Postpericardiotomy syndrome
Synonyms and keywords:Postcommissurotomy syndrome; PCS; PPS; Dressler syn; Post cardiac injury syndrome; Post heart injury syndrome; Post pericardial injury syndrome

# Overview
The postpericardiotomy syndrome is inflammation of the pericardium following cardiac surgery. Symptoms can occur from days to weeks after the operation. The syndrome is thought to have an autoimmune basis. Postcardiac injury was first discovered by soloff, in 1953. Later Itoh in 1958 ,was first discovered same syndrome and labelled it postpericardiotomy syndrome. In 1956, Dressler described PMIS, and therefore referred to as Dressler syndrome. It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma. Persistance of  Various viral agents,such as coxsackie B, adenovirus, and cytomegalovirus ,suggesting autoimmune response associated with a viral infection. It is thought that postpericardiotomy syndrome is mediated by development of antibodies againts heart. The progression to postpericardiotomy syndrome  usually secondary to cell-mediated immunity.

# Historical Perspective
- Postcardiac injury was first discovered by Soloff, in 1953.
- Later Itoh in 1958, was first discovered the same syndrome and labeled it postpericardiotomy syndrome.
- In 1956, Dressler described PMIS, and therefore referred to as Dressler syndrome.

# Classification
There is no established system for the classification of postpericardiotomy syndrome.

# Pathophysiology
- It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma.
- Persistance of  Various viral agents,such as coxsackie B, adenovirus, and cytomegalovirus ,suggesting autoimmune response associated with a viral infection.
- It is thought that postpericardiotomy syndrome is mediated by development of antibodies againts heart.
- The progression to postpericardiotomy syndrome  usually secondary to cell-mediated immunity.

# Causes
The most important causes of the postpericardiotomy syndrome:
- Pericardial and/or pleural bleeding
- Heart surgery
- Postpericardiotomy syndrome can be an unusual complication after percutaneous coronary intervention such as stent implantation or after implantation of epicardial pacemaker leads and transvenous pacemaker leads, following blunt trauma, stab wounds, and heart puncture.

# Differentiating Postpericardiotomy Syndrome from other Conditions
Postpericardiotomy syndrome should be distinguished from Dressler's syndrome which is an autoimmune process that occurs 2-10 weeks following ST elevation MI. It should also be differentiated from the much more common post myocardial infarction pericarditis that occurs between days 2 and 4 after myocardial infarction. Postpericardiotomy syndrome should also be differentiated from pulmonary embolism, another cause of pleuritic chest pain in people who have been hospitalized and/or undergone surgical procedures within the preceding weeks.

# Epidemiology and Demographics
It is estimated that anywhere from 2000-30,000 out of 100,000 of patients who undergo heart surgery who have had their pericardium opened will develop postpericardiotomy syndrome.

## Age
The risk of postpericardiotomy syndrome increases with age.
- Infants: Uncommon
- Children: Not uncommon
- Adults: Common, occurs in 30% of patients following surgery in which the pericardium is opened

# Risk Factors
- Postpericardiotomy syndrome occurs more frequently in patients who have undergone heart surgery that involves opening the pericardium.
- Many studies has been shown higher  incidence of pps after AVR, MVR, and aortic surgery.

# Natural History, Complications, Prognosis

## Natural History
The onset of symptoms is 1 to 6 weeks after cardiac surgery. In general the disease is self-limited and the symptoms and signs are mild and resolve in 2 to 3 weeks.

## Complications
- Pericardial effusion may result from the accumulation of fluids as a result of inflammation in the pericardial sac.
- Cardiac tamponade can occur if the accumulation of fluids in the pericardium is large enough and rapid enough. This occurs in <1% of patients.
- Constrictive pericarditis can occur if there is a chronic inflammatory response.

## Prognosis
Prognosis is generally good.

# Diagnosis

## Diagnostic Study of Choice
The diagnosis of postpericardiotomy syndrome is made when at least two of the following five  diagnostic criteria are met: New or worsening pleural effusion, new or worsening pericardial effusion, fever, pleural chestpain, pleural or pericardial rubbing.

## History and Symptoms
Common symptoms of postpericardiotomy syndrome include fever, chest pain, dyspenea. Less symptoms of postpericardiotomy syndrome are malaise, decrease appetite, arthralgia.

## Physical Examination

### Vital signs
Tachycardia may be present hypoxemia may be present.

### Cardiac
Pericardial friction rub is often present, an enlarged heart may be present.

### Lungs
Signs of a pleural effusion may be present.

### Abdominal Exam
Hepatomegaly may be present.

### Extremities
Pedal edema may be present if pericardial constriction or a pericardial effusion is present.

## Laboratory Findings
- CBC will be elevated with a leukocytosis and a leftward shift.
- ESR will be elevated.
- CRP will be elevated.
- Given the presence of fever and the post-operative status of the patient, blood cultures should be obtained to rule out endocarditis.
- Antiheart antibodies are elevated.
- Cardiac biomarker testing is usually not helpful as it has not been shown to differ between those patients with and those without postpericardiotomy syndrome.
- Send pericardial fluid for CBC and differential, culture and sensitivity, gram stain, protein and triglyceride level (to rule out chylopericardium).

## Electrocardiogram
An ECG may be helpful in the diagnosis of postpericardiotomy syndrome. Findings on an ECG diagnostic of pericarditis include ST-segment elevation and T-wave inversion and PR depression in multiple leads.

## Chest X Ray
- Often a pleural effusion is present with blunting of the costophrenic angles.
- Cardiomegaly may be present if there is a sufficient pericardial effusion.

## Echocardiography or Ultrasound
- Echocardiography  may be helpful in the diagnosis of postpericardiotomy syndrome.
- Finding on an echocardiography of postpericardiotomy syn include pericardial effusion.

## CT scan
- Cardiac CT scan may be helpful in the diagnosis of pericardial effusion.
- Findings on CT scan suggestive of postpericardiotomy syndrome include pericardial effusion and findings on CT scan diagnostic of pericardial effusion include pericardial thickening.

## MRI
Cardiac MRI may be helpful in the diagnosis of postpericardiotomy syn. Findings on MRI suggestive of pericardial effusion is pericardial thickening.

## Other Imaging Findings
There are no other imaging findings associated with postpericardiotomy syndrome.

## Other Diagnostic Studies
There are no other diagnostic studies associated with postpericardiotomy syndrome.

# Treatment

## Medical Therapy
- The mainstay of treatment for is nonsteroidal anti inflammatory drugs,such as Aspirin and Ibuprofen.
- Pharmacologic medical therapies for postpericardiotomy sydrome include NSAIDs, colchicine and golococorticoid.

## Surgery
- Surgical intervention is not recommended for the management of postpericardiotomy syndrome.
- In 2016, there was a case report  who was treated by IPC(indwelling pleural catheter) because of recurrent pleural effusion due to pps.

## Primary Prevention
- Effective measures for the primary prevention of postpericardiotomy syndrome is prophylactic administration of colchicine.
- Colchicine will be given to patients pre or post cardiac surgery.

## Secondary Prevention
There are no established measures for the secondary prevention of postpericardiotomy syndrome.

## ACC/AHA Treatment Guidelines (DO NOT EDIT)

# Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction 
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction