Early Post-operative ECG Changes as a Predictor of Post-pericardiotomy Syndrome Following Atrial Septal Defect Repair.

To identify risk factors associated with post-pericardiotomy syndrome (PPS) in patients undergoing surgical repair of atrial septal defects (ASD). A single-center retrospective study. Tertiary academic hospital. Included were patients of all ages who underwent surgical ASD repair, while exclusion criteria included the absence of post-operative electrocardiogram (ECG), lack of follow-up post-discharge and factors hindering ECG interpretation. Demographic and clinical data, including ECG changes indicative of pericardial inflammation, were collected. The primary outcome measure was the development of PPS, determined based on the standardized European Society of Cardiology (ESC) criteria. Among 190 patients who underwent surgical ASD repair, 154 (81%) met the inclusion criteria. Of these, 25 (16%)in total developed PPS, of which 60% were ≥ 18 years of age and 56% female. Significant associations relating both early ECG changes and pre-discharge pericardial effusion with subsequent occurrence of PPS were found in both univariate and multivariate analyses. The study establishes correlations of both early post-operative ECG changes indicative of inflammation and pre-discharge pericardial effusion with subsequent occurrence of PPS in patients undergoing surgical ASD repair. Both utilizing the standardized ESC definition of PPS and incorporating a physician-validated ECG evaluation strengthened the methodologic approach in establishing these relationships. The results also highlight the importance of considering age as a potential risk factor for PPS. Further research is needed to validate these findings and explore additional risk factors predicting early identification and management of patients at high risk for PPS following surgical ASD repairs.

Treatment and Prophylaxis of Post-pericardiotomy Syndrome in Cardiac Surgery Patients: a Systematic Review.

PURPOSE: Post-pericardiotomy syndrome (PPS) is a common complication of cardiac surgery. This systematic review aimed to investigate the efficacy of colchicine, indomethacin, and dexamethasone in the treatment and prophylaxis of PPS. METHODS: Literature research was carried out using PubMed. Studies investigating ≥ 10 patients with clinically PPS treated with colchicine, dexamethasone, and indomethacin and compared with placebo were included. Animal or in vitro experiments, studies on < 10 patients, case reports, congress reports, and review articles were excluded. Cochrane risk-of-bias tool for randomized trials (RoB2) was used for the quality assessment of studies. RESULTS: Seven studies were included. Among studies with postoperative colchicine treatment, two of them demonstrated a significant reduction of PPS. In the single pre-surgery colchicine administration study, a decrease of PPS cases was registered. Indomethacin pre-surgery administration was linked to a reduction of PPS. No significant result emerged with preoperative dexamethasone intake. CONCLUSION: Better outcomes have been registered when colchicine and indomethacin were administered as primary prophylactic agents in preventing PPS and PE. Further RCT studies are needed to confirm these results.

Pericardiocentesis in children: 20-year experience at a tertiary children's hospital.

BACKGROUND: Pericardiocentesis is the invasive percutaneous procedure for acute and chronic excessive accumulation of pericardial fluid. There is a paucity of data on the effectiveness and safety of pericardiocentesis in children. OBJECTIVES: To evaluate the effectiveness and safety of pericardiocentesis and factors associated with acute procedural failure and adverse events. METHODS: This was a single-centered retrospective study to describe all the children aged ≤20 years who underwent pericardiocentesis. Data on demographics, etiologies of pericardial effusion, and repeat intervention at follow-up were collected. RESULTS: A total of 127 patients underwent 153 pericardiocentesis. The median age was 6.5 years (1 day-20 years) with weight of 17 kg (0.5-125). Most common etiology was post-pericardiotomy syndrome (n = 56, 44%), followed by infectious (12%), malignant (10%), and iatrogenic (9%). Pericardiocentesis was performed more commonly in the catheterisation laboratory (n = 86, 59%). Concurrent pericardial drain placement was performed in 67 patients (53%). Acute procedural success was 92% (141/153). Repeat intervention was performed in 33 patients (22%). The incidence of adverse events was 4.6% (7/153): hemopericardium requiring emergent surgery (n = 2); hemopericardium with hypotension (n = 2); seizure with anesthesia induction (n = 1); and right ventricle puncture with needle (n = 2). Pericardiocentesis at the bedside had a higher rate of acute procedural failure than that in the catheterisation lab (17 versus 1%, p < 0.01). No identifiable risk factors were associated with adverse events. CONCLUSIONS: Pericardiocentesis was life-saving in children with its high effectiveness and safety even in urgent situations. Although initial pericardiocentesis was effective, one of five patients required re-intervention for recurrent pericardial effusion.

