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Objectives: To evaluate feasibility, efficacy, and safety of an approach to atrial septal defect (ASD) occlusion in children ≤20 kg that eliminates cardiac wall erosion risk. Background: Cardiac wall erosion is a potentially catastrophic complication of ASD device closure. The HELEX Septal Occluder (HSO) is a compliant device with no reports of erosion. The HSO is technically difficult to deploy in smaller children and cannot be used to close larger defects. To eliminate wall erosion risk, we use the HSO when feasible and surgery for larger defects. Methods: Retrospective review of ASD procedures performed in children ≤20 kg. Results: Between January 2006 and January 2011, 60 children underwent ASD closure. HSO placement was successful in 32 of 34 patients, and surgical closure was successful in all of 28 patients. Surgical patients were younger (35.1 ± 12.6 vs. 47.4 ± 15.3 months, P < 0.01) and smaller (15.3 ± 3.2 vs. 12.6 ± 4.3 kg; P < 0.01) with larger ASDs (15.8 ± 4.5 vs. 9.8 ± 3.0 mm; P < 0.01). No surgical patients demonstrated residual leak. Residual leak was seen in 14 of 32 (44%) HSO patients on postprocedure day #1 and in 1 of 26 (3.8%) with ≥6 months follow-up. Indications for surgery included: deficient inferior/superior rims (n = 17), provider preference (n = 2), and HSO device not feasible (n = 9). Serious adverse events included device embolization with percutaneous retrieval (n = 1) and postpericardiotomy syndrome without intervention (n = 1). Conclusions: The HSO can be safely used in most children ≤20 kg. Our approach to ASD closure is associated with minimal morbidity and good short-term results. This approach requires no more than a 15% increase in surgical referrals and eliminates risk of cardiac wall erosion. © 2012 Wiley Periodicals, Inc.

The pericardium provides an enclosed lubricated space for the beating heart and functions to fix the heart in the chest cavity relative to adjacent organs. Pericardial pathophysiology is often manifested in a spectrum of distinct cardiac and systemic disease states. The pericardial response to injury typically involves a spectrum of inflammation with both acute and chronic features and/or fluid accumulation. Recent advances in imaging methods have refined the diagnosis and therapy of pericardial disease. This article presents the anatomy and physiology of pericardial disease and the clinical approach for diagnosis and treatment.

Aims No drug has been proven efficacious to prevent the post-pericardiotomy syndrome (PPS), but colchicine seems safe and effective for the treatment and prevention of pericarditis. The aim of the COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS) trial is to test the efficacy and safety of colchicine for the primary prevention of the PPS. Methods and results The COPPS study is a multicentre, double-blind, randomized trial. On the third post-operative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males), 180 in each treatment arm, were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients

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.

Objective: To review the efficacy and safety of colchicine as primary and secondary prophylaxis for pericarditis. Data Sources: We searched MEDLINE, EMBASE, PubMed, BSOSIS Previews. International Pharmaceutical Abstracts. Web of Science, and CENTRAL for controlled studies from database inception date to July 2009. Search terms included colchicine, pericarditis, and postpericardiotomy syndrome (PPS). Study Selection and Data Extraction: Prospective, randomized, controlled trials investigating the use of colchicine in preventing pericarditis were included. Data extracted included design, inclusion criteria, demographics, interventions, background therapy, and pericarditis-related clinical outcomes. Data Synthesis: Data were synthesized qualitatively, given variable study designs. Three trials were identified. A single trial examining primary prevention evaluated the use of colchicine versus placebo for preventing PPS in patients undergoing cardiopulmonary bypass grafting. No significant reduction in PPS was found. Two studies examined secondary prevention of pericarditis, comparing colchicine plus aspirin versus aspirin alone. One study examined using these comparators to treat a first episode of pericarditis. After 3 months, there was a significant reduction in recurrent pericarditis with colchicine plus aspirin (11.7% vs 33%; p = 0,009). Another study examined this same regimen in recurrent pericarditis, finding a significant reduction in recurrence after 6 months (21% vs 45%;p = 0.02). Conclusions: Despite limitations in study designs, current evidence suggests a role for colchicine in the secondary prophylaxis for recurrent pericarditis. The evidence for use of colchicine as primary prophylaxis in PPS is indeterminate; therefore, colchicine cannot be recommended routinely. While colchicine should be recommended for the prevention of recurrent pericarditis, questions regarding the optimal regimen and long-term safety profile need to be further elucidated.

