Postcardiotomy syndrome

Overview

Postcardiotomy syndrome (PCS) is a type of postpericardiotomy syndrome—a rare but recognized complication that occurs after surgical procedures involving the pericardium or myocardium, most commonly following open-heart surgery. PCS is characterized by an inflammatory response that affects the pericardium (the sac surrounding the heart), pleura (lining of the lungs), and sometimes the lungs themselves. It typically develops days to weeks after surgery and presents with symptoms such as chest pain, fever, pericardial effusion, and pleural effusion.

PCS is believed to be an autoimmune or inflammatory reaction triggered by surgical trauma to heart tissues. Though often self-limiting, the syndrome can lead to significant morbidity if not properly recognized and managed, especially in cases involving large pericardial effusions or cardiac tamponade.

Causes

The exact cause of postcardiotomy syndrome is not fully understood, but it is believed to be immune-mediated. Surgical injury to the pericardium and myocardium may release cardiac antigens into the bloodstream, provoking an inflammatory response in predisposed individuals. Common triggers include:

• Cardiac surgery: Most commonly seen after procedures like coronary artery bypass grafting (CABG), valve replacement, or heart transplantation.

• Pericardial injury: Manipulation or incision of the pericardium during surgery triggers an immune response.

• Use of cardiopulmonary bypass: May enhance systemic inflammatory activation.

• Genetic predisposition or prior autoimmune conditions: May increase susceptibility to post-surgical inflammatory reactions.

PCS is considered a subtype of postpericardiotomy syndrome, which also includes similar reactions after non-surgical trauma to the pericardium (e.g., pacemaker insertion or blunt chest trauma).

Symptoms

Symptoms of postcardiotomy syndrome typically develop within a few days to several weeks after cardiac surgery. The presentation may vary from mild to severe and include the following:

• Pleuritic chest pain: Sharp, stabbing pain that worsens with deep breathing or coughing, often relieved by sitting up and leaning forward.

• Fever: Low-grade or intermittent fever without signs of infection.

• Pericardial friction rub: A scratchy sound heard on auscultation due to inflamed pericardial layers rubbing against each other.

• Dyspnea (shortness of breath): Due to pericardial or pleural effusion or mild pulmonary involvement.

• Fatigue and malaise: General feelings of unwellness or low energy.

• Pericardial effusion: Accumulation of fluid in the pericardial sac, which may be seen on imaging.

• Pleural effusion: Especially left-sided, resulting in respiratory discomfort.

In severe cases, pericardial effusion may progress to cardiac tamponade—a life-threatening condition requiring urgent intervention.

Diagnosis

The diagnosis of postcardiotomy syndrome is clinical and supported by imaging and laboratory findings. Diagnostic criteria include the presence of pericardial or pleural inflammation after cardiac surgery. Investigations may include:

• Patient history: Recent history of cardiac surgery with symptom onset within days to weeks.

• Physical examination: Identification of pericardial rub, diminished breath sounds (due to effusion), or signs of tamponade.

• Electrocardiogram (ECG): May show diffuse ST-segment elevations or PR depressions in cases of pericarditis.

• Chest X-ray: May reveal pleural effusion or an enlarged cardiac silhouette due to pericardial fluid.

• Echocardiography: The most useful test to detect pericardial effusion and assess cardiac function.

• Laboratory tests: Elevated inflammatory markers such as ESR, CRP, and white blood cell count may support the diagnosis.

Other potential causes such as infection, pulmonary embolism, or myocardial infarction should be excluded.

Treatment

Treatment for postcardiotomy syndrome focuses on controlling inflammation, relieving symptoms, and preventing complications. Most cases respond well to anti-inflammatory medications. Management includes:

Pharmacological Treatment

• NSAIDs (Nonsteroidal anti-inflammatory drugs): First-line therapy for pain and inflammation (e.g., ibuprofen, aspirin).

• Colchicine: Used in combination with NSAIDs to reduce recurrence and shorten symptom duration.

• Corticosteroids: Reserved for cases unresponsive to NSAIDs and colchicine, or when NSAIDs are contraindicated.

• Analgesics: May be used for symptom control, especially in mild cases.

Procedural Interventions

• Pericardiocentesis: Required for significant pericardial effusion or tamponade to drain excess fluid.

• Thoracentesis: May be needed if large pleural effusion causes respiratory compromise.

Supportive Measures

• Rest and activity modification

• Monitoring for recurrence or progression of effusion

• Follow-up echocardiography to assess resolution

In rare, recurrent, or refractory cases, pericardiectomy (surgical removal of the pericardium) may be considered.

Prognosis

The prognosis for postcardiotomy syndrome is generally favorable with appropriate diagnosis and treatment. Most patients recover within a few weeks to a couple of months. However, recurrence can occur in up to 20%–30% of patients, especially if initial therapy is insufficient or if colchicine is not used.

Complications, though rare, may include:

• Cardiac tamponade

• Constrictive pericarditis (in chronic or untreated cases)

• Persistent or recurrent pericardial or pleural effusions

Early recognition, patient education, and regular follow-up with echocardiography help ensure timely management and minimize long-term risks. With appropriate treatment, most patients resume normal activities without lasting effects.