Postpericardiotomy Syndrome

Postpericardiotomy syndrome (PPS) is an inflammatory pericardial syndrome, often with pleural involvement, that develops days to weeks after cardiac surgery, usually 1 to 6 weeks and up to 3 months.

It belongs to the post-cardiac injury family, which also includes post-myocardial infarction pericarditis (Dressler syndrome), and pericarditis after trauma, percutaneous coronary intervention, ablation and device lead placement. Reported incidence after cardiac surgery is about 10 to 30%, with wide variation by definition.

It is more frequent in younger patients, after valve surgery or surgery that opens the pericardium widely, and in patients with previous pericarditis. Late tamponade is the main hazard and occurs in about 1 to 2% of cardiac surgery patients, more often in patients on warfarin, and may occur in the absence of typical pain.

Pathophysiology. Injury exposes the pericardium to blood and tissue antigens and, with a viral trigger, provokes an immune mediated inflammatory response with antiheart and anti-sarcolemmal antibodies. Effusion accumulates, and clots or loculated collections, which are often posterior, can compress the atria or ventricles.

Persistent inflammation can cause constriction in a few patients.

• Fever, pleuritic or pericarditic chest pain, malaise, dyspnoea, and arthralgia, usually 1 to 6 weeks after surgery.
• Pericardial or pleural friction rub. Pericardial and pleural effusions. Often atypical ECG because of postoperative changes.
• Tamponade presenting with hypotension, tachycardia, raised venous pressure, pulsus paradoxus, falling urine output or fatigue, sometimes with minimal pain.
• Diagnosis needs 2 of: fever without other cause, pericarditic or pleuritic chest pain, a friction rub, a new or worsening pericardial effusion, and a pleural effusion with raised CRP.

Red flags.

• Hypotension, raised venous pressure or pulsus paradoxus (tamponade)
• Therapeutic anticoagulation or INR over 3.0
• New atrial fibrillation or sustained tachycardia
• Fever with sternal wound drainage, instability or bacteraemia (infection)
• Troponin rise or ischaemic ECG change (graft failure)
• Rapidly enlarging effusion, or a localised posterior collection
• Recurrent episodes or persistent effusion over 3 months

• Echocardiography. Effusion size and site, early diastolic chamber collapse, inflow variation, and localised clot. Transthoracic windows are often poor after surgery, so use transoesophageal echocardiography or CT when tamponade is suspected and the transthoracic study is non-diagnostic.
• Chest X-ray for the cardiac silhouette and pleural effusion. CT chest for loculated pericardial or mediastinal collections.
• Blood tests. CRP, full blood count, creatinine, INR, troponin, blood cultures with fever.
• ECG compared with the postoperative tracing.
• Pleural fluid analysis when a pleural effusion is large or the diagnosis is doubtful.

Differential diagnosis.

• Early postoperative pericardial effusion without inflammation
• Sternal wound infection, mediastinitis or endocarditis
• Graft failure or perioperative myocardial infarction
• Pulmonary embolism and pneumonia
• Pleural effusion from heart failure or atelectasis
• Constrictive pericarditis
• Post-operative atrial fibrillation
• Drug fever and heparin induced thrombocytopenia
• Haemothorax or haemopericardium after surgery

• Anti-inflammatory therapy with gastric protection (omeprazole 20 mg orally once daily).
  • Aspirin 750 to 1,000 mg orally every 8 hours (maximum 4 g daily) for 1 to 2 weeks, then tapered by 250 to 500 mg every 1 to 2 weeks. Aspirin is preferred in patients on aspirin for graft protection, because ibuprofen blunts its antiplatelet effect.
  • Alternative: ibuprofen 600 mg orally every 8 hours (maximum 2.4 g daily), tapered over weeks, when no cardioprotective aspirin is needed.
  • Avoid in creatinine clearance under 30 mL/min, active ulcer, and in anticoagulated patients with high bleeding risk, in whom the bleeding risk of NSAIDs outweighs their benefit.
• Colchicine 0.5 mg orally once daily under 70 kg, or 0.5 mg twice daily at 70 kg or over, for 3 months, then taper. Reduce to 0.5 mg once daily at eGFR 30 to 50 mL/min/1.73 m2 and avoid under 30 mL/min/1.73 m2. Avoid with strong CYP3A4 and P-glycoprotein inhibitors (clarithromycin, ketoconazole, ritonavir, ciclosporin, verapamil, diltiazem). Check full blood count, liver enzymes and creatine kinase at baseline and at 1 month. Stop for diarrhoea, cytopenia or myopathy.
• Prednisolone 0.2 to 0.5 mg/kg orally once daily when anti-inflammatory drugs are contraindicated or fail, with a slow taper (over 25 mg daily, reduce by 5 to 10 mg every 1 to 2 weeks; 15 to 25 mg, by 2.5 mg every 2 to 4 weeks; under 15 mg, by 1.25 to 2.5 mg every 2 to 6 weeks). Exclude infection first, and watch wound healing and glucose.
• Prevention. Perioperative colchicine reduced PPS in one study and failed to do so in another, with more gastrointestinal effects, so it is not routine.
• Tamponade. Urgent drainage. Surgical re-exploration is preferred for posterior, loculated or clotted collections and in patients after surgery. Echo directed pericardiocentesis is used for free fluid.
  • Anticoagulated patients: stop warfarin, give vitamin K (phytomenadione) 5 to 10 mg intravenously by slow injection, and prothrombin complex concentrate with the dose set by INR and the product label (usually 25 to 50 units/kg intravenously), then drain.
  • Haemodynamic support while awaiting drainage: intravenous fluid, avoid diuretics and vasodilators, and use noradrenaline 0.05 microgram/kg/min intravenously, titrated to a mean pressure of 65 mm Hg, usual maximum 0.5 microgram/kg/min.
• Large symptomatic pleural effusion: therapeutic thoracentesis.
• Recurrent or refractory disease: use aspirin 750 to 1,000 mg orally every 8 hours with colchicine 0.5 mg twice daily at 70 kg or over, and add anakinra 100 mg subcutaneously once daily (every other day at creatinine clearance under 30 mL/min) after screening for infection.
• Anticoagulation after surgery: keep INR in the target range and avoid over anticoagulation. Repeat INR more often when anti-inflammatory drugs or steroids are started, because interactions raise the INR.

Special groups. In renal impairment avoid anti-inflammatory drugs and reduce colchicine to 0.5 mg once daily at eGFR 30 to 50 mL/min/1.73 m2 and avoid it under 30 mL/min/1.73 m2. In children, drug doses are set by weight under paediatric supervision.

Monitoring. Symptoms and CRP weekly until normal, then at the end of the taper. Echocardiography at 1 week after starting treatment, at 1 month, and with any change in symptoms. INR as directed. Review for constriction at 3 and 6 months when effusion or CRP persists.

Referral and escalation. Refer to the cardiac surgical team for any suspected postoperative effusion. Urgent for tamponade, anticoagulated patients with an enlarging effusion, or suspected infection.