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Postpericardiotomy syndrome is not uncommon following cardiac surgery. The syndrome is characterized by fever, chest pain, leucocytosis, and signs of pericardial and pleural effusions. A patient with similar symptoms after laparoscopic treatment of reflux esophagitis is reported. Antibiotic treatment had no effect on a suspected bacteriological infection. There was a dramatic clinical response to corticosteroid treatment. The etiology and pathogenesis of the syndrome are discussed.

"Pericardial effusion and tamponade are recognised complications of permanent transvenous pacemakers implantation. This is more common when active fixation leads are used. We describe a patient who developed right ventricular failure with significant pericardial effusion following permanent transvenous pacemaker implantation."

Darlong describes a new endoscopic technique known as pectus tunneloscopy to avoid cardiac injury at the time of the Nuss procedure for pectus excavatum [1]. As stated by the author, this is one of the major perioperative complications in minimally invasive repair. By studying literature data, we have, in fact, collected 16 cardiac injuries leading to death in two patients and severe hypoxic brain injury in one (in four articles, detailed outcomes were, however, not provided). Furthermore, in their landmark study in the field, Bouchard et al. stated: “Dr Nuss, in personal conversations with three of the authors, has noted other catastrophic outcomes in both placing the bars and removing them, yet these complications are rare but profound” [2]. We agree that pectus tunneloscopy as described by Darlong is a significant enhancement of the procedure, potentially minimizing the risk of cardiac, vascular (mainly internal thoracic artery) or pulmonary injury during the Nuss procedure. Delayed severe complications, however, could not be avoided, such as mechanical occlusion of the inferior vena cava requiring prompt bar removal [3], late-onset haemothorax, aortic cross or pulmonary artery injuries due to bar dislocation, and last but not least, catastrophic haemorrhage during bar removal due to transmyocardial migration, as observed in two patients and leading to death in one [2]. Besides these cardiovascular complications, postpericardiotomy syndrome, infection of the bar, metal allergy, mechanical conflicts and consecutive thoracic outlet syndrome or sternal erosion, and difficulties encountered at the time of bar removal due to neo-ossification are other causes for concern. Finally, a recent meta-analysis comparing both Nuss and Ravitch-type repair suggested no differences with respect to overall complications, but the rate of reoperation, postoperative haemothorax, and pneumothorax after the Nuss repair were significantly higher compared to the Ravitch-type repair [4]. Furthermore, in the real world, such a meta-analysis does not reflect well on the reality in terms of severe complications, since the majority of these, published in the form of case report/series, were excluded from this study. Thus, the acceptance of the Nuss procedure appears questionable to us. In our clinical practice since 2001, we perform a simplified pectus open repair (using an easily removable metallic strut under local anaesthesia) with no severe complications and favourable outcomes, and providing satisfactory long-term cosmetic results in 97.5% of patients (in line with prior published series) [5]. Conflict of interest: none declared

To examine the hypothesis that the incidence of significant pericardial effusion following aortic root surgery is higher than anticipated after cardiac surgery.A retrospective data analysis.A tertiary referral centre for cardiothoracic surgery.All patients undergoing aortic root surgery either with or without aortic valve replacement between January 1991 and July 1993.Three patients developed late cardiac tamponade (7-10 days post-operatively) and a further three developed clinically significant pericardial effusions as a result of post-pericardiotomy syndrome. The 31.6% (95% confidence limit: 12.5-56%) incidence of significant pericardial effusions following aortic root surgery is therefore significantly higher than anticipated after cardiac surgery (0.8-6).These data support the hypothesis that the incidence of significant pericardial effusion following aortic root surgery is higher than anticipated after cardiac surgery. We recommend that echocardiography is routinely performed during the post-operative period in these patients to exclude significant pericardial effusions.