Diagnostic pericardial window (by either subxyphoid or transdiaphragmatic approach) is commonly utilized to exclude traumatic cardiac injury. Although regarded as a low-risk procedure, rare complications such as bacterial pericarditis, iatrogenic cardiac injury, cardiac herniation and postpericardiotomy syndrome can occur. We report the first description of postpericardiotomy syndrome following transdiaphragmatic pericardial window.

A positive result for antinuclear antibodies (ANA), often as a fortuitous observation, may be cause for concern in idiopathic recurrent pericarditis (IRP), nevertheless data are lacking on their prevalence and clinical significance. This study is sought to investigate the prevalence and clinical significance of ANA in IRP.ANA titres were assessed in consecutive patients with recurrent pericarditis, and matched healthy controls. Baseline and follow-up data were recorded and compared according to ANA results.A total of 145 consecutive patients with recurrent pericarditis were studied: 122 patients with IRP, 23 patients with pericarditis due to known etiologies (rheumatologic diagnoses and postpericardiotomy syndrome), and 122 healthy controls. ANA were detected in 53 of 122 (43.4%) patients with IRP, and in only 12 of 122 (9.8%) controls (p0.001). Low titres (1/40-1/80) were found in the majority of cases, while moderate positivity (1/160-1/320) was more common in patients with a known rheumatic disease (26.7% vs. 5.7%; p=0.020). High concentrations of ANA (or =1/640) were not recorded. Women were at increased risk for ANA (OR 2.22 95%CI 1.07-4.60; p=0.033). During a mean follow-up of 32 months, complications and new diagnoses were similar in patients with or without ANA positivity.Low-positive titres are more common in patients with IRP than in controls, suggesting a possible autoimmune pathogenesis. Nevertheless, they are often a clinically non-specific finding. Routine serologic testing for ANA suggests a source for recurrent pericarditis in less than 10% of cases, and in these cases other evidence typically suggests the underlying disease.

Postpericardiotomy syndrome (PPS) occurs in 10-40% of patients after cardiac operations. Pericardial effusions and tamponade occurring7 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.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.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).Intraoperative, single-dose methylprednisolone may confer protection against PPS in patients undergoing CABG.

Pleural effusion secondary to postpericardiotomy syndrome (PPS) is a relatively common complication after cardiac surgery. These effusions and syndrome complex usually respond well to anti-inflammatory agents. The use of indwelling pleural catheter (IPC) for nonmalignant recurrent pleural effusions is growing. We report the use of IPC for a case of recurrent pleural effusion due to PPS in a gentleman that could not tolerate anti-inflammatory medications. To our knowledge, there has been no other report of the use of IPC due to recurrent pleural effusion from PPS.

OBJECTIVE Limited data are available about recurrent pericarditis in children. We sought to explore contemporary causes, characteristics, therapies and outcomes of recurrent pericarditis in paediatric patients. METHODS A multicentre (eight sites) cohort study of 110 consecutive cases of paediatric patients with at least two recurrences of pericarditis over an 11-year period (2000-2010) [median 13 years, interquartile range (IQR) 5, 69 boys]. RESULTS Recurrences were idiopathic or viral in 89.1% of cases, followed by postpericardiotomy syndrome (9.1%) and familial Mediterranean fever (0.9%). Recurrent pericarditis was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) in 80.9% of cases, corticosteroids in 64.8% and colchicine was added in 61.8%. Immunosuppressive therapies were administered in 15.5% of patients after subsequent recurrences. After a median follow-up of 60th months, 528 subsequent recurrences were recorded (median 3, range 2-25). Corticosteroid-treated patients experienced more recurrences (standardized risk of recurrence per 100 person-years was 93.2 for patients treated with corticosteroids and 45.2 for those without), side effects and disease-related hospitalizations (for all P

Objectives This study sought to compare the safety and efficacy of the HELEX septal occluder (HSO) with surgical repair of atrial septal defect (ASD). Background The HSO is a low-profile, double-disk occluder device for percutaneous closure of secundum ASD. Methods Patients were enrolled (HSO arm prospectively, surgery arm prospectively/retrospectively) from 14 U.S. sites and followed up for 12 months postprocedure. Investigator-reported outcomes were evaluated, including closure success (no or clinically insignificant residual shunt) and the incidence of adverse events. The first 3 HSO patients at each site were considered training cases and were excluded from analysis. Results Between March 2001 and April 2003, 119 nontraining cases received an HSO and 128 had surgical repair. The groups were similar with statistical but clinically unimportant differences in median age, weight, and preprocedural echocardiographic defect size. Anesthesia time and hospital stay were significantly shorter in the HSO group. Closure success, defined as complete closure or a clinically insignificant residual shunt, was similar in both groups. Major and minor adverse events rates were not statistically different. The most common major adverse events for the HSO group was device embolization requiring catheter retreival (1.7%), and in the surgery group was postpericardiotomy syndrome (6.3%), including one death because of tamponade. The primary end point, clinical success, a composite of closure success and no major adverse events at 12 months, satisfied the noninferiority hypothesis comparing device closure with surgery. Conclusions Closure of ASD with the HELEX septal occluder is safe and effective when compared with surgical repair, with reduced anesthesia time and hospital stay. (U.S. Multicenter Pivotal Study of the HELEX Septal Occluder for Percutaneous Closure of Secundum Atrial Septal Defects; this study was approved by the Food and Drug Administration before the National Institutes of Health website was active, so there is not a URL or registration number.)

