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 the 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 during the supine position, but improved while sitting upright and leaning forward. Emesis has also been reported as the main symptom in children with impending cardiac tamponade secondary to postpericardiotomy syndrome.^[26]

Physical Examination

Patients often demonstrate tachycardia, muffled heart sounds, 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 in the setting of low cardiac output due to impaired ventricular filling. Pulses paradoxicus may also be evident and is represented by a decrease in systemic blood pressure over 10 mmHg during inspiration and diminished pulse-wave amplitude by palpation of the radial artery. Pleural friction rubs are common. Signs of pneumonitis, including cough, fever, and decreased oxygen saturation, may also be present.

Differential Diagnoses

Andreev DA, Giliarov MIu, Syrkin AL, Udovichenko AE, Gerok DV. [Postcardiotomy syndrome outside a cardiosurgical clinic]. Klin Med (Mosk). 2008. 86(10):67-71. [QxMD MEDLINE Link].
Jaworska-Wilczynska M, Abramczuk E, Hryniewiecki T. Postcardiac injury syndrome. Med Sci Monit. 2011 Nov. 17(11):CQ13-14. [QxMD MEDLINE Link].
Tamarappoo BK, Klein AL. Post-pericardiotomy syndrome. Curr Cardiol Rep. 2016 Nov. 18 (11):116. [QxMD MEDLINE Link].
Lehto J, Virolainen J. Postpericardiotomy syndrome. Duodecim. 2017. 133(4):411-6. [QxMD MEDLINE Link].
Gabaldo K, Sutlic Z, Miskovic D, et al. Postpericardiotomy syndrome incidence, diagnostic and treatment strategies: experience AT two collaborative centers. Acta Clin Croat. 2019 Mar. 58(1):57-62. [QxMD MEDLINE Link]. [Full Text].
Gungor B, Ucer E, Erdinler IC. Uncommon presentation of postcardiac injury syndrome: acute pericarditis after percutaneous coronary intervention. Int J Cardiol. 2008 Aug 1. 128(1):e19-21. [QxMD MEDLINE Link].
Peters RW, Scheinman MM, Raskin S, Thomas AN. Unusual complications of epicardial pacemakers. Recurrent pericarditis, cardiac tamponade and pericardial constriction. Am J Cardiol. 1980 May. 45(5):1088-94. [QxMD MEDLINE Link].
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. 2007 Feb. 28(2):137-40. [QxMD MEDLINE Link].
Zeltser I, Rhodes LA, Tanel RE, et al. Postpericardiotomy syndrome after permanent pacemaker implantation in children and young adults. Ann Thorac Surg. 2004 Nov. 78(5):1684-7. [QxMD MEDLINE Link].
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. 2001 Apr. 65(4):343-4. [QxMD MEDLINE Link].
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. 1995 Dec. 88(12):1901-3. [QxMD MEDLINE Link].
Hargreaves M, Bashir Y. Postcardiotomy syndrome following transvenous pacemaker insertion. Eur Heart J. 1994 Jul. 15(7):1005-7. [QxMD MEDLINE Link].
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. 1960 Nov 3. 263:874-81. [QxMD MEDLINE Link].
Tabatznik B, Isaacs JP. Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiol. 1961 Jan. 7:83-96. [QxMD MEDLINE Link].
Peter RH, Whalen RE, Orgain ES, McIntosh HD. Postpericardiotomy syndrome as a complication of percutaneous left ventricular puncture. Am J Cardiol. 1966 Jan. 17(1):86-90. [QxMD MEDLINE Link].
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. 1993 Jul. 104(1):71-8. [QxMD MEDLINE Link].
Herrera-Franco R, Narvaez-Rivera JL, Benitez-Perez C, et al. Recurrent cardiac tamponade secondary to postpericardiotomy syndrome. Gac Med Mex. 1999 Nov-Dec. 135(6):593-7. [QxMD MEDLINE Link].
Imazio M, Brucato A, Rovere ME, et al. Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. Am J Cardiol. 2011 Oct 15. 108(8):1183-7. [QxMD MEDLINE Link].
Engle MA, Zabriskie JB, Senterfit LB, et al. Viral illness and the postpericardiotomy syndrome. A prospective study in children. Circulation. 1980 Dec. 62(6):1151-8. [QxMD MEDLINE Link].