Coronary artery ectasia in post-pericardiotomy syndrome.

Post-pericardiotomy syndrome (PPS) is a common inflammatory process following cardiac surgery, in which the pericardial space was opened. Pericardial effusion (PE) is a common manifestation in PPS; however, coronary artery dilation is not associated with PPS. Inflammatory vasculitis in children are known to cause coronary dilation, in conditions such as in Kawasaki Disease (KD). We report a patient with PPS and concomitant coronary dilation by transthoracic echocardiography (TTE) following repair of her ventricular septal defect (VSD).

Meta-analysis for the value of colchicine for the therapy of pericarditis and of postpericardiotomy syndrome.

BACKGROUND: Colchicine has been used as anti-inflammatory agent in pericardial effusion (PE). We sought to perform a meta-analysis of randomized trials assessing the efficacy and safety of colchicine in patients with pericarditis or postpericardiotomy syndrome (PPS). METHODS: In the systematic literature search following the PRISMA statement, 10 prospective randomized controlled studies with 1981 patients with an average follow-up duration of 13.6 months were identified. RESULTS: Colchicine reduced the recurrence rate of pericarditis in patients with acute and recurrent pericarditis and reduced the incidence of PPS (RR: 0.57, 95% CI: 0.44-0.74). Additionally, the rate of rehospitalizations as well as the symptom duration after 72 h was significantly decreased in pericarditis (RR 0.33; 95% CI 0.18-0.60; and RR 0.43; 95% CI 0.34-0.54; respectively), but not in PPS. Treatment with colchicine was associated with significantly higher adverse event (AE) rates (RR 1.42; 95% CI 1.05-1.92), with gastrointestinal intolerance being the leading AE. The reported number needed to treat (NNT) for the prevention of recurrent pericarditis ranged between 3 and 5. The reported NNT for PPS prevention was 10, and the number needed to harm (NNH) was 12, respectively. Late colchicine administration > 7 days after heart surgery did not reduce postoperative PE. CONCLUSIONS: Our meta-analysis confirms that colchicine is efficacious and safe for prevention of recurrent pericarditis and PPS, while it reduces rehospitalizations and symptom duration in pericarditis. The clinical use of colchicine for the setting of PPS and postoperative PE after heart surgery should be investigated in further multicenter RCT.

Does Prophylactic Ibuprofen After Surgical Atrial Septal Defect Repair Decrease the Rate of Post-Pericardiotomy Syndrome?

Post-pericardiotomy syndrome (PPS) is an inflammatory process involving the pleura, pericardium, or both and occurs after cardiothoracic surgery. Surgical atrial septal defect (ASD) closure is associated with higher incidence of PPS post-operatively as compared to other operations. Reported incidence of PPS varies from 1 to 40%. NSAIDs are often used to treat PPS and in our center, some practitioners have prescribed ibuprofen prophylactically. This study sought to investigate the impact of prophylactic treatment with ibuprofen on the development and severity of PPS following surgical ASD closure, with particular attention to secundum-type ASDs. We retrospectively reviewed clinical and operative data of all surgical ASD repairs in our center from 1/2007 to 7/2017. ASDs were grouped by subtype. PPS was considered positive if the primary cardiologist diagnosed and documented clinical signs of PPS on post-operative outpatient follow-up. Records were reviewed to confirm documented diagnosis of PPS. A total of 245 cases were reviewed with 207 having sufficient data. Median age was 2 years (range 4 months-27 years), female 57%. Overall incidence of PPS was 10%. There was no difference in incidence of PPS in those prescribed ibuprofen as compared to those who were not. This was true for both the entire cohort and the subgroup analysis (P = 1.0). Four patients overall required pericardiocentesis, none of whom received prophylactic ibuprofen. Prophylactic ibuprofen prescription following surgical ASD repair did not reduce the rate of PPS in our cohort.

