Postpericardiotomy syndrome

Synonyms and Related Keywords: Postcommissurotomy syndrome, PCS

Overview
The postpericardiotomy syndrome is inflammation of the pericardium (the sac surrounding the heart) following cardiac surgery. Symptoms can occur from days to weeks after the operation. The syndrome is thought to have an autoimmune basis.

Epidemiology and Demographics
Postpericardiotomy syndrome occurs more frequently in patients who have undergone cardiac surgery that involves opening the pericardium.

Pathophysiology
It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma. Various viral agents, including coxsackie B, adenovirus, and cytomegalovirus, are identified in approximately two thirds of patients with postpericardiotomy syndrome, suggesting that postpericardiotomy syndrome is an autoimmune response that may be associated with a coincident viral infection.

Conditions that Postpericardiotomy Syndrome should be Distinguished From
Postpericardiotomy syndrome should be distinguished from Dressler's syndrome which is an autoimmune process that occurs 2-10 weeks following ST elevation MI. It should also be differentiated from the much more common post myocardial infarction pericarditis that occurs between days 2 and 4 after myocardial infarction. Postpericardiotomy syndrome should also be differentiated from pulmonary embolism, another cause of pleuritic chest pain in people who have been hospitalized and/or undergone surgical procedures within the preceding weeks.

Causes

 * Pericardial and/or pleural bleeding
 * Surgical trauma
 * Postpericardiotomy syndrome can be an unusual complication after percutaneous coronary intervention such as stent implantation or after implantation of epicardial pacemaker leads and transvenous pacemaker leads, following blunt trauma, stab wounds, and heart puncture.

Symptoms
Symptoms usually become manifest several weeks after a major cardiac operation and may include:
 * Anorexia
 * Chest pain
 * Fever
 * Irritability
 * Joint pain
 * Malaise
 * Muscle pain
 * Palpitation
 * Shortness of breath

Vital signs
Tachycardia

Cardiac
Pericardial friction rub, Enlarged heart

Lungs
Signs of a pleural effusion may be present

Laboratory Studies
The following biomarkers may be located:
 * CBC
 * ESR
 * CRP

Treatment
Postpericardiotomy syndrome is typically treated similar to Dressler's syndrome with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin. Acetominophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion.

NSAIDs such as ibuprofen should be avoided in the peri-infarct period as they:
 * 1) Increase the risk of reinfarction
 * 2) Adversely impact left ventricular remodeling.
 * 3) Block the effectiveness of aspirin
 * 4) May cause increased bleeding

===ACC/AHA Treatment Guidelines (DO NOT EDIT) ===

{{cquote|

Class I
1. Aspirin is recommended for treatment of pericarditis after STEMI. Doses as high as 650 mg orally (entericcoated) every 4 to 6 hours may be needed. (Level of Evidence: B)

2. Anticoagulation should be immediately discontinued if pericardial effusion develops or increases. (Level of Evidence: C)

Class IIa
1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following:
 * a. Colchicine 0.6 mg orally every 12 hours (Level of Evidence: B)
 * b. Acetaminophen 500 mg orally every 6 hours. (Level of Evidence: C)

Class IIb
1. Corticosteroids might be considered only as a last resort in patients with pericarditis refractory to aspirin or NSAIDs. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. (Level of Evidence: C)

2. Nonsteroidal anti-inflammatory drugs may be considered for pain relief; however, they should not be used for extended periods because of their effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion. (Level of Evidence: B)

Class III
1. Ibuprofen should not be used for pain relief because it blocks the antiplatelet effect of aspirin and it can cause myocardial scar thinning and infarct expansion. (Level of Evidence: B) }}