The document discusses postpericardiotomy syndrome, which is an inflammatory condition that can occur after surgery involving opening of the pericardium. It has three key characteristics: 1) It presents with symptoms like fever, chest pain, and pericardial friction rub within 1-6 weeks after cardiac surgery. 2) It is characterized by pericardial and sometimes pleural effusions seen on imaging like echocardiography. 3) It is typically treated with anti-inflammatory drugs like NSAIDs or corticosteroids, and pericardiocentesis if cardiac tamponade develops.

1. Manuel Alejandro González Ramírez
Interno XII
Universidad Nacional
2009

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. 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. Sindrome postpericardiotomia

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. 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. 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. 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. 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. IAM

TEP

Neumonia

Diseccion Aoritca

Miocarditis

Endocarditis


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. 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.

14. 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
◦

15. 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.

16. 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

17. 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

18. 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.

19. 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.

20. 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)

21. 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.

22. 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.