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.

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.

Ozaki procedure complicated by postpericardiotomy syndrome and cardiac tamponade.

Aortic valve replacement has long been the standard of care for many aortic valve diseases. Neo sinus reconstruction and aortic valve reconstruction with native pericardium, known as the Ozaki procedure, is a relatively new technique with early studies showing good mid-term durability and hemodynamics without the need for life-long anticoagulation. We present the case of a 56-year-old male presenting with aortic valve endocarditis and severe aortic insufficiency who underwent successful aortic valve reconstruction via the Ozaki procedure complicated by postpericardiotomy syndrome and cardiac tamponade. Although the Ozaki procedure is a promising alternative to conventional aortic valve replacement, further study is needed to determine long-term re-operation rates, stability and mortality.

Postpericardiotomy syndrome after cardiac surgery.

Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.

Do Colchicine and Prednisone Affect the Rate of Recurrence of Post-Pericardiotomy Syndrome.

BACKGROUND: Post-pericardiotomy syndrome (PPS) is a major cause of pericarditis, yet data on the risk of recurrence are limited, and the impact of steroids and colchicine in this context is unknown. OBJECTIVES: To examine the effect of prednisone and colchicine on the rate of recurrence of PPS. METHODS: Medical files of patients diagnosed with PPS were reviewed to extract demographic, echocardiographic, X-ray imaging, and follow-up data. RESULTS: The study comprised 132 patients (57% men), aged 27-86 years. Medical treatment included prednisone in 80 patients, non-steroidal anti-inflammatory agents in 41 patients, colchicine monotherapy in 2 patients, and no anti-inflammatory therapy in 9 patients. Fifty-nine patients were given colchicine for prevention of recurrence. The patients were followed for 5-110 months (median 64 months). Recurrent episodes occurred in 15 patients (11.4%), 10 patients had a single episode, 4 patients had two episodes, and one patient had three episodes. The rate of recurrence was lower in patients receiving colchicine compared to patients who did not (8.5% vs. 13.7%), and in patients not receiving vs. receiving prednisone (7.7% vs. 13.8%) but the differences were non-significant. Twenty-three patients died and there were no recurrence-related deaths. CONCLUSIONS: The rate of recurrence after PPS is low and multiple recurrences are rare. The survival of patients with recurrent PPS is excellent. Prednisone pre-treatment was associated with a numerically higher rate of recurrence and colchicine treatment with a numerically lower rate, but the differences were non-significant.

Adverse events and survival with postpericardiotomy syndrome after surgical aortic valve replacement.

OBJECTIVES: Postpericardiotomy syndrome (PPS) is a relatively common complication after cardiac surgery. However, long-term follow-up data on the adverse events and mortality of PPS patients requiring invasive interventions are scarce. METHODS: We sought to assess the occurrence of mortality, new-onset atrial fibrillation (AF), cerebrovascular events, and major bleeds in PPS patients requiring medical attention in a combination database of 671 patients who underwent isolated surgical aortic valve replacement with a bioprosthesis (n = 361) or mechanical prosthesis (n = 310) between 2002 and 2014 (Cardiovascular Research Consortium-A Prospective Project to Identify Biomarkers of Morbidity and Mortality in Cardiovascular Interventional Patients [CAREBANK] 2016-2018). PPS was defined as moderate if it resulted in delayed hospital discharge, readmission, or medical therapy because of the symptoms; and severe if it required interventions for the evacuation of pleural or pericardial effusion. RESULTS: The overall incidence of PPS was 11.2%. Median time to diagnosis was 16 (interquartile range, 11-36) days. Severe PPS was diagnosed in 3.6% of patients. Severe PPS seemed to be associated with higher mortality (hazard ratio, 2.01; 95% confidence interval, 1.03-3.91; P = .040). Moderate or severe PPS increased the risk of new-onset AF during the early postoperative period (hazard ratio, 1.72; 95% confidence interval, 1.12-2.63; P = .012). No significant associations were found between PPS and cerebrovascular events or major bleeds during the follow-up. CONCLUSIONS: Patients with PPS requiring invasive interventions are at increased risk for mortality unlike those with mild to moderate forms of the disease. PPS requiring medical attention is associated with a higher AF rate during the early postoperative period but has no significant effect on the occurrence of major stroke, stroke or transient ischemic attack, or major bleeds during long-term follow-up.