Colchicine is a very old drug that has been used for centuries for the treatment and prevention of gouty attacks. More recently, following its efficacy in the treatment and prevention of poliserositis attacks of familial Mediterranean fever (FMF), the drug has been proposed for the therapy of recurrent pericarditis in the absence of FMF. After the first non-randomised observations, a number of different multicentre, randomised, double-blind placebo-controlled clinical trials (RCT) have demonstrated its efficacy and safety in the treatment of acute and recurrent pericarditis (ICAP, CORP, CORP-2 trials)1–3 and also for the primary prevention of the postpericardiotomy syndrome (PPS) (COPPS, COPPS-2 trials).4 ,5 In the COPPS trial, colchicine, given postoperatively on day 3 after cardiac surgery, at the attack dose of 1.0 mg for 1 day followed by a maintenance dose of 0.5 mg twice daily for 1 month, prevented the PPS and postoperative effusions.4 ,6 On this basis, there is a growing interest in the use of this drug, which is relatively cheap and safe, being the most common side effect, …

Utkan Sevuk,1 Erkan Baysal,2 Rojhat Altindag,2 Baris Yaylak,2 Mehmet Sahin Adiyaman,2 Nurettin Ay,3 Vahhac Alp,3 Unal Beyazit,3 1Department of Cardiovascular Surgery, 2Department of Cardiology, 3Department of General Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey Objective: Postpericardiotomy syndrome (PPS), which is thought to be related to autoimmune phenomena, represents a common postoperative complication in cardiac surgery. Late pericardial effusions after cardiac surgery are usually related to PPS and can progress to cardiac tamponade. Preventive measures can reduce postoperative morbidity and mortality related to PPS. In a previous study, diclofenac was suggested to ameliorate autoimmune diseases. The aim of this study was to determine whether postoperative use of diclofenac is effective in preventing early PPS after cardiac surgery. Methods: A total of 100 patients who were administered oral diclofenac for postoperative analgesia after cardiac surgery and until hospital discharge were included in this retrospective study. As well, 100 patients undergoing cardiac surgery who were not administered nonsteroidal anti-inflammatory drugs were included as the control group. The existence and severity of pericardial effusion were determined by echocardiography. The existence and severity of pleural effusion were determined by chest X-ray. Results: PPS incidence was significantly lower in patients who received diclofenac (20% vs 43%) (P

The number of children surviving medical management and surgical repair of congenital heart lesions has steadily increased. Children with complex heart defects are therefore seen with increasing frequency in emergency departments. This article reviews the epidemiology of congenital heart disease, some common types of surgical repair, and a few postoperative complications and their management.

The isolated perimembranous ventricular septal defect is one of the most common congenital cardiac malformations. Although surgery has been performed and has a low associated risk, it still involves morbidity due to factors such as residual leaks, atrioventricular block, postpericardiotomy syndrome and arrhythmias. It has been speculated that percutaneous closure of these defects could minimize such complications. Recently, a device designed specifically for perimembranous ventricular septal defect closure, the Amplatzer membranous ventricular septal defect occluder, has been developed. Initial clinical experience with this device has been very encouraging with results showing a high rate of complete closure and a low incidence of complications at mid-term follow-up. In this article, the authors review their own and others' experience with this device.