Post-cardiac injury syndrome: an atypical case following percutaneous coronary intervention.

Post-cardiac injury syndrome (PCIS) is a syndrome characterized by pericardial and/or pleural effusion, triggered by a cardiac injury, usually a myocardial infarction or cardiac surgery, rarely a minor cardiovascular percutaneous procedure. Nowadays, the post-cardiac injury syndrome, is regaining importance and interest as an emerging cause of pericarditis, especially in developed countries, due to a great and continuous increase in the number and complexity of percutaneous cardiologic procedures. The etiopathogenesis seems mediated by the immunitary system producing immune complexes, which deposit in the pericardium and pleura and trigger an inflammatory response. We present the atypical case of a 76-year-old man presenting with a hydro-pneumothorax, low-grade fever and elevated inflammation markers, after two complex percutaneous coronary interventions, executed 30 and 75 days prior. The clinical features of our case are consistent with the diagnostic criteria of PCIS: prior injury of the pericardium and/or myocardium, fever, leucocytosis, elevated inflammatory markers, remarkable steroid responsiveness and latency period. Only one element does not fit with this diagnosis and does not find any further explanation: the air accompanying the pleural effusion, determining a hydro-pneumothorax and requiring a pleural drainage catheter positioning.

Colchicine in addition to conventional therapy for pericarditis recurrence : An update meta-analysis.

BACKGROUND: Randomized controlled trials (RCTs) have investigated the use of colchicine and conventional therapy for reducing the recurrence of pericarditis in patients with acute pericarditis or post-pericardiotomy syndrome. However, the benefits of these treatments are variable. METHODS: Studies were retrieved from PubMed, the Cochrane Library, and the EMBASE database. RESULTS: We identified nine RCTs with 1832 patients and a mean follow-up of 13.1 months. Overall, colchicine therapy significantly decreased the risk of pericarditis recurrence (odds ratio, OR 0.42; 95 % confidence interval, CI 0.33-0.52; P < 0.001; I2 = 17.0 %). Colchicine therapy was associated with significantly lower rates of pericarditis-associated rehospitalization (OR 0.29; 95 % CI 0.16-0.53; P < 0.0001; I2 = 0.0 %) and persistence of symptoms (OR 0.29; 95 % CI, 0.21-0.41; P = 0.000; I2 = 0.0 %) at 72 h. Adverse events were higher in the colchicine group (relative risk, RR 1.48; 95 % CI, 1.06-2.07; P = 0.02; I2 = 0.0 %). Subgroup analysis showed that recurrence of pericarditis was significantly lower in the colchicine therapy group, irrespective of prednisone use and the cause of pericarditis. CONCLUSION: Colchicine significantly decreases the rate of pericarditis recurrence, regardless of prednisone use and the cause of pericarditis. Larger studies are needed to confirm this effect.

Successful treatment of post-pericardiotomy syndrome via C1 inhibitor replacement therapy in a hereditary angioedema patient with Marfan syndrome.