Clapp SK, Garson A Jr, Gutgesell HP, Cooley DA, McNamara DG. Postoperative pericardial effusion and its relation to postpericardiotomy syndrome. Pediatrics. 1980 Oct. 66(4):585-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Webber SA, Wilson NJ, Junker AK, et al. Postpericardiotomy syndrome: no evidence for a viral etiology. Cardiol Young. 2001 Jan. 11(1):67-74. [QxMD MEDLINE Link].
van Osch D, Nathoe HM, Jacob KA, et al. Determinants of the postpericardiotomy syndrome: a systematic review. Eur J Clin Invest. 2017 Jun. 47(6):456-67. [QxMD MEDLINE Link].
Wessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J. 2006 Mar. 99(3):309-14. [QxMD MEDLINE Link].
Dechtman ID, Grossman C, Shinar Y, et al. Carriage of Mediterranean fever (MEFV) mutations in patients with postpericardiotomy syndrome (PPS). Isr Med Assoc J. 2017 Sep. 19(9):562-5. [QxMD MEDLINE Link].
Scarfone RJ, Donoghue AJ, Alessandrini EA. Cardiac tamponade complicating postpericardiotomy syndrome. Pediatr Emerg Care. 2003 Aug. 19(4):268-71. [QxMD MEDLINE Link].
[Guideline] Maisch B, Seferovic PM, Ristic AD, et al, for The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases executive summary. Eur Heart J. 2004 Apr. 25(7):587-610. [QxMD MEDLINE Link].
[Guideline] Adler Y, Charron P, Imazio M, et al, for the European Society of Cardiology (ESC). 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Endorsed by The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7. 36(42):2921-64. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Fardman A, Charron P, Imazio M, Adler Y. European guidelines on pericardial diseases: a focused review of novel aspects. Curr Cardiol Rep. 2016 May. 18(5):46. [QxMD MEDLINE Link].
Vogel-Claussen J, Elshafee ASM, Kirsch J, et al, for the Expert Panel on Cardiac Imaging. ACR Appropriateness Criteria dyspnea-suspected cardiac origin. J Am Coll Radiol. 2017 May. 14(5S):S127-37. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr. 2013 Sep. 26(9):965-1012.e15. [QxMD MEDLINE Link].
Imazio M, Adler Y, Ristic AD, Charron P. A new scoring system for the triage of cardiac tamponade. Expert Rev Cardiovasc Ther. 2015 Mar. 13(3):237-8. [QxMD MEDLINE Link].
Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial issues in the management of pericardial diseases. Circulation. 2010 Feb 23. 121(7):916-28. [QxMD MEDLINE Link].
Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010 Jun. 85(6):572-93. [QxMD MEDLINE Link]. [Full Text].
Seferovic PM, Ristic AD, Maksimovic R, et al. Pericardial syndromes: an update after the ESC guidelines 2004. Heart Fail Rev. 2013 May. 18(3):255-66. [QxMD MEDLINE Link].
Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management. Am Fam Physician. 2014 Apr 1. 89(7):553-60. [QxMD MEDLINE Link].
Cantinotti M, Spadoni I, Assanta N, et al. Controversies in the prophylaxis and treatment of postsurgical pericardial syndromes: a critical review with a special emphasis on paediatric age. J Cardiovasc Med (Hagerstown). 2014 Dec. 15(12):847-54. [QxMD MEDLINE Link].
Wendelin G, Fandl A, Beitzke A. High-dose intravenous immunoglobulin in recurrent postpericardiotomy syndrome. Pediatr Cardiol. 2008 Mar. 29(2):463-4. [QxMD MEDLINE Link].
Zucker N, Levitas A, Zalzstein E. Methotrexate in recurrent postpericardiotomy syndrome. Cardiol Young. 2003 Apr. 13(2):206-8. [QxMD MEDLINE Link].
del Fresno MR, Peralta JE, Granados MA, Enriquez E, Dominguez-Pinilla N, de Inocencio J. Intravenous immunoglobulin therapy for refractory recurrent pericarditis. Pediatrics. 2014 Nov. 134(5):e1441-6. [QxMD MEDLINE Link].
Little AG, Kremser PC, Wade JL, Levett JM, DeMeester TR, Skinner DB. Operation for diagnosis and treatment of pericardial effusions. Surgery. 1984 Oct. 96(4):738-44. [QxMD MEDLINE Link].
Naunheim KS, Kesler KA, Fiore AC, et al. Pericardial drainage: subxiphoid vs. transthoracic approach. Eur J Cardiothorac Surg. 1991. 5(2):99-103; discussion 104. [QxMD MEDLINE Link].
Moores DW, Allen KB, Faber LP, et al. Subxiphoid pericardial drainage for pericardial tamponade. J Thorac Cardiovasc Surg. 1995 Mar. 109(3):546-51; discussion 551-2. [QxMD MEDLINE Link].