A 42-year-old male patient with three-vessel cormal effusion diameter was 5.2 cm inferolaterally. The onary artery disease and reduced left ventricular pericardium of the right ventricular free wall, adjafunction was referred 10 days after coronary artery cent to the thoracic wall, which was opened at CBG, bypass surgery (CBG). He complained of severe was not involved. shortness of breath, thoracic pain and fever. Blood Pericardiocentesis was performed followed by antitests indicated moderate signs of inflammation with inflammatory and corticosteroid therapy. The pericarleukocytosis and elevated C-reactive protein. ECG dial effusion was serosanguineous with a protein showed non-specific STand T-wave alteration (Fig. content of 4.7 mg/dl and a white cell count of 2.6 /nl. 1). X-ray suggested extremely enlarged heart with CMR after pericardiocentesis showed a much smaller bilateral pleural effusions (Fig. 2). residual pericardial effusion of the left ventricular Cardiovascular magnetic resonance (CMR) was anterior and lateral wall (Fig. 4, arrows). Cine performed to assess cardiac function. Cine imaging imaging showed still impaired, but improved left demonstrated markedly reduced left ventricular funcventricular function (ejection fraction 46%). tion (ejection fraction 35%) with a swinging heart The excellent resolution of CMR demonstrated the compromised by an enormous pericardial effusion size and extension of the pericardial effusion and was (Fig. 3) and imminent cardiac tamponade. The maxihelpful in decision making.

OBJECTIVE: To verify the association of serum markers of myocardial injury, such as troponin I, creatinine kinase, and creatinine kinase isoenzyme MB, and inflammatory markers, such as tumor necrosis factor alpha (TNF-alpha), C-reactive protein, and the erythrocyte sedimentation rate in the perioperative period of cardiac surgery, with the occurrence of possible postpericardiotomy syndrome. METHODS: This was a cohort study with 96 patients undergoing cardiac surgery assessed at the following 4 different time periods: the day before surgery (D0); the 3rd postoperative day (D3); between the 7th and 10th postoperative days (D7-10); and the 30th postoperative day (D30). During each period, we evaluated demographic variables (sex and age), surgical variables (type and duration , extracorporeal circulation), and serum dosages of the markers of myocardial injury and inflammatory response. RESULTS: Of all patients, 12 (12.5%) met the clinical criteria for a diagnosis of postpericardiotomy syndrome, and their mean age was 10.3 years lower than the age of the others (P=0.02). The results of the serum markers for tissue injury and inflammatory response were not significantly different between the 2 assessed groups. No significant difference existed regarding either surgery duration or extracorporeal circulation. CONCLUSION: The patients who met the clinical criteria for postpericardiotomy syndrome were significantly younger than the others were. Serum markers for tissue injury and inflammatory response were not different in the clinically affected group, and did not correlate with the different types and duration of surgery or with extracorporeal circulation.

We present 2 children who developed postpericardiotomy syndrome (PPS) and the rare complication of cardiac tamponade after cardiac surgery, each requiring life-saving pericardiocentesis in the emergency department (ED). Each child presented with vomiting as a chief complaint, an initial sign that has not been reported previously. As the frequency of orthotopic heart transplants and other cardiac surgeries among children increases, it is likely that ED physicians will encounter PPS and cardiac tamponade with greater frequency, and it is imperative that it be recognized promptly and treated appropriately. We review PPS, cardiac tamponade, and the proper performance of a pericardiocentesis.

Objectives: To determine the prevalence and time course of pericardial effusion after open heart surgery for congenital heart diseases and to identify predisposing risk factors. Design and patients: Prospective assessment of development of pericardial effusion in 336 patients (163 males) undergoing open heart surgery for congenital heart disease by serial echocardiography on days 5, 7, 14, 21, and 28 postoperatively. Setting: Tertiary paediatric cardiac centre. Results: The prevalence of pericardial effusion was 23% (77 of 336). Of the 77 patients who developed effusion, 43 (56%) had moderate to large effusions and 18 (23%) were symptomatic. Patients who had a large amount of effusion were more likely to be symptomatic than those with only a small to moderate amount (47.4% v 15.5%, p = 0.01). The mean (SD) onset of pericardial effusion was 11 (7) days after surgery, with 97% (75 of 77) of cases being diagnosed on or before day 28 after surgery. The prevalence of effusion after Fontan-type procedures (60%, 6 of 10) was significantly higher than that after other types of cardiac surgery: repair of left to right shunts (22.1%, 43 of 125), repair of lesions with right ventricular outflow tract obstruction (22.6%, 19 of 84), arterial switch operation (6.7%, 1 of 15), and miscellaneous procedures (25%, 8 of 32) (p = 0.037). Univariate analyses showed that female patients (p = 0.009) and those receiving warfarin (p = 0.002) had increased risk of postoperative pericardial effusion. A greater pericardial drain output in the first four hours after surgery also tended to be significant (p = 0.056). Multivariate logistic regression similarly identified warfarin treatment (β = 1.73, p = 0.009) and female sex (β for male = -0.63, p = 0.037) as significant determinants. Conclusions: Pericardial effusion occurs commonly after open heart surgery for congenital heart disease. Serial echocardiographic monitoring up to 28 days postoperatively is indicated in selected high risk patients such as those with symptoms of postpericardiotomy syndrome and those given warfarin., published_or_final_version

Two cases of postpericardiotomy syndrome (PPS) after thymothymectomy associated with pericardiotomy are described. The incidence of PPS in cardiac operations is reportedly 10–30 %. Although no reports have been described in the English literature, our retrospective analysis revealed similar incidents following mediastinal tumor operation associated with pericardiotomy in cardiac surgery. Clinicians should thus be aware of this syndrome.

