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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODkxNDcxLW92ZXJ2aWV3\nPostpericardiotomy Syndrome\nAuthor: M Silvana Horenstein, MD; Chief Editor: Howard S Weber, MD, FSCAI more...\nSections Postpericardiotomy Syndrome\nChest Radiography\nCardiac Magnetic Resonance Imaging\nPostpericardiotomy syndrome (PPS) is a febrile illness secondary to an inflammatory reaction involving the pleura and pericardium. [1, 2, 3, 4] It is more common in patients who have undergone surgery that involves opening the pericardium (in the United States, the estimated frequency varies from 2% to 30% of these patients). However, postpericardiotomy syndrome has also been described following myocardial infarction (Dressler syndrome) and as an unusual complication after percutaneous procedures such as coronary stent implantation, [5] after implantation of epicardial pacemaker leads [6] and transvenous pacemaker leads, [7, 8, 9, 10, 11] and following blunt trauma, [12] stab wounds, [13] and heart puncture. [14]\nPericardial effusions often accompany the syndrome and may develop into early or late postoperative cardiac tamponade [15] and even recurrent cardiac tamponade. [16] The syndrome is also characterized by pericardial or pleuritic pain, friction rubs, pleural effusions, pneumonitis, and abnormal ECG and radiography findings (see Workup).\nPPS usually occurs as a single episode; however, it can recur years later. [17] It is uncommon in patients younger than 2 years, [18] but the frequency increases in children and adults to as much as 30%. It is more common after repair of tetralogy of Fallot, repair of atrial and ventricular septal defects, [19] and after cardiac transplantation. [20]\nIt is essential that clinicians diagnose and adequately treat PPS as well as recognize and treat impending or manifest cardiac tamponade.\nPostpericardiotomy syndrome is often associated with the development of antiheart antibodies, leading to an inflammatory reaction within the pericardial space. [21] Various viral agents, including coxsackie B, adenovirus, and cytomegalovirus, have been present in approximately two thirds of patients with postpericardiotomy syndrome, suggesting an autoimmune response associated with a viral infection. However, a prospective study found no evidence to support a viral etiology for postpericardiotomy syndrome. [22] This study suggested that the use of viral titers in the setting of cardiopulmonary bypass and recent blood transfusions is unreliable.\nThe etiology may be multifactorial; a systematic review found that the inflammatory response and perioperative bleeding and coagulation may play a role in the development of postpericardiotomy syndrome. [23] Factors that were associated with a higher risk of this condition included the following [23] :\nLower levels of preoperative interleukin 8, platelets, and hemoglobin\nHigher postoperative complement conversion products\nYounger age\nRed blood cell transfusions\nThe precise etiology of postpericardiotomy syndrome is not known. Postpericardiotomy syndrome is postulated to be an autoimmune response involving autoantibodies which target antigens exposed after the percardium has been damaged. [21]\nIn a study of patients who had developed postpericardiotomy syndrome after transplantation, an increased proportion of activated helper T cells (CD4+/25+) and cytotoxic T cells (Leu-7+/CD8+) was found. This led the investigators to conclude that, in this population, postpericardiotomy syndrome was possibly secondary to cell-mediated immunity. [20]\nMost cases of postpericardiotomy syndrome resolve within a few weeks. Rarely, symptoms may occur for more than 6 months.\nRelapse may occur after tapering anti-inflammatory medications; it is estimated to occur in 10-15% of patients. Most recurrences occur within 6 months of the initial insult.\nMorbidity/mortality\nPostpericardiotomy syndrome usually manifests as a mild, self-limited inflammatory illness. Life-threatening pericardial tamponade can develop due to a rapidly increasing pericardial effusion. [3, 4] Tamponade occurs in less than 1% of patients with postpericardiotomy syndrome. Elevation of cardiac filling pressures, progressive limitation of ventricular diastolic filling, and reduction of stroke volume and cardiac output characterize cardiac tamponade. This also correlates with the rapidity of pericardial effusion accumulation, because slow accumulation of even large pericardial effusions may not result in clinical signs and symptoms of tamponade. This is directly related to the ability of the pericardial space to enlarge significantly over an extended time period, thereby accomodating the fluid volume, and not resulting in cardiac tamponade.\nA study that evaluated 822 patients undergoing nonemergent valve surgery found postpericardiotomy syndrome in 119 (14.5%), with a 20.9% incidence of reoperation for tamponade at 1 year in patients who developed the syndrome compared to 2.5% in those who did not, but also having similar 1-year mortality (4.2% vs 5.5%, respectively). [23] Patients with postpericardiotomy syndrome also had longer median hospital stays (13 days vs 11 days, respectively) and were more likely to have had preoperative therapy for pulmonary disease without corticosteroids. [23]\nCarriage of the Mediterranean Fever (MEFV) gene may affect the severity of postpericardiotomy syndrome. In a study of 86 patients who underwent cardiac surgery, of whom 45 developed this condition and 41 did not, investigators found a significantly lower rate of mutation carriage in patients with severe postpericardiotomy syndrome (4.8%) relative to those with mild-moderate postpericardiotomy syndrome (25%) (P <0.05).