Postpericardiotomy Syndrome after Cardiac Operations.

The postpericardiotomy syndrome (PPS) is an important cause of morbidity and mortality following heart operation. This systematic review reviewed the literature regarding PPS. It was found to occur on day 18.3 ±15.9 after cardiac operations, most often after coronary artery bypass grafting, and mitral valve replacement. The most common symptoms were new/worsening pericardial effusions, pleuritic chest pain, and fever. The inflammation markers, such as C-reactive protein and erythrocyte sedimentation rate, were found to increase significantly in each patient who had these parameters examined. The subjects were managed conservatively in 472 (83.5%) patients, by surgical pericardial drainage in 85 (15.0%) patients, by thora-/pericardio-centesis in 3 (0.5%) patients, and were under surveillance without being treated in 5 (0.9%) patients. Conservative treatment was likely to be associated with a higher recovery rate. Surgical trauma and cardiopulmonary bypass trigger the systemic inflammatory response, which results in antiheart autoantigen release, and the deposited immune complex could be found in the pericardial, pleural, and lung tissues, thereby provoking the occurrence of PPS. Therapeutic options for the refractory cases are long-term oral corticoids or pericardiectomy. Surgical intervention was warranted in 2.6% of the cases due to cardiac tamponade.

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.

Postpericardiotomy syndrome incidence, diagnostic and treatment strategies: experience AT two collaborative centers.

Postpericardiotomy syndrome (PPS) is worsening or new formation of pericardial and/or pleural effusion mostly 1 to 6 weeks after cardiac surgery, as a result of autoimmune inflammatory reaction within pleural and pericardial space. Its incidence varies among different studies and registries (2% to 30%), as well as according to the type of cardiac surgery performed. We conducted this retrospective analysis of PPS incidence and diagnostic and treatment strategies in patients referred for cardiac surgery for revascularization, valvular and/or aortic surgery. We retrospectively analyzed 461 patients referred for an urgent or elective cardiac surgery procedure between 2009 and 2015. PPS diagnosis was established using well defined clinical criteria. Demographic and clinical characteristics were used in regression subanalysis among patients having undergone surgery of aortic valve and/or ascending aorta. Within 6 weeks after cardiac surgery, 47 (10.2%) patients had PPS. The median time from the procedure to PPS diagnosis was 14 days. The incidence of PPS was 26% after aortic valve and/or aorta surgery, and 7.9% and 8.3% after coronary bypass and mitral valve surgery, respectively. Among patients subjected to aortic valve and/or aortic surgery, regression analysis showed significant association of fever, C-reactive protein (CRP) elevation between 5 and 100 mg/L, urgent procedure and postoperative antibiotic use with PPS diagnosis, whereas younger age showed near-significant association. All patients had complete resolution of PPS, mostly after corticosteroid therapy, with only 2 cases of recurrent PPS that successfully resolved after colchicine therapy. Pleural drainage was indicated in 15 (32%) patients, whereas only one patient required pericardial drainage. In conclusion, PPS incidence in our retrospective analysis was similar to previous reports. Patients having undergone aortic valve and/or aortic surgery were most likely to develop PPS. The most relevant clinical criteria for diagnosis in these patients were fever, CRP elevation between 5 and 100 mg/L, and pericardial and/or pleural effusion formation or worsening 2 weeks after cardiac surgery.

Delayed recurrent pleuropericardial effusions following atrial septal defect closure with Amplatzer septal occluder device: a case of postpericardiotomy syndrome?

The authors present the case of a 41-year-old woman, who presented with moderate pericardial effusion and bilateral pleural effusion 11 months following a secundum atrial septal defect closure with an Amplatzer septal occluder (ASO) device. The acute presentation responded well to diuretics and a short course of corticosteroid therapy. The patient, however, continued to experience pleuritic chest pain and a recurrence of pericardial effusion a month later. The patient showed significant symptomatic improvement with a 2-month course of down-titrating prednisolone. Six months later, the echocardiogram showed complete remission of pleural and pericardial effusion. The possibility of cardiac erosion following ASO implantation has been excluded. The aetiology of the reoccurrence of steroid-responsive pleuropericarditis remains unknown.

