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Postpericardiotomy Syndrome Treatment & Management

  • Author: M Silvana Horenstein, MD; Chief Editor: Howard S Weber, MD, FSCAI  more...
 
Updated: Dec 10, 2015
 

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, although close follow-up is warranted.

Medical management includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, which is given for 4-6 weeks and is tapered as the fluid decreases. For patients not responsive to aspirin, ibuprofen, or naproxen, corticosteroids such as prednisone may be administered for 1 week, followed by a 4-week tapering. There are very limited data, if any, regarding the efficacy of colchicine for managing PPS in the pediatric population.[29]

Anecdotally, successful treatment of recurrent pericardial effusion has been described using a single high-dose of intravenous immunoglobulin in one patient[30] and a low weekly dose of methotrexate in one other.[31]  More recently, two children with refractory recurrent pericarditis following cardiac surgery were successfully treated with 3 and 5 monthly high-dose (2 g/kg) intravenous immunoglobulin until resolution of their pericardial effusions.[32]

Inpatient care of patients with PPS is indicated in more severe cases, such as patients with symptoms and signs indicative of tamponade. Patients with tamponade must be admitted to the hospital for pericardial drainage.

After drainage of the pericardial effusion and improvement in the clinical symptoms, most patients can be treated on an outpatient basis.

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 who cannot be effectively drained via pericardiocentesis or who have recurrent relapses after intervention. These patients may require a pericardial window.

Transfer

Patients whose conditions are refractory to medical management require transfer to a facility that has a pediatric cardiothoracic surgeon available. These patients may require a surgical pericardial window.

Diet and activity

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

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.

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Surgical Care

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

A surgically created pericardial window may be necessary in patients with recurrent relapses after medical-  and catheter-based therapy. This may be achieved through an open thoracotomy[33, 34, 35] or through a video-assisted thoracoscopic technique.[36]

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.[37, 38, 39]  The procedure effectively results in the pericardial fluid draining into the abdominal cavity via a perforation of the diaphragm. 

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Prevention

Currently, there is no known preventative therapy available for postpericardiotomy syndrome.[40]

A randomized controlled trial evaluating the use of colchicine to prevent postpericardiotomy syndrome (PPS) in patients undergoing cardiopulmonary bypass did not find a statistically significant difference from placebo.[41]  However, the authors noted a trend toward significance that may be more evident with larger study.[42, 43]

Preliminary findings from the Colchicine for Prevention of the Postpericardiotomy Syndrome and Postoperative Atrial Fibrillation (COPPS) trial in adults indicated that compared with placebo, perioperative use of colchicine reduced the incidence of PPS but not of postoperative atrial fibrillation or postoperative pericardial/pleural effusion.[44] However, there was also an increased risk of gastrointestinal adverse effects with colchicine administration, which offset the potential benefits.[44]

In a systematic review of the literature for prophylaxis and treatment of PPS, Cantinotti et al found three major medication classes were used: nonsteroidal anti-inflammatory agents (NSAIDs), and colchicine.[29] There were more data to support the use of colchicine prophylaxis in adults, but there was no significant prophylactic advantage with NSAIDs/corticosteroids in children.[29]

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Contributor Information and Disclosures
Author

M Silvana Horenstein, MD Assistant Professor, Department of Pediatrics, University of Texas Medical School at 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, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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 Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, Western Society for Pediatric Research, American College of Cardiology, American Heart Association, American Pediatric Society

Disclosure: Nothing to disclose.

Chief Editor

Howard S Weber, MD, FSCAI Professor of Pediatrics, Section of Pediatric Cardiology, Pennsylvania State University College of Medicine; Director of Interventional Pediatric Cardiology, Penn State Hershey Children's Hospital

Howard S Weber, MD, FSCAI is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, Society for Cardiovascular Angiography and Interventions

Disclosure: Received income in an amount equal to or greater than $250 from: St. Jude Medical.

Additional Contributors

Ira H Gessner, MD Professor Emeritus, Pediatric Cardiology, University of Florida College of Medicine

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, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Kelly S Skoumal, DO, MS, FAAP; John W Graneto, DO, FACEP, FAAP; and David A Lewis, MD, FAAP, FACC, to the original writing and development of this article.

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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.
 
 
 
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