Pericarditis Postpericardiotomia


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Pericarditis Postpericardiotomia

  1. 1. Manuel Alejandro González Ramírez Interno XII Universidad Nacional 2009
  2. 2. Dos componentes  ◦ serosa (pericardio visceral) monocapa mesotelial facilita intercambio de liquidos y electrolitos ◦ fibrosa (pericardio parietal) tejido fibrocolagenoso Liquido Pericardico  ◦ 15 - 50 ml de un ultrafiltrado de plasma Ligamentos  ◦ Al esternón, columna vertebral y diafragma
  3. 3. No necesario para la vida  Funciones Fisiologicas  Limita la dilatacion cardiaca ◦ Limita el desplazamiento cardiaco ◦ maintiene el compliance ventricular normal ◦ Reduce friccion al movimiento cardiaco ◦ Barrera ante la inflamacion ◦
  4. 4. Sindrome postpericardiotomia
  5. 5. El sindrome Postpericardiotomia es una  enfermedad febril en pacientes quienes han sido sometidos a cirugias que involucran apertura del pericardio. Se caracteriza por dolor pleuritico, frote  pericardico, efusion pericardica o pleural, neumonitis y cambios electrocardiograficos y radiologicos. Se describe tambien como un evento siguiente a  un IAM y es una complicacion inusual posterior a colocacion de STENTS coronarios, Marcapasos, epicardicos y transvenosos, postrauma, herida cortopunzantes y puncion cardiaca.
  6. 6. Reaccion inflamatoria que involucra pleura y  pericardio. Se acompaña de efusiones que pueden llevar a  taponamiento cardiaco postoperatorio e inclusive taponamientos recurrentes. Se asocia con el desarrollo de Anticuerpos  anticardiacos. Agentes virales como el Coxsakie B, el  Adenovirus y el Citomegalovirus, se han presentado en dos tercios de los pacientes, lo que sugiere respuesta autoinmune asociada con infeccion viral.
  7. 7. Frecuencia estimada varia entre 2-30% de los  pacientes que han sido sometidos a procedimiento quirrurgico con apertura de pericardio. Mortalidad/Morbilidad  ◦ Se manifiesta generalmente como una enfermedad inflamatoria leve y autolimitada. ◦ El taponamiento cardiaco que amenaza la vida puede desarrollar efusion oericardica progresivamente creciente. ◦ El taponamiento ocurre en menos del 1% de los pacientes. La elevacion de las presiones de llenado cardiaco la progresiva limitacion del llenado diastolico y la reduccion del volumen de eyeccion caracteriza el taponamiento. Edad  ◦ Es poco comun en infantes y va aumentando progresivamente hasta llegar hasta un 30% en adultos.
  8. 8. Symptoms usually develop within 1-6 weeks after  surgery involving pericardiotomy. Temperature after the first postoperative week usually reaches 38-39°C orally but may spike as high as 40°C. Despite a high temperature, the patient may not appear ill. The fever usually subsides within 2-3 weeks. Malaise, chest pain, irritability, and decreased appetite are typical presenting symptoms. Patients may also report dyspnea and arthralgias. Children may report chest pain that worsens with inspiration and when in the supine position. Emesis has also been reported as the main symptom in 2 children with impending cardiac tamponade secondary to PPS.
  9. 9. Patients often demonstrate tachycardia and a  pericardial friction rub. The pericardial rub disappears either with improvement or with further accumulation of pericardial fluid. Systemic fluid retention and hepatomegaly can also occur. Pleural friction rubs are common. Signs of pneumonitis, including cough, fever, and decreased oxygen saturation, may also be present.
  10. 10. IAM  TEP  Neumonia  Diseccion Aoritca  Miocarditis  Endocarditis 
  11. 11. The expected CBC count findings include leukocytosis with a  leftward shift. As with other patients with suspected inflammatory versus  infectious conditions, obtain blood cultures early in the workup. The results of the blood cultures should be negative. Acute phase reactants, such as erythrocyte sedimentation rate  (ESR) and C-reactive protein (CRP) levels, are elevated. Antiheart antibodies are usually present in high titers.  Cardiac enzyme testing is not usually helpful because the results  vary. In addition, studies have reported no difference in enzyme levels compared with patients who underwent cardiopulmonary bypass that do not have clinical signs of postpericardiotomy syndrome (PPS). If a pericardial drain is placed, fluid should be obtained for cell  count, differential, cytology, culture, gram stain, triglyceride level, and total protein level.
  12. 12. Chest radiography may be helpful in diagnosing PPS.  ◦ Chest radiography usually reveals blunting of the costophrenic angles due to a pleural effusion. A pericardial effusion enlarges the cardiac silhouette. ◦ The cardiac silhouette enlarges in proportion to the amount of fluid contained in the pericardial sac. Echocardiography is the diagnostic standard. It is a much more sensitive  imaging study than plain radiography. ◦ In the early stages of PPS, a small amount of fluid may be detected posterior to the left ventricle during systole. ◦ With increasing fluid accumulation, detection using echocardiography becomes easier. ◦ Echocardiography assists in differentiating suspected PPS from congestive heart failure; cardiac output is reduced in both conditions. In PPS with a large effusion one or more cardiac chambers may be compressed by the pericardial fluid. ◦ Echocardiography is particularly helpful in evaluating ventricular contractility. Cardiac MRI has been used more frequently to evaluate cardiac dynamics  and pericardial abnormalities. Cardiac MRI may be more helpful in identifying posterior pericardial fluid collections that may have become loculated and are not easily viewed with trans-thoracic echocardiography.