Postpericardiotomy syndrome.

Postpericardiotomy syndrome (PPS) is a common complication following cardiac surgery. In most cases it develops 2 to 3 weeks after the operation. An inflammatory reaction develops in the pericardium or pleural space with fever, chest pain and dyspnea as typical symptoms. The disease process is usually self-limiting. At present, the etiology is unknown, but an immunological mechanism is suspected as the cause of the disease. The incidence of PPS is essentially dependent on diagnostic criteria, patient group and type of operation. Treatment is carried out with anti-inflammatory analgesics, combined with colchicine in more severe cases.

[Concentration of proinflammatory cytokines, peroxiredoxin-1 and glutathione peroxidase activity in the blood plasma of patients with coronary artery disease undergoing coronary artery bypass grafting].

76 patients with coronary heart disease (who had undergone coronary artery bypass grafting) were examined to investigate the role of pro-inflammatory cytokines and enzymes involved in redox regulation, in the mechanisms of development of systemic inflammatory response syndrome. Patients were divided into 2 groups: 1st - patients with coronary heart disease, who as a result of clinical trials has not been set postpericardiotomy syndrome; 2nd - patients with coronary heart disease who have been diagnosed postpericardiotomy syndrome. The blood plasma of both groups indicated intensification of production of interleukin-6, intrleukin-8, as well as - an imbalance in the peroxiredoxin-1 and glutathione peroxidase. These changes by patients with postpericardiotomy syndrome are observed at the earliest time and differed depth of expression. The results of this work confirm the high potential of the investigated indicators for prevention and monitoring postpericardiotomy syndrome development.

Post-pericardiotomy Syndrome.

Post-pericardiotomy syndrome (PPS) occurs in a subgroup of patients who have undergone cardiothoracic surgery and is characterized by fever, pleuritic pain, pleural effusion, and pericardial effusion. It is associated with significant morbidity, and the leading complications include tamponade and constrictive pericarditis. Epidemiologic studies have found that PPS often occurs among younger patients; however, there is a lack of comprehensive risk stratification. It is therefore important to be able to identify patients who are at high risk for developing this disease. The diagnosis is made if patients present with 2 out of the following 5 criteria; fever, pericardial or pleuritic chest pain, pericardial or pleural friction rub, pericardial effusion, and pleural effusion with elevated C-reactive protein (CRP). Pericardial effusion associated with PPS is detected by echocardiography, and cardiac MRI is used for evaluation of pericardial thickening as well as inflammation associated with PPS. These imaging modalities have been invaluable for monitoring the efficacy of treatment in PPS. Aspirin, nonsteroidal anti-inflammatory agents (NSAID), and colchicine are the mainstay of the current treatment for PPS. Although steroids are used for refractory cases of PPS, they are associated with significant side effects when used for long-term treatment of this disease. It is important for future research to focus on identification of clinical, serologic, and genetic markers that may predispose patients to PPS. There is also a need for clinical trials to address the use of targeted immunomodulatory treatment for this disease.

Value of the neutrophil-to-lymphocyte ratio in predicting post-pericardiotomy syndrome after cardiac surgery.

