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Postpericardiotomy Syndrome Workup

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

Laboratory Studies

The expected complete blood cell (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.

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Electrocardiography

Electrocardiographic (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.
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Chest Radiography

Chest radiography may be helpful in diagnosing postpericardiotomy syndrome. Chest radiographs usually reveal 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 wit 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.

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Echocardiography

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 (usually the atria) may be compressed by the pericardial fluid and is indicative of cardiac tamponade.

Echocardiography is particularly helpful in evaluating ventricular contractility.

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Cardiac Magnetic Resonance Imaging

Cardiac magnetic resonance imaging (MRI) has been used more frequently to evaluate cardiac dynamics and pericardial abnormalities. This imaging modality may be more helpful in identifying posterior pericardial fluid collections that may have become loculated and are not easily viewed with transthoracic echocardiography.

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Procedures

Pericardiocentesis

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 when the effusion is global and evident anterior to the right ventricle. 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.

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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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