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      Drugs & Diseases > Pediatrics: Cardiac Disease and Critical Care Medicine

      Postpericardiotomy Syndrome Workup

      Updated: Dec 30, 2020
      • Author: M Silvana Horenstein, MD; Chief Editor: Howard S Weber, MD, FSCAI  more...
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      Workup

      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 (not usually obtained).

      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, although it is not diagnostic 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.
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      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 procedure of choice to confirm the diagnosis and assess the severity of postpericardiotomy syndrome.

      Echocardiographic subcostal view demonstrating a l 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.
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      Four-chamber echocardiographic view following emer 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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      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, the pericardial effusion becomes more global and 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, the atria are usually compressed by the pericardial fluid and indicative of cardiac tamponade.

      Echocardiography is particularly helpful in evaluating ventricular contractility.

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      Cardiac Magnetic Resonance Imaging

      Cardiac magnetic resonance imaging (cMRI) has been used more frequently to evaluate cardiac dynamics and pericardial abnormalities, such as pericardial thickening and inflammation associated with postpericardiotomy syndrome. [3] 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 and the rapid accumulation of pericardial fluid. The inflammatory changes seen in postpericardiotomy syndrome may cause pericardial adhesions that result in a localized collections of pericardial fluid, which is apparent on echocardiography. Pericardiocentesis may be emergently required if cardiac tamponade is present.

      The standard subxiphoid approach is recommended when the effusion is global and evident anterior and apical 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 diameter or French size of the pericardial drainage catheter should be dependent on the size of the patient and the characteristics of the pericardial effusion. If the pericardial fluid is considered to be an exudate in nature (bacterial), then a larger diameter drainage catheter will be necessary in order to avoid catheter occlusion due to the increased viscosity of the fluid. The drainage tube is usually left in place for 24-48 hours and aspirated periodically, during which anti-inflammatory treatment is initiated.

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      Treatment & Management
       
       
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