Postpericardiotomy syndrome

Overview

Postpericardiotomy syndrome (PPS) is an inflammatory condition that occurs after surgical incision or trauma to the pericardium—the thin sac surrounding the heart. It typically arises days to weeks following procedures such as open-heart surgery, pericardiotomy, or chest trauma. PPS is a form of secondary pericarditis and is believed to be an autoimmune reaction triggered by pericardial injury.

While PPS is usually self-limited, it can lead to complications such as pericardial effusion, pleural effusion, or in rare cases, cardiac tamponade. It is relatively common after cardiac surgery, with reported incidence rates between 10% and 40% depending on the type of surgery and patient factors.

Causes

The exact mechanism behind postpericardiotomy syndrome is not fully understood, but it is believed to be autoimmune in nature. When the pericardium is incised or injured during surgery, intracellular components such as cardiac antigens may leak into the bloodstream. This exposure can provoke an immune response, resulting in systemic inflammation.

Common triggers of PPS include:

• Open-heart surgery: Especially coronary artery bypass grafting (CABG), valve replacements, and congenital heart defect repair.

• Pericardiectomy or pericardiotomy: Direct procedures involving the pericardium.

• Chest trauma: Blunt or penetrating injuries to the thoracic cavity.

• Pacemaker or implantable cardioverter-defibrillator (ICD) insertion: In rare cases involving manipulation near the pericardium.

Risk factors may include prior history of pericarditis, younger age, or genetic predisposition to autoimmune conditions.

Symptoms

Symptoms of postpericardiotomy syndrome generally develop within a few days to several weeks after the inciting event. Common clinical features include:

• Fever: Low-grade to moderate, often the earliest symptom.

• Pleuritic chest pain: Sharp pain that worsens with deep breathing or lying flat, often relieved by sitting upright and leaning forward.

• Pericardial friction rub: A scratchy sound heard on auscultation, indicative of inflamed pericardial surfaces rubbing together.

• Dyspnea: Shortness of breath, especially with exertion or lying down.

• Fatigue and malaise: General feeling of weakness and discomfort.

• Pericardial effusion: Accumulation of fluid around the heart, which may present with muffled heart sounds or jugular venous distension.

• Pleural effusion: Especially left-sided, causing additional respiratory discomfort.

In severe cases, large pericardial effusions can lead to cardiac tamponade, a life-threatening condition requiring urgent drainage.

Diagnosis

Diagnosis of PPS is clinical and supported by imaging and laboratory findings. A combination of recent cardiac surgery history and classic symptoms helps establish the diagnosis. Key diagnostic steps include:

• Medical history: Recent cardiac or thoracic surgery, with symptoms emerging in the postoperative period.

• Physical examination: Presence of fever, chest tenderness, pericardial rub, or signs of fluid accumulation.

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

• Chest X-ray: Can reveal cardiomegaly due to pericardial effusion or evidence of pleural effusion.

• Echocardiography: The primary tool for detecting pericardial effusion and assessing cardiac function.

• Laboratory tests:

  • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)

  • Leukocytosis (increased white blood cell count)

Other causes of postoperative fever such as infection, pneumonia, or pulmonary embolism should be ruled out.

Treatment

Treatment of postpericardiotomy syndrome aims to reduce inflammation, relieve symptoms, and prevent complications. Most cases respond well to medical therapy.

First-Line Therapy

• Non-steroidal anti-inflammatory drugs (NSAIDs): Such as ibuprofen or aspirin, used to reduce pain and inflammation.

• Colchicine: Often added to NSAIDs to reduce recurrence and duration of symptoms. It has become a standard adjunct therapy for pericarditis and PPS.

Second-Line Therapy

• Corticosteroids: Reserved for patients who are unresponsive to NSAIDs/colchicine or have contraindications. Prolonged use should be avoided due to risk of recurrence after tapering.

Procedural Intervention

• Pericardiocentesis: In cases of large pericardial effusion or cardiac tamponade, fluid drainage may be required.

• Pleural drainage: If large pleural effusions impair respiration.

Supportive Care

• Rest and gradual return to physical activity

• Close follow-up with echocardiography to monitor for recurrence

Prognosis

The prognosis for postpericardiotomy syndrome is generally excellent with appropriate treatment. Most patients recover fully within a few weeks to a few months. However, some may experience recurrent episodes of pericarditis or effusion, particularly if treatment is delayed or inadequate.

Factors that influence prognosis include:

• Prompt recognition and treatment initiation

• Presence of complications like tamponade or constrictive pericarditis

• Patient adherence to anti-inflammatory therapy

With current treatment strategies, especially the use of colchicine-recurrence rates and duration of illness have significantly decreased. Long-term outcomes are favorable, and life-threatening complications are rare when PPS is managed appropriately.