BACKGROUND: Hereditary angioedema with C1 inhibitor deficiency (HAE-C1INH) is caused by dysfunctional C1-INH protein due to mutations in the SERPING1 gene encoding C1-INH. Marfan syndrome is a genetic connective tissue disease that affects the cardiovascular and ocular systems along with the skeletal system. In this case, we present the successful treatment of post-pericardiotomy syndrome unresponsive to classical therapy, which has not been described in the literature. The syndrome developed in a patient with hereditary angioedema (HAE) who underwent open heart surgery due to cardiac involvement in Marfan syndrome. CASE: A nine-year-old male HAE-C1INH patient underwent open heart surgery secondary to cardiac involvement caused by Marfan syndrome. To prevent HAE attacks, 1000 units of C1 inhibitor concentrate therapy were given 2 hours before and 24 hours after the operation. Post-pericardiotomy syndrome was diagnosed on the postoperative second day and ibuprofen 15 mg/kg/day (3 weeks) was started. Since there was no response to classical treatment on the 21st postoperative day, C1 inhibitor concentrate treatment was planned as 1000 units/ dose for 2 days a week considering a prolonged hereditary angioedema attack. In the second week of treatment, complete recovery was achieved for pericardial effusion with a total of 4 doses. CONCLUSIONS: We emphasize that in patients with hereditary angioedema undergoing this treatment, care should be taken in terms of complications that may be associated with the disease even if short-term prophylaxis is given before operations and that longer-term use of C1 inhibitor concentrate has a place in treatment.

Incidence and predictors of pericardial effusion following surgical closure of atrial septal defect in children: A single center experience.

Objectives: To evaluate the incidence of pericardial effusion (PE) after surgical atrial septal defect (ASD) closure and to investigate the presence of predictive risk factors for its development. Methods: We collected data from 203 patients followed at Bambino Gesù Children's Hospital of Rome who underwent cardiac surgery for ASD repair between January 2015 and September 2019. Results: A total of 200/203 patients with different types of ASD were included. Patients were divided into two groups: Group 1) 38 (19%) who developed PE and Group 2) 162 (81%) without PE. No differences were noted between the two groups with regard to gender or age at the surgery. Fever in the 48 h after surgery was significantly more frequent in group 1 than in group 2 (23.7 vs. 2.5%; p < 0.0001). ECG at discharge showed significant ST-segment elevation in children who developed PE, 24.3 vs. 2.0% in those who did not (p < 0.0001). Group 1 patients were divided into two subgroups on the basis of the severity of PE, namely, 31 (81.6%) with mild and 7 (18.4%) with moderate/severe PE. Patients with moderate/severe PE had a significantly higher BMI value (median 19.1 Kg/m2) (range 15.9-23.4, p = 0.004). Conclusion: The presence of fever and ST-segment elevation after surgery predicts subsequent development of PE suggesting a closer follow-up for these categories of patients. A higher BMI appears to be associated with a higher risk of moderate/severe PE.

Post-pericardiotomy syndrome: insights into neglected postoperative issues.

ABSTRACT OBJECTIVES: Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge. METHODS: A literature review was performed that included relevant prospective and retrospective studies on the subject. RESULTS: PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention. CONCLUSIONS: Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies.

Giant Left Ventricular Papillary Fibroelastoma Presented as Transient Ischemic Attack and Complicated by Post-Pericardiotomy Syndrome.

Papillary fibroelastoma is a benign cardiac tumour that most commonly presents as an incidental finding on imaging but may present with an acute neurological event due to embolic phenomena. We report a 51-year-old female who presented with focal neurology of the right hand that lasted for 30 minutes. Her initial investigations including CT-brain were unremarkable, and given her low-risk profile for stroke she was discharged for routine outpatient workup of possible transient ischaemic attack. Transthoracic echo detected a large mobile mass attached to the left ventricular wall. This was mistakenly diagnosed as a left ventricular thrombus, for which she was commenced on warfarin. After three months on warfarin without reduction in the size of the mass, cardiac MRI was performed. The scan was repeated as the initial imaging failed to demonstrate the tumour. This was followed by positron emission tomography which suggested a benign mass of the left ventricle. The patient underwent surgical excision of the tumour and developed post-pericardiotomy syndrome. Histopathology confirmed papillary fibroelastoma. Though rare, cardiac neoplasm may remain a differential diagnosis for acute neurological presentations in non-classical patients.

Post-cardiac injury syndrome: An evidence-based approach to diagnosis and treatment.