Postpericardiotomy syndrome (PPS) is a troublesome complication of cardiac surgery, occurring in 10-45% of cases. Accepted modalities of treatment include nonsteroidal anti-inflammatory drugs, corticosteroids, and pericardiectomy in severe cases. The optimal method for prevention of PPS has not been established. Recent trial data have shown that colchicine is efficient in the secondary prevention of recurrent episodes of pericarditis. The aim of the present study was to evaluate the possible benefit of colchicine for the primary prevention of PPS in patients after cardiac surgery. To the best of our knowledge, this is the first study addressing this issue.A prospective, randomized, double-blind design was used. The initial study group included 163 patients who underwent cardiac surgery in two centers in Israel between October 1997 and September 1998. On the 3rd postoperative day, the patients were randomly assigned to receive colchicine (1.5 mg/day) or placebo for 1 month. All were evaluated monthly for the first 3 postoperative months for development of PPS.52 of the 163 patients were excluded because of postoperative complications, noncompliance, or gastrointestinal side effects of treatment. Of the 111 patients who completed the study, 47 (42.3%) received colchicine and 64 (57.7%) placebo. There was no statistically significant difference between the groups in clinical or surgical characteristics. PPS was diagnosed in 19 patients (17.1%), 5/47 cases (10.6%) in the colchicine group and 14/64 (21.9%) in the placebo group. The difference showed a trend toward statistical significance (p0.135).Colchicine may be efficacious for the prevention of PPS in patients after cardiac surgery. Further evaluations in larger clinical trials are warranted.

Background Complete surgical revascularization that includes left internal thoracic artery grafting to the left anterior descending coronary artery remains the gold standard of treatment for coronary artery disease. Not all patients are good candidates for sternotomy. Therefore, we sought to identify a strategy that would combine the long-term advantages of internal thoracic artery grafting to lessen surgical trauma while still allowing complete revascularization. Methods A total of 54 consecutive patients from four institutions underwent hybrid revascularization combining surgery and angioplasty. All internal thoracic artery grafts were endoscopically harvested with robotic assistance using either the Aesop or Zeus system, and all anastomoses were manually constructed through a 4- to 6-cm anterior thoracotomy incision. Angioplasty was carried out to achieve total revascularization to ungrafted vessels. Results There were no early or late deaths, myocardial infarctions, strokes, or wound infections. Of the patients, 37 (69%) were extubated in the operating room. Length of stay in the intensive care unit averaged 24.4 hours and hospital stay 3.45 days. In all, 16 patients (29.6%) required transfusion of packed red blood cells. Late complications included 1 patient with stent occlusion at 3 months and 2 patients with in-stent restenosis. Three patients were treated for postpericardiotomy syndrome. Mean follow-up was 11.7 months. Event-free was survival 87.1% and freedom from recurrent angina 98.3%. Conclusions Hybrid endoscopic atraumatic internal thoracic artery to anterior descending coronary artery graft surgery combined with angioplasty is a reasonable revascularization strategy in multiple vessel coronary artery disease in selected patients. Longer follow-up and more patient data in a randomized study are needed to determine the patient cohort most likely to benefit from this approach.

The aetiologies, clinical features and follow-up data of 62 children with pericarditis admitted to a university hospital during a 6-year period were retrospectively assessed. Uraemic pericarditis was the most frequent and infections the second most frequent cause. In this series, the proportion of children with purulent pericarditis is less than in previous reports from developing countries. Familial Mediterranean fever, neoplasias, acute rheumatic fever and post-pericardiotomy syndrome were other important causes of pericarditis.

Fever following cardiac surgery is common and may be infectious or noninfectious in etiology. In this article, we review the major causes of postoperative fever while highlighting special considerations in cardiac surgery patients. We also outline a structured approach to evaluation and present an overview of diagnostic and management considerations for mediastinitis, postpericardiotomy syndrome, prosthetic valve endocarditis, aortic vascular graft infections, and ventricular assist device infections.

Between January 1985 and November 1998, 270 patients (aged 2 to 220 months) underwent surgical closure of a secundum atrial septal defect. Cardiopulmonary bypass times ranged from 12 to 103 minutes, with aortic crossclamp times of 5 to 49 minutes. Use of blood products decreased from 2.7 units per patient in the first 5 years to 0.2 units in the last 4 years. Median intensive care unit and hospital stays were 2 days and 6 days, respectively. Complications included: bleeding in 6 patients (2%), which required reexploration in 3; air embolism in 1; and arrhythmias in 4. Postpericardiotomy syndrome occurred in 43 patients (16%), requiring drainage in 5. Follow-up (12 to 179 months) was available in 245 patients (91%). There were no early or late deaths. Most patients (94%) were in sinus rhythm, 8 had low atrial rhythm, 3 had first-degree atrioventricular block, and 1 had atrial flutter. Echocardiography in 207 patients (77%) demonstrated a residual shunt in 1 (0.5%), which was hemodynamically insignificant. Late reoperation was required in 4 patients for sternal nonunion. Surgical closure of secundum atrial septal defect remains the gold standard with which transcatheter closure should be compared, particularly with reference to morbidity and residual shunts.

Cardiovascular surgery with cardiopulmonary bypass (CPB) can lead to postoperative complications like postpericardiotomy syndrome (PPS), capillary leak syndrome or multiple organ failure. PPS morbidity in children is up to 30%, mortality up to 4%. For these complications the CPB is made responsible. Their etiology is not yet clarified in detail, but it is thought to be of immunologic origin. The exact knowledge of these reactions is crucial for the selection of treatment strategies and is the issue of this overview. Cardiovascular surgery is accompanied by the release of proinflammatory cytokines (IL-6, IL-8) and the activation of the alternative complement pathway. This reaction is mainly a response to the surgical trauma and the medication. The exclusively CPB-specific response is the elevated activation of the alternative complement pathway. CPB also induces an antiinflammatory response. The immunosuppressive cytokine IL-10 is systemically released before the release of proinflammatory cytokines. Perioperatively T-helper (Th) cells shift transiently to the Th2 phenotype and indicate the prevalence for a humoral immune response. This shift starts immediately after the onset of the CPB. Increased immunosuppression may be involved in PPS development and seems to be linked to an allergic/atopic predisposition. CPB surgery induces population shifts of the leukocyte subsets, changes of their degree of activation and contributes to the peripheral phenotype of immune suppression. During CPB surgery, circulating neutrophils are inactivated and activated cells are selectively depleted by the CPB filters. In children, cardiovascular surgery with CPB induces a systemic antiinflammatory response. The following factors contribute to this response: elimination of activated cells; compensatory reaction to local, systemically not observable, proinflammatory responses; IL-10 release; anesthetics and medication; and leukocyte extravasation. The subsequent proinflammatory reaction is the reaction to surgical trauma and modulates the antiinflammatory reaction. Immune suppression seems to be an important response to CPB and PPS development and may lead to temporary anergy. Possible therapeutic consequences may include treatment strategies that modulate the antiinflammatory response. More studies in neonates and infants are needed to test this hypothesis. Novel microanalytical techniques have to be developed to achieve this goal.

OBJECTIVE The aim of this study was to determine the effect of prophylactic immune suppression on the incidence and severity of postpericardiotomy syndrome (PPS) in children after cardiac surgery with cardiopulmonary bypass (CPB). BACKGROUND Prophylactic suppression of the inflammatory response has an unknown effect on the incidence and severity of PPS in children undergoing surgery with CPB. METHODS This randomized double-blind placebo controlled trial included two study groups. Group A received pre-CPB intravenous methylprednisolone (1 mg/kg) plus four additional intravenous doses over 24 h, and Group B received intravenous saline placebo at identical intervals. Data included patient demographics, cardiac diagnosis/operation, CPB time, incidence and severity of PPS. Noncomplicated PPS—temperature >100.5°F, pericardial friction rub, patient irritability, small pericardial ± pleural effusion. Complicated PPS—noncomplicated PPS plus hospital readmission ± pericardiocentesis or thoracentesis. RESULTS We randomized 266 children: 20 exclusions (6 perioperative deaths, 14 reasons unrelated to treatment) leaving Group A (n = 126) and Group B (n = 120). There were no significant group differences in gender, cardiac diagnosis or CPB time. Group mean age differed (p = 0.05) and was treated as a covariate with no substantive outcome effect. In total, 39/246 children (16%) developed PPS (noncomplicated: n = 30, complicated: n = 9). There was no inter-group difference in overall PPS incidence (p = 0.73). However, Group A had a marginally significant increase in complicated PPS (p = 0.05). CONCLUSIONS Intravenous methylprednisolone at a standard anti-inflammatory dose administered pre-CPB and early post-CPB neither prevents nor attenuates PPS in children. Short-term pre-CPB and post-CPB methylprednisolone treatment may complicate PPS.

