events leading to inflammation.


Aspirin (Anacin, Ascriptin, Bayer Aspirin, Bayer Buffered Aspirin)

First-line medication for patients with PPS. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.

Adult

650 mg PO q4h

Pediatric

80-120 mg/kg/d PO divided q6h

Possible decreased effects with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose lowering effect of sulfonylurea drugs

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not use in children (<16 y) with flu or varicella

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Category D in third trimester of pregnancy; may cause transient decrease in renal function and aggravate chronic kidney disease; avoid use with severe anemia, with history of blood coagulation defects, or with anticoagulants


Indomethacin (Indocin)

Nonsteroidal anti-inflammatory medication often used as a first-line drug in PPS. Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Adult

25-50 mg PO bid/tid

Pediatric

1-3 mg/kg/d PO divided q6-8h; not to exceed 200 mg/d

Increased risk of serious NSAID-related adverse effects when coadministered with aspirin; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; GI bleeding or renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs)


Prednisone (Deltasone, Orasone, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Usually reserved for treating more severe cases or relapses. May also be used as a first-line drug. Corticosteroid use has been shown to result in faster resolution of symptoms than other therapies.

Adult

20-60 mg/d PO

Pediatric

Week 1: 2 mg/kg/d PO; tapered over 2-4 wk
Week 2: 1 mg/kg/d PO
Week 3: 0.5 mg/kg/d PO

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur

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
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References

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Further Reading

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

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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

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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.

 
 
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