Post-cardiac injury syndrome (PCIS) is an umbrella term used for the post-pericardiotomy syndrome, post-myocardial infarction (MI) related pericarditis (Dressler syndrome), and post-traumatic pericarditis (percutaneous coronary intervention (PCI) or cardiac implantable electronic device (CIED) placement). All these conditions give rise to PCIS due to an inciting cardiac injury to pericardial or pleural mesothelial cells, leading to subsequent inflammation syndromes ranging from uncomplicated pericarditis to massive pleural effusion. We did a literature search on MEDLINE/PubMed for relevant studies using the terms "post-acute cardiac injury syndrome", "post-cardiac injury syndrome", "post-cardiotomy syndrome", "post-pericardiotomy syndrome", "post-MI pericarditis" and to summarize the body of evidence, all relevant full texts were selected and incorporated in a narrative fashion. Pathophysiology of PCIS is suggested as autoimmune-mediated in predisposed patients who develop anti-actin and anti-myosin antibodies following a cascade of cardiac injury in various forms. Colchicine and NSAIDs including ibuprofen are demonstrated as efficacious in preventing recurrent attacks of PCIS while corticosteroids show no benefit on prognosis and recurrence of the disease.

Recurrent Left Pleural Effusion Following Left Atrial Appendage Closure With the Watchman Device.

A 75-year-old woman with recent left atrial appendage closure with the Watchman device (Boston Scientific, Natick, Massachusetts) presented with recurrent left pleural effusion. The constellation of chest pain, pericardial effusion, and exudative pleural effusion were suggestive of an inflammatory process precipitated by microperforation of the fixation anchors during the Watchman placement. (Level of Difficulty: Intermediate.).

Massive pericardial effusion after Nuss procedure: to drain or not to drain?

A 11-year-old boy presented with refractory fever and dyspnoea after Nuss procedure. Massive pericardial effusion was detected on computer tomography scan performed under corticosteroid cover for his asthmatic history. With rapid clinical improvement following corticosteroids, a clinical diagnosis of post-pericardiotomy syndrome (PPS) was made. Following a course of oral prednisolone, serial blood test and echocardiogram showed gradual resolution of inflammation and pericardial effusion. This rarely-reported case serves as a poignant reminder to PPS after Nuss procedure as a cause of febrile massive pericardial effusion. Early therapeutic trial of corticosteroids may prevent clinical deterioration, and have invasive pericardial drainage avoided.

Primary prevention of post-pericardiotomy syndrome using corticosteroids: a systematic review.

INTRODUCTION: Post-pericardiotomy syndrome is a well-recognized inflammatory phenomenon that commonly occurs in patients following cardiac surgery. Due to the increased morbidity and resource utilization associated with this condition, research has recently focused on ways of preventing its prevention this condition; primarily using colchicine, NSAIDs and corticosteroids. Areas covered: This systematic review summarizes the three clinical studies that have used corticosteroids for PPS primary prevention in the perioperative period. Due to the heterogeneity amongst these three studies in terms of population (both pediatric and adult patients), surgical procedure, administration regimen and results (only 1/3 studies reporting a positive effect), the effectiveness of corticosteroids remains unproven. Expert commentary: Corticosteroids have shown to be useful in the treatment of PPS but have thus far have shown mixed results as a primary prevention method. Research on patients taking corticosteroids pre-operatively have shown a significant reduction in the risk of developing PPS. Further research is required to determine if corticosteroids are helpful in preventing PPS in patient undergoing cardiac surgery, before any recommendations regarding their use in cardiovascular surgery can be made.

Colchicine for prevention and treatment of cardiac diseases: A meta-analysis.