<ref>24</ref>​ However, the rate of MEFV mutation carriage between the groups with and without postpericardiotomy syndrome was similar.\nCardiac tamponade is a life-threatening complication of postpericardiotomy syndrome. Emergent pericardiocentesis and drainage of the pericardial effusion is necessary. As noted earlier, tamponade occurs in approximately 1% of patients with postpericardiotomy syndrome.\nConstrictive pericarditis occurs late postoperatively in fewer than 0.5% of patients but may not be related to postpericardiotomy syndrome. The high prevalence of postpericardiotomy syndrome and quite low prevalence of constriction suggests that a direct association is unlikely. With constriction, the pericardium becomes thickened and adherent to the heart and restricts filling of the ventricles. A pericardiectomy may be required for treatment.\nPatients with pain from the inflammatory response may demonstrate splinting during breathing. This can result in hypoxemia. Monitor oxygen saturation by pulse oximetry in patients presenting with these findings.\nCoronary artery bypass grafting is an unusual procedure in children. Occlusion of the graft is reported as a rare, but fatal, complication of postpericardiotomy syndrome.\nAndreev DA, Giliarov MIu, Syrkin AL, Udovichenko AE, Gerok DV. [Postcardiotomy syndrome outside a cardiosurgical clinic]. Klin Med (Mosk). 2008. 86(10):67-71. [Medline].\nJaworska-Wilczynska M, Abramczuk E, Hryniewiecki T. Postcardiac injury syndrome. Med Sci Monit. 2011 Nov. 17(11):CQ13-14. [Medline].\nTamarappoo BK, Klein AL. Post-pericardiotomy syndrome. Curr Cardiol Rep. 2016 Nov. 18 (11):116. [Medline].\nLehto J, Virolainen J. Postpericardiotomy syndrome. Duodecim. 2017. 133 (4):411-6. [Medline].\nGungor 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. [Medline].\nPeters 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. [Medline].\nVinit 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. [Medline].\nZeltser 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. [Medline].\nSasaki 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. [Medline].\nGoutal 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. [Medline].\nHargreaves M, Bashir Y. Postcardiotomy syndrome following transvenous pacemaker insertion. Eur Heart J. 1994 Jul. 15(7):1005-7. [Medline].\nGoodkind 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. [Medline].\nTabatznik B, Isaacs JP. Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiol. 1961 Jan. 7:83-96. [Medline].\nPeter 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. [Medline].\nRusso 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. [Medline].\nHerrera-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. [Medline].\nImazio 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. [Medline].\nEngle 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. [Medline].\nClapp 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. [Medline].\nCabalka 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. [Medline].\nWessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J. 2006 Mar. 99(3):309-14. [Medline].\nWebber SA, Wilson NJ, Junker AK, et al. Postpericardiotomy syndrome: no evidence for a viral etiology. Cardiol Young. 2001 Jan. 11(1):67-74. [Medline].\nvan 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. [Medline].\nDechtman 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. [Medline].\nScarfone RJ, Donoghue AJ, Alessandrini EA. Cardiac tamponade complicating postpericardiotomy syndrome. Pediatr Emerg Care. 2003 Aug. 19(4):268-71. [Medline].\n[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. [Medline].\n[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. [Medline]. [Full Text].\n[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. [Medline].\nVogel-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. [Medline]. [Full Text].\n[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. [Medline].\nImazio 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. [Medline].\nImazio 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. [Medline].\nKhandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010 Jun. 85(6):572-93. [Medline]. [Full Text].\nSeferovic 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. [Medline].\nSnyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management. Am Fam Physician. 2014 Apr 1. 89(7):553-60. [Medline].\nCantinotti 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. [Medline].\nWendelin G, Fandl A, Beitzke A. High-dose intravenous immunoglobulin in recurrent postpericardiotomy syndrome. Pediatr Cardiol. 2008 Mar. 29(2):463-4. [Medline].\nZucker N, Levitas A, Zalzstein E. Methotrexate in recurrent postpericardiotomy syndrome. Cardiol Young. 2003 Apr. 13(2):206-8. [Medline].\ndel 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. [Medline].\nLittle 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. [Medline].\nNaunheim KS, Kesler KA, Fiore AC, et al. Pericardial drainage: subxiphoid vs. transthoracic approach. Eur J Cardiothorac Surg. 1991. 5(2):99-103; discussion 104. [Medline].\nMoores 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. [Medline].\nHazelrigg 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. [Medline].\nForbes TJ, Horenstein MS, Vincent JA. Balloon pericardiotomy for recurrent pericardial effusions following fontan revision. Pediatr Cardiol. 2001 Nov-Dec. 22(6):527-9. [Medline].\nZiskind 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. [Medline].\nHajduczok 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. [Medline].\nImazio 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. [Medline].\nFinkelstein Y, Shemesh J, Mahlab K, et al. Colchicine for the prevention of postpericardiotomy syndrome. Herz. 2002 Dec. 27(8):791-4. [Medline].\nImazio 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. [Medline].\nImazio 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. [Medline].\nImazio 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. [Medline].\nBartels C, Honig R, Burger G, et al. The significance of anticardiolipin antibodies and anti-heart muscle antibodies for the diagnosis of postpericardiotomy syndrome. Eur Heart J. 1994 Nov. 15(11):1494-9. [Medline].\nCheung EW, Ho SA, Tang KK, et al. Pericardial effusion after open heart surgery for congenital heart disease. Heart. 2003 Jul. 89(7):780-3. [Medline].\nDe 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. [Medline].\nDressler W. The post-myocardial-infarction syndrome: a report on forty-four cases. AMA Arch Intern Med. 1959 Jan. 103(1):28-42. [Medline].\nHoffman 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.\nHorneffer PJ, Miller RH, Pearson TA, et al. The effective treatment of postpericardiotomy syndrome after cardiac operations. A randomized placebo-controlled trial. J Thorac Cardiovasc Surg. 1990 Aug. 100(2):292-6. [Medline].\nKim BJ, Ma JS. Constrictive pericarditis after surgical closure of atrial septal defect in a child. J Korean Med Sci. 1998 Dec. 13(6):658-61. [Medline].\nKronick-Mest C. Postpericardiotomy syndrome: etiology, manifestations, and interventions. Heart Lung. 1989 Mar. 18(2):192-8. [Medline].\nPrabhu AS, Ross RD, Heinert MR, et al. Decreased incidence of postoperative pericardial effusions after cardiac surgery for congenital heart disease. Am J Cardiol. 1996 Apr 1. 77(9):774-6. [Medline].\nPrince SE, Cunha BA. Postpericardiotomy syndrome. Heart Lung. 1997 Mar-Apr. 26(2):165-8. [Medline].\nTakata M, Robotham JL. Pericardial effusion and tamponade. Critical Heart Disease in Infants, Children, and Adolescents. 1995. 255-71.\nTsang 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. [Medline].\nTsang 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. [Medline].\nWilson 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. [Medline].\nCasanova 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. [Medline].\nJohnston DR. Surgical management of pericardial diseases. Prog Cardiovasc Dis. 2017 Jan - Feb. 59(4):407-16. [Medline]. [Full Text].\nUpright 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.\nEchocardiographic 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.\nFour-chamber echocardiographic view following emergent pericardiocentesis (800 mL removed) for clinical and echocardiographic evidence of cardiac tamponade. Virtually no residual pericardial effusion is evident.\nM Silvana Horenstein, MD Assistant Professor, Department of Pediatrics, University of Texas Medical School at Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc\nM Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Medical Association\nHoward 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\nHoward S Weber, MD, FSCAI is a member of the following medical societies: Society for Cardiovascular Angiography and Interventions\nDisclosure: Received income in an amount equal to or greater than $250 from: Abbott Medical .\nIra H Gessner, MD Professor Emeritus, Pediatric Cardiology, University of Florida College of Medicine\nIra 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\nThe 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.\nencoded search term (Postpericardiotomy Syndrome) and Postpericardiotomy Syndrome\nNeurologic/Myocardial Protection During Pediatric Cardiac Surgery\nTetralogy of Fallot With Pulmonary Stenosis\nLibman-Sacks Endocarditis\nFetal Surgery for Congenital Heart Disease\nEisenmenger Syndrome\nRBC Transfusion and Cardiac Surgery: Be Strict and Restrict?\n'Uber of Interventional Cardiology' Pushes Stents Over Surgery\nAd hoc PCI, CABG in Type 2 Diabetes Featured in Stable CAD Guidelines Update\nTop News From EASD 2019: Slideshow\nNews Improvements in Heart-Surgery Outcomes in Kids Seen With Interhospital Collaboration\nNews Cardiac Surgery Not Linked to Cognitive Decline\nJournal Article Aviation Cardiology: Occupational Hazards and Cardiac Surgery Facts for Aircrew and Passengers Undergoing Cardiac Surgery Are Discussed\nJournal Article Emergency Cardiac Surgery Following TAVI"