  13. 13. ECG findings are abnormal in PPS and may  include the following: Initial findings may simulate pericarditis,  with global ST segment elevation and T- wave inversion. Subepicardial injury, resulting from  myocardial inflammation, causes ST segment elevation. The ECG may also reveal low QRS  amplitude, especially with a large pericardial effusion. ST-segment elevation  reflecting epicardial inflammation ◦ leads I, II, aVL, and V3-V6 ◦ lead aVR and V1usually shows ST depression ◦ ST concave upward  ST in AMI concave downward like a “dome” ◦ PR segment depression  early stage ◦ T-wave inversion  occurs after the ST returns to baseline ◦
  14. 14. Tamponade is a life-threatening condition that can result  from PPS. The inflammatory changes seen in PPS may cause pericardial adhesions that result in a localized collection of pericardial fluid. Pericardiocentesis may be emergently required if cardiac tamponade is present. The standard subxiphoid approach is recommended. Because of the possible localized nature of the tamponade, echocardiographic guidance is recommended. Echocardiography-guided pericardiocentesis with extended catheter drainage is considered the primary management for patients with clinically significant pericardial effusions. The drainage tube is usually left in place for 24-48 hours, during which anti-inflammatory treatment is initiated.
  15. 15. Evaluation of patients with suspected postpericardiotomy  syndrome (PPS) is usually performed in an outpatient setting. The workup and treatment may continue on an outpatient basis if the patient is not hemodynamically affected. Medical management includes the use of nonsteroidal anti-inflammatory agents and corticosteroids. Pericardial drainage is indicated in patients with symptoms consistent with tamponade. Patients with tamponade must be admitted to the hospital for definitive care. Anecdotally, successful treatment of recurrent pericardial effusion has been described using a single high dose of intravenous immunoglobulin in one patient16 and a low weekly dose of methotrexate in one other.17
  16. 16. Immediate pericardiocentesis is necessary to relieve  life-threatening cardiac tamponade. A surgically created pericardial window may be necessary in patients with persistent symptoms or relapse after medical therapy. This may be achieved through an open thoracotomy18, 19, 20 or through a video-assisted thoracoscopic technique.21 Percutaneous balloon pericardiotomy (PBP) may be another alternative for these patients. This is a less invasive procedure in which a pericardial window is created in the catheterization laboratory using a balloon catheter under fluoroscopic guidance.22, 23, 24
  17. 17. The mainstay of medical therapy is use of anti-  inflammatory agents. Various drugs are available; all have similar efficacy. Corticosteroids are often used in more severe or refractory cases. Corticosteroids have resulted in rapid improvement in clinical symptoms and decrease in antiheart antibodies. No evidence suggests that steroids administered prior to cardiopulmonary bypass reduce the risk of developing postpericardiotomy syndrome (PPS). One case has been reported of low-dose methotrexate used in PPS refractory to standard therapy;17 however, this has not been further supported.
  18. 18. En los síndromes post-pericardiotomía con signos  inflamatorios evidentes (dolor pericardítico, fiebre, roce) se administrará tratamiento con aspirina, paracetamol o AINES en los pacientes que no requieran tratamiento anticoagulante. En los pacientes con prótesis cardiacas se podrá iniciar tratamiento con paracetamol o AINES en el caso de que la pericarditis sea poco severa y no exista derrame pericárdico o éste sea ligero. Si el derrame pericárdico es moderado o severo se considerará indicada la administración de corticoides (prednisona 1 mg/Kg de peso/día durante 1 semana, con posterior reducción progresiva de la dosis). El tratamiento anticoagulante se basará en heparina hasta la resolución del cuadro inflamatorio. Se considerará también la administración de corticoides en los pacientes con derrame pericárdico muy abundante y con requerimiento de tratamiento anticoagulante, aunque no tengan signos inflamatorios.
  19. 19. reposo mientras persistan dolor o fiebre. Se  administrarán salicilatos durante un mínimo de dos semanas. La dosis inicial (2 gr de ácido acetil-salicílico o más, según necesidad) se mantendrá mientras persistan dolor y fiebre y se retirará paulatinamente. En caso de falta de respuesta se asociarán paracetamol 500mg/8h o antiinflamatorios no esteroides (por ejemplo, indometacina 25-50 mg/8h o ibuprofeno 600mg/12h), pudiéndose recurrir a asociaciones de varios de ellos (por ejemplo, aspirina más paracetamol más indometacina)
  20. 20. Cardiac tamponade is a life-threatening complication of PPS.  Emergent pericardiocentesis and drainage of pericardial effusion is necessary. Tamponade occurs in approximately 1% of patients with PPS. Constrictive pericarditis occurs late postoperatively in fewer than  0.5% of patients but may not be related to PPS. The high prevalence of PPS 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. Patients 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. Coronary artery bypass grafting is an unusual procedure in  children. Occlusion of the graft is reported as a rare, but fatal, complication of PPS.
  21. 21. Most cases resolve within a few weeks.  Rarely, symptoms may occur for more than 6 months. Relapse may occur after tapering anti-  inflammatory medications. Relapse is estimated to occur in 10-15% of patients. Most recurrences occur within 6 months of the initial surgery.