AIMS: Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. The goal of this study was to review all randomized controlled trials that assess the use of colchicine for the prevention and treatment of cardiac diseases. METHODS: We performed a meta-analysis of the effects of colchicine on pericarditis, postpericardiotomy syndrome and postprocedural atrial fibrillation recurrence, in-stent restenosis, gastrointestinal adverse effects, and treatment discontinuation rates. We conducted an EMBASE and MEDLINE search for prospective controlled trials. RESULTS: We identified 17 prospective controlled randomized studies with 2082 patients that received colchicine and 1982 controls with an average follow-up duration of 12 months. Treatment with colchicine is associated with reduced risk of pericarditis recurrence/postpericardiotomy syndrome (OR: 0.37; 95% CI: 0.29-0.47; P<0.001) and lower recurrence of atrial fibrillation rates after cardiac surgery and ablation procedures. However, gastrointestinal side effects were more common in patients treated with colchicine (OR: 2.6; 95% CI: 1.82-3.72; P<0.001) in all subgroups except for those treated for prevention of recurrent pericarditis. The higher rates of side effects resulted in higher incidence of treatment discontinuation in patients treated with colchicine. CONCLUSION: Colchicine appears to be efficacious and well tolerated for recurrent pericarditis/postpericardiotomy syndrome and recurrence of postprocedural atrial fibrillation. However, its efficacy may be limited by its gastrointestinal adverse events and treatment discontinuation rates particularly in postoperative patients.

Effectiveness of colchicine for the prevention of recurrent pericarditis and post-pericardiotomy syndrome: an updated meta-analysis of randomized clinical data.

The aim of this study is to assess the safety and efficacy of colchicine in prevention of recurrence, symptom reduction, and complications in patients with pericarditis. Pericarditis is an important cause of chest pain leading to frequent emergency room visits and reduced quality of life. Pericarditis has traditionally been treated symptomatically with anti-inflammatory drugs, but growing evidence suggests the use of colchicine for both first episode and recurrent pericarditis in the prevention of recurrences and reducing symptoms. PubMed, EMBASE, and the Cochrane Central register of controlled trials (CENTRAL) databases were searched and the studies were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. All randomized clinical trials with head-to-head comparison between colchicine and standard of care were included. A total of five studies were included in the primary analysis of pericarditis and three in the analysis for prevention of post-pericardiotomy syndrome (PPS). Colchicine reduced the incidence rate of recurrent pericarditis in patients with both the first episode and recurrent pericarditis, compared with placebo [16.7 vs. 36.8%; risk ratio (RR) 0.46; 95% confidence interval (CI) 0.36-0.58; P < 0.00001; I(2) = 0%], with a significant increase in adverse effects (12.5 vs. 8.5%, RR 1.45; 95% CI 1.09-1.95; P = 0.01; I(2) = 0%) and drug withdrawal rate (10.8 vs. 8.5%; RR 1.44; 95% CI 1.01-2.05; P = 0.04; I(2) = 14%). In addition, colchicine decreased symptom duration in patients with recurrent pericarditis (63.1 vs. 78.6%; RR 0.58; 95% CI 0.39-0.87; P = 0.02; I(2) = 65%), but had no significant effect on symptom duration in patients with an initial episode of pericarditis (RR 0.91; 95% CI 0.65-1.28; P = 0.57; I(2) = 0%). Colchicine was superior to placebo in the prevention of PPS at 1 year (13.2 vs. 25.8%, RR 0.56, 95% CI 0.42-0.76; P < 0.01). In this quantitative analysis of randomized clinical data, colchicine demonstrated superior clinical efficacy compared with standard therapy for the prevention of recurrent pericarditis and PPS at the cost of a small increase in the incidence rate of side effects.

Post-cardiac injury syndromes. An emerging cause of pericardial diseases.

The term "post-cardiac injury syndromes" includes post-myocardial infarction pericarditis, post-pericardiotomy syndrome, and post-traumatic pericarditis (iatrogenic, i.e. after percutaneous coronary or intracardiac interventions, such as pacemaker lead insertion, radiofrequency ablation, or non-iatrogenic, i.e. following blunt or penetrating trauma). All these conditions represent different clinical conditions characterized by an initial cardiac injury involving the pericardium/myocardium and/or pleura and the subsequent inflammatory syndrome ranging from simple, uncomplicated pericarditis to more complicated cases with pleuropericarditis, cardiac tamponade or massive pleural effusion. The etiopathogenesis is presumed to be immune-mediated in predisposed individuals that develop autoreactive reactions following the initial traumatic event. Treatment is essentially based on empirical anti-inflammatory therapy and adjunctive colchicine, which has been shown to be safe and efficacious for the prevention of pericarditis.