Postpericardiotomy syndrome (PPS) is a frequent complication of various cardiac procedures that involve entry into the pericardium, but rarely occurs after pulmonary surgery because the pericardium is usually preserved during this procedure. The standard treatment for PPS is the administration of non-steroidal anti-inflammatory drugs (NSAIDs). Recent studies have indicated however, that colchicine may be useful for the treatment and prevention of this syndrome. Here, we describe the successful use of colchicine to treat PPS in a lung cancer patient who developed this complication following a lung lobectomy. A 64-year-old woman with a stage IA lung tumor underwent a left upper lobectomy with a mediastinal lymph node dissection. Severe precordial pain occurred 10 days after surgery, and accumulations of pericardial and pleural fluid were revealed by chest X-ray, echocardiogram, and chest computed tomography. These symptoms were not alleviated by antibiotics, thoracic cavity drainage, or NSAIDs. However, the administration of colchicine (initial dose of 1.0 mg and maintenance dose of 0.5 mg daily for three months) in combination with NSAIDs resolved these symptoms immediately after the first dosage. In addition, the patient remains free of any recurrent pericarditis at six months after this episode.

Objective. To present our experience of cardiac injuries treated at one Swedish emergency department in the 10 years 1988-97. Design: Retrospective study. Setting: Teaching hospital. Subjects: 11 patients (9 men and 2 women, mean age 33 years, range 19-54); in 7 they were penetrating injuries and in 4 blunt. Main outcome measures: Morbidity and mortality. Results: The mechanisms of injury were stab wound (n = 7), and car crash, fall, boat crash, and abuse (n = I each); drug or alcohol misuse played a part in all those with penetrating injuries. The penetrating wounds involved the left ventricle (n = 3), the right ventricle (n=2), and the pericardium (n=2). All 5 patients with ventricular wounds presented with cardiac tamponade, in 1 of whom it was fatal (he bled to death during emergency thoracotomy). The main complications were anoxic brain damage and postpericardiotomy syndrome (1 each). There was no case of myocardial concussion. Conclusion. Our data reflect the Swedish experience of heart trauma: there are few cases, alcohol and drug misuse is the principal risk factor, and there were no gunshot wounds.

The extant nomenclature for pericardial disease is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories, using synonyms where appropriate. No classification system has been reported. The groups were based on disease processes, and include: effusive pericarditis (pericardial effusion), constrictive pericarditis, cardiac tamponade, postoperative pericardial effusion, postoperative cardiac tamponade, postpericardiotomy syndrome, congenital defect, neoplastic process, benign mass, pericardial cyst, pneumopericardium, and chylopericardium. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail, which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends.

Postpericardial injury syndrome (PPIS) is defined as pericarditis or pericardial effusion that results from recent or earlier injury of the pericardium. The clinical features of this syndrome include fever, leukocytosis, and elevated erythrocyte sedimentation rate. Recent studies have established a connection between this clinical presentation and an underlying autoimmune process. The role of the humoral immune response is well established regarding the pathogenesis of PPIS with elevated titers of different antibodies and immune complexes in the circulation correlating with disease activity. Nevertheless, cell-mediated response by different subgroups of T lymphocyte has a significant importance with direct infiltration of pericardial tissue and fluids. The diagnosis of PPIS is still challenging. A strong connection between specific serological immunological markers and the disease would be of great value in diagnosis and treatment.

Postcardiac injury syndrome (PCIS) is a common complication after cardiac surgery and myocardial infarction which is defined as a late developing pleuropericarditis accompanied by a friction rub, elevated inflammation markers and pericardial or pleural effusion. Although almost all of the cases follow a major cardiac operation or myocardial infarction, and are called as postpericardiotomy syndrome (PPS) and postmyocardial infarction syndrome (PMIS), unusual presentations after minor cardiac insults, have also been reported in the literature. We have described an unusual case of PCIS with typical clinical, laboratory, echocardiographic findings that occurred after a prolonged and complicated stent implantation procedure.