Hazelrigg SR, Mack MJ, Landreneau RJ, Acuff TE, Seifert PE, Auer JE. Thoracoscopic pericardiectomy for effusive pericardial disease. Ann Thorac Surg. 1993 Sep. 56(3):792-5. [QxMD MEDLINE Link].
Forbes TJ, Horenstein MS, Vincent JA. Balloon pericardiotomy for recurrent pericardial effusions following fontan revision. Pediatr Cardiol. 2001 Nov-Dec. 22(6):527-9. [QxMD MEDLINE Link].
Ziskind AA, Pearce AC, Lemmon CC, et al. 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. 1993 Jan. 21(1):1-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Imazio M, Brucato A, Markel G, et al. Meta-analysis of randomized trials focusing on prevention of the postpericardiotomy syndrome. Am J Cardiol. 2011 Aug 15. 108(4):575-9. [QxMD MEDLINE Link].
Wamboldt R, Bisleri G, Glover B, et al. Primary prevention of post-pericardiotomy syndrome using corticosteroids: a systematic review. Expert Rev Cardiovasc Ther. 2018 Jun. 16(6):405-12. [QxMD MEDLINE Link].
Finkelstein Y, Shemesh J, Mahlab K, et al. Colchicine for the prevention of postpericardiotomy syndrome. Herz. 2002 Dec. 27(8):791-4. [QxMD MEDLINE Link].
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). 2007 Dec. 8(12):1044-8. [QxMD MEDLINE Link].
Imazio M, Brucato A, Ferrazzi P, et al. Colchicine reduces postoperative atrial fibrillation: results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) atrial fibrillation substudy. Circulation. 2011 Nov 22. 124(21):2290-5. [QxMD MEDLINE Link].
Imazio M, Brucato A, Ferrazzi P, et al, for the COPPS-2 Investigators. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation: the COPPS-2 randomized clinical trial. JAMA. 2014 Sep 10. 312(10):1016-23. [QxMD MEDLINE Link].
Cheung EW, Ho SA, Tang KK, et al. Pericardial effusion after open heart surgery for congenital heart disease. Heart. 2003 Jul. 89(7):780-3. [QxMD MEDLINE Link].
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. 2002 Jul. 3(7):435-6. [QxMD MEDLINE Link].
Dressler W. The post-myocardial-infarction syndrome: a report on forty-four cases. AMA Arch Intern Med. 1959 Jan. 103(1):28-42. [QxMD MEDLINE Link].
Hoffman JIE, Stanger P. Diseases of pericardium. Rudolph AM, Hoffman JIE, Rudolph CD, eds. Rudolph's Pediatrics. 20th ed. Stamford, Conn: Appleton & Lange; 1996. 1530-1.
Prince SE, Cunha BA. Postpericardiotomy syndrome. Heart Lung. 1997 Mar-Apr. 26(2):165-8. [QxMD MEDLINE Link].
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. 1999 Aug. 116(2):322-31. [QxMD MEDLINE Link].
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. 1998 Nov. 11(11):1072-7. [QxMD MEDLINE Link].
Wilson NJ, Webber SA, Patterson MW, et al. Double-blind placebo-controlled trial of corticosteroids in children with postpericardiotomy syndrome. Pediatr Cardiol. 1994 Mar-Apr. 15(2):62-5. [QxMD MEDLINE Link].
Casanova P, Artola RT, Mihos CG, Pineda AM, Santana O. The cardiovascular effects of colchicine: a comprehensive review. Cardiol Rev. 2015 Nov-Dec. 23(6):317-22. [QxMD MEDLINE Link].
Johnston DR. Surgical management of pericardial diseases. Prog Cardiovasc Dis. 2017 Jan - Feb. 59(4):407-16. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

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.
Echocardiographic subcostal view demonstrating a large global pericardial effusion, with evidence of right atrial collapse (<i>red arrow</i>) consistent with cardiac tamponade prior to pericardiocentesis.
Four-chamber echocardiographic view following emergent pericardiocentesis (800 mL removed) for clinical and echocardiographic evidence of cardiac tamponade. Virtually no residual pericardial effusion is evident.

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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: Society for Cardiovascular Angiography and Interventions

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

Postpericardiotomy Syndrome Clinical Presentation

History

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