This is the first reported case of cardiac tamponade presumed to be caused by postpericardiotomy syndrome (PPS) following endocardial pacemaker placement. An 84-year-old woman developed fever and dyspnea 3 weeks after pacemaker placement. Physical examination revealed hypotension, tachycardia, and pulsus paradoxus. Auscultation revealed clear lungs and diminished heart sounds. The sedimentation rate was 60 mm/h. Echocardiography revealed a large pericardial effusion with signs of cardiac tamponade. Surgical drainage of the pericardial space resulted in complete resolution of symptoms. The pericardial fluid was culture- and cytologically negative. PPS is a common complication of cardiothoracic surgery and chest trauma. It rarely occurs after percutaneous procedures such as percutaneous transluminal coronary angioplasty and transvenous pacemaker placement. While usually having a benign, self-limited course, PPS can cause a serious complication as illustrated in this case report.

The authors report a new case of the post-pericardiotomy syndrome occurring after implantation of a DDD pacemaker. This is a rare complication of the insertion of a screw atrial electrode, the iatrogenic potential of which has already been reported. The immediate outcome was favourable with anti-inflammatory therapy.

Since April 1986, 82 patients have received a pneumatic total artificial heart, 62 a JARVIK-7, and 20 a Cardiowest. The duration of support ranged from less than 1 day to 603 days (mean duration: 27 +/- 82). The indications were for acute shock (38 cases) or for chronic deterioration on the transplant waiting list (44 cases). The etiology was mainly due to idiopathic and ischemic cardiomyopathy. With the help of our scoring system, we divided our patients in three groups: Chronic Implantation, represented by two females staying on device for 6 and 19 months, respectively; a High-Risk group of 29 patients characterized by high-risk indications; graft failure, rejection, postcardiotomy patient, postpartum cardiomyopathy, and valvular and congenital reoperation. In addition, the dilated and ischemic cardiomyopathy patients with a score over 6 were included in this group; and an Elective Indication group (51 patients) represented all of the dilated and ischemic cardiomyopathy patients with a score under 6. Due to the shortage of donors, our criteria for transplantation are very strict. Transplants should be made only in cases of hemodynamic stability, on an extubated patient with normal renal and liver functions, without coagulation problems or infection. With such criteria, in the high-risk group, only four patients could be transplanted and of these two are still alive. In contrast, in the elective group, 31 were transplanted (61%), and 71% of these patients were discharged. The rate is improved in the most recent cases, with 90% of the Cardiowest patients being survivors.

After nearly any form of cardiac surgery, an acute febrile illness characterized by leukocytosis, pericarditis with pericardial effusion, and pleural effusion may occur. In some instances, this postpericardiotomy syndrome may suggest the presence of mediastinal infection. Treatment of postpericardiotomy syndrome is conservative, and symptoms typically resolve with nonsteroidal antiinflammatory medication. We report a case of postpericardiotomy syndrome that mimicked recurrent mediastinal infection and developed after muscle flap closure of an infected sternal wound. Pericardial, pleural, and periflap fluid accumulated postmuscle flap closure and was sterile on culture. A diagnosis of postpericardiotomy syndrome was made, and the patient improved while receiving oral indomethacin. She has remained free of infection as of the 2-year follow-up.

Postpericardiotomy syndrome is a frequent complication of cardiac surgery and is characterized by fever, chest pain, and a pericardial friction rub. Based on current evidence, there may be an immunologic basis to this syndrome. Treatment is aimed at reducing inflammation and promoting comfort. Although this syndrome is usually benign and self-limiting, it can recur and has been complicated by cardiac tamponade and early bypass graft closure.