Background . Allograft conduits are among many varieties of material used for right ventricular outflow tract reconstruction. They invariably need to be replaced due to growth of the patient or conduit failure. Methods . From June 1984 to June 1996, a total of 76 patients underwent reconstruction of the right ventricular outflow tract with an allograft conduit: 51 aortic and 25 pulmonary. The median age, weight and conduit size at surgery were 37 months (range, 0.2 to 228 months), 12.4 kg (range, 2.9 to 61.4 kg), and 17 mm (range, 8 to 26 mm), respectively. Results . The hospital mortality was 5.3% (4 of 76 patients) and 2 patients died at 9 and 78 months follow-up. The median follow-up was 61 months (range, 2 to 132 months). Reoperation was necessary in 22 patients (28.9%) at a median interval of 50.5 months (range, 3 to 109 months) and the median conduit size was 21 mm (range, 12 to 23 months). There was no mortality. Freedom from reoperation at 64 months was 49.5% for conduits 15 mm and smaller, and 73.3% for conduits 16 mm and larger. Analysis by age shows freedom from reoperation at 64 months of 49.4% and 74.5% for patients younger than and older than 2 years, respectively. At 54 months there was no statistical difference in freedom from reoperation between pulmonary and aortic allografts. Conclusion . Right ventricular outflow tract reconstruction with allograft conduits results in a high reoperation rate at 4 years but provides significantly longer freedom from reoperation with conduits larger than 15 mm or in patients over 24 months of age.

Background The postpericardiotomy syndrome (PPS) is a common complication following cardiac surgery. The pathophysiology remains unclear, although evidence exists that surgical trauma and the use of cardiopulmonary bypass provoke an immune response leading to PPS. We hypothesized that an intraoperative dose of dexamethasone decreases the risk of PPS, by reducing this inflammatory response. Methods We performed a subanalysis of the DECS study, which is a multicenter, double-blind, placebo-controlled, randomized trial of 4,494 patients undergoing cardiac surgery with use of cardiopulmonary bypass. The aim of the DECS study was to investigate whether a single intraoperative dose of 1 mg/kg dexamethasone reduced the incidence of a composite of death, myocardial infarction, stroke, renal failure, or respiratory failure, within 30 days of randomization. In this substudy, we retrospectively analyzed the occurrence of PPS in 822 patients who were included in the DECS trial and underwent valvular surgery. Postpericardiotomy syndrome was diagnosed if 2 of 5 listed symptoms were present: unexplained fever, pleuritic chest pain, pericardial or pleural rub, new or worsening pericardial or pleural effusion. All medical charts, x-rays, and echocardiograms were reviewed. Secondary end point was the occurrence of complicated PPS, defined as PPS with need for evacuation of pleural effusion, pericardiocentesis, and tamponade requiring intervention or hospital readmission for PPS. This is a blinded, single-center, post hoc analysis. Results Postpericardiotomy syndrome occurred in 119 patients (14.5%). The incidence of PPS after dexamethasone compared with placebo was 13.5% vs 15.5% (relative risk 0.88, 95% CI 0.63-1.22). For complicated PPS, the incidence was 3.8% versus 3.2% (relative risk 1.17, 95% CI 0.57-2.41, P = .66), respectively. Conclusion In patients undergoing valvular cardiac surgery, high-dose dexamethasone treatment had no protective effect on the occurrence of PPS or complicated PPS.

IMPORTANCE: Postpericardiotomy syndrome, postoperative atrial fibrillation (AF), and postoperative effusions may be responsible for increased morbidity and health care costs after cardiac surgery. Postoperative use of colchicine prevented these complications in a single trial. OBJECTIVE: To determine the efficacy and safety of perioperative use of oral colchicine in reducing postpericardiotomy syndrome, postoperative AF, and postoperative pericardial or pleural effusions. DESIGN, SETTING, AND PARTICIPANTS: Investigator-initiated, double-blind, placebo-controlled, randomized clinical trial among 360 consecutive candidates for cardiac surgery enrolled in 11 Italian centers between March 2012 and March 2014. At enrollment, mean age of the trial participants was 67.5 years (SD, 10.6 years), 69% were men, and 36% had planned valvular surgery. Main exclusion criteria were absence of sinus rhythm at enrollment, cardiac transplantation, and contraindications to colchicine. INTERVENTIONS: Patients were randomized to receive placebo (n=180) or colchicine (0.5 mg twice daily in patients ≥70 kg or 0.5 mg once daily in patients

Cardiac tamponade is a life-threatening complication after cardiac surgery which may develop in the early or late postoperative period. The latest have been defined arbitrarily as the ones occurring after the 7th postoperative day. They are less common than the early ones and most of the cases have been reported up to six months after the operation. They usually determine diagnostic difficulties that can negatively influence the prognosis. Because of its atypical late appearance, a case of a 65 year old man is presented who developed a postpericardiotomy syndrome and subsequently a pericardial clot nearly two years after aortocoronary bypass grafting.