OBJECTIVE: Post-pericardiotomy syndrome (PPS) occurs in 10-40% of patients after cardiac surgery. PPS is considered an autoimmune phenomenon. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory marker that is associated with various cardiovascular diseases. Studies have reported that the NLR increases in certain autoimmune diseases. This study examined whether the NLR is helpful to predict the occurrence of PPS after elective on-pump coronary artery bypass graft (CABG) surgery. PATIENTS AND METHODS: The records of patients who underwent elective first-time on-pump CABG were reviewed retrospectively. In total, 72 patients with PPS were included in the study, and 100 patients who did not develop PPS were included as the control group. Peripheral blood samples collected preoperatively and on postoperative day 1 were used to calculate the NLR. RESULTS: No differences in preoperative white blood cell (WBC) count, neutrophil count, lymphocyte count, or NLR were observed between the patients with PPS and the control group. The WBC (p < 0.001) and neutrophil counts (p < 0.001) and NLR (p = 0.01) were significantly higher during the postoperative period in patients with PPS than in the control group. A receiver operating characteristic curve analysis showed that the postoperative NLR predicted PPS with 60% sensitivity and 59% specificity (area under the curve, 0.61; 95% confidence interval [CI], 0.51-0.70; p = 0.017), using a cut-off of 8.34. The postoperative WBC count (odds ratio [OR], 1.6; 95% CI, 1.36-2.03; p < 0.001) and NLR (OR, 3.3; 95% CI, 1.56-7.01; p = 0.002) were independently associated with PPS. CONCLUSIONS: The postoperative NLR may be useful to predict the development of PPS in patients undergoing on-pump CABG.

Role of methylprednisolone in the prevention of postpericardiotomy syndrome after cardiac surgery.

OBJECTIVE: Postpericardiotomy syndrome (PPS) occurs in 10-40% of patients after cardiac operations. Pericardial effusions and tamponade occurring > 7 days after surgery are usually related to PPS and remain an important cause of cardiac surgery-related morbidity and mortality; therefore, preventing PPS is important. Colchicine affords safe and efficacious protection against PPS and related complications. However, the roles of corticosteroids and nonsteroidal anti-inflammatory drugs in PPS prevention remains unclear. This study aimed to determine whether the intraoperative use of single-dose methylprednisolone can effectively prevent PPS. PATIENTS AND METHODS: This retrospective study included 100 patients undergoing elective coronary artery bypass grafting (CABG) who received a single intraoperative dose of 1 mg/kg methylprednisolone. A further 100 patients undergoing CABG, who were not given methylprednisolone, comprised the control group. The presence and severity of pericardial effusion was determined by echocardiography, with chest X-ray used to assess pleural effusion. RESULTS: PPS occurrence and pericardial effusion occurrence were significantly lower in patients who received methylprednisolone (p = 0.02 and p = 0.007 respectively). Although the differences were not statistically significant, pericardial and pleural effusions were more severe in the control group than in the methylprednisolone group. Logistic regression analysis demonstrated that methylprednisolone administration was independently associated with prevention of PPS (OR 0.8, 95% CI 0.25-0.91, p <  0.026). CONCLUSIONS: Intraoperative, single-dose methylprednisolone may confer protection against PPS in patients undergoing CABG.

Wearing the mask of ST-elevation myocardial infarction: postpericardiotomy syndrome.

INTRODUCTION: Postpericardiotomy syndrome (PPS) is an inflammatory process, affecting 15% to 20% of patients, after surgery involving pleura, pericardium, or both. The role of electrocardiogram (ECG) in diagnosing PPS is uncertain because ECG is rarely normal (especially after cardiac surgery). We report a case of PPS that presented initially with localized ST-segment elevation and also discuss proposed mechanisms. CLINICAL CASE: A 60-year-old White man presented to the emergency department (ED) after having chest pain, shortness of breath, and palpitation for approximately 2 hours. Patient had known coronary artery disease, status postcoronary artery bypass graft a month earlier with a graft to right coronary artery, and 2 grafts to marginal arteries. In the ED, ECG revealed localized ST-segment elevations in leads II, III, and aVF. Coronary angiography did not reveal significant coronary artery stenosis, and all the grafts were found to be patent. Following ECG showed PR depression along with diffuse ST elevation consistent with pericarditis. Patient was started on nonsteroidal anti-inflammatory drugs and colchicine with significant improvement of his symptoms in a few days. DISCUSSION: In our patient, injury or surgical manipulation to the area perfused by right coronary artery might have initiated a process, initially localized to the inferior wall with subsequent diffuse involvement of the entire pericardium. The presentation of our patient shortly after the development of chest pain and availability of 2 ECGs a few minutes apart may have shed light on the pathophysiology of PPS.