Orlando – The gout medication colchicine nearly halved the incidence of postoperative atrial fi brillation after cardiac surgery in a Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) trial substudy. The incidence of atrial fi brillation (AF) between postoperative days 3 and 30 was 12% with colchicine (Colcrys) vs. 22% with placebo (P value = .021), or a relative risk reduction of 46%. “Though I don’t recommend the routine use of colchicine for the prevention of postoperative atrial fi brillation on the basis of a single trial, ... colchicine as [empirical] anti-inflammatory therapy appears to be an inexpensive and safe means to reduce the incidence of postoperative atrial fi brillation, hospitalization length of stay, and the incidence of postpericardiotomy syndrome and postoperative effusions,” principal investigator Dr. Massimo Imazio said at the annual scientific sessions of the American Heart Association. Colchicine was approved in the United States in 2007 for gout, but is not registered for the prevention of pericarditis in North America or Europe. The study has also been published in Circulation (2011;124:2290-2295). Invited discussant Dr. Nancy Nussmeier, director of anesthesia at the State University of New York, Syracuse, said that the substudy has practical implications. She pointed out, however, that COPPS was conducted in a relatively healthy, adult, white population, and that colchicine was started on postoperative day 3, thereby missing early postoperative atrial fi brillation (POAF) cases. Notably, 43% of the 97 POAF episodes occurred on postoperative days 1 and 2 before colchicine was started. Gastrointestinal intolerance, largely diarrhea, may also limit widespread use of the drug, she said. Dr. Nussmeier called for larger multicenter trials to confirm the efficacy of colchicine and said that future research should address earlier administration, the possibility of preoperative administration, or administration as an adjunct for the treatment and prevention of recurrent POAF after it develops. COPPS randomized 360 patients undergoing cardiac surgery at six hospitals in northern Italy to placebo or colchicine 1.0 mg twice-daily for 1 month in those weighing 70 kg or more and 0.5 mg in those less than 70 kg or intolerant to the higher dose. Data previously reported from COPPS at the European Society of Cardiology meeting showed that colchicine reduced the relative risk of postpericardiotomy syndrome (PPS) by 57.9% (Eur. Heart J. 2010;31:2749-54). Among the 250 patients included in the substudy, the number needed to treat to prevent one case of POAF was 11, said Dr. Imazio of the Maria Vittoria Hospital in Turin, Italy. Patients who were given colchicine, compared with those given placebo, had shorter cardiac surgery hospital stays (9.3 days vs. 10.3 days), rehabilitation stays (12.1 days vs. 13.9 days), and overall hospital stays (defined as both cardiac plus rehabilitation stays; 21.4 days vs. 24.2 days). The rate of death or stroke was identical in both groups at 1.2%. Side effects were reported in 16 patients in the colchicine group and in 8 in the placebo group, and were driven entirely by gastrointestinal events in the colchicine group, he said. Side effects contributed to drug withdrawal in 16 of 20 patients in the colchicine group and in 8 of 11 withdrawals in the placebo group. In multivariate analysis, patients with POAF were significantly more likely to have a left atrial anteroposterior diameter of more than 45 mm, to have undergone surgery other than cardiac bypass surgery, and to have pericardial effusion. Those without POAF were more likely to have had perioperative beta-blockade and to have been treated with colchicine, Dr. Imazio said. Acarpia Lda supplied the drug for the trial. Dr. Imazio reported no conflict of interest. Dr. Nussmeier reported serving as a consultant/advisor to Merck. CfA

We describe a case of postcardiotomy syndrome following permanent pacemaker insertion. A 79-year-old woman presented with complete heart block. Following temporary pacing, a dual chamber permanent pacemaker was inserted. Two weeks later she developed fevers and malaise with an acute rise in inflammatory markers. After systemic infection had been carefully excluded, she was commenced on prednisolone with immediate benefit. Prednisolone was withdrawn over 2 months without recurrence of symptoms. Although the postcardiotomy syndrome is rare following transvenous pacemaker insertion it should be considered in the differential diagnosis of fevers and malaise after implantation.

36 women (43%) and 40 men (53%) (total 76) before cardiac surgery underwent the study. The average age was 50 +/- 12,62. The postpericardiotomy syndrome (PPS) was observed in 44 patients (58%). Statistically significant higher mean level CD8 lymphocytes was preoperatively stated in non-PPS patients in comparison with PPS ones (12 PPS pts-38% v.s. 4 non-PPS-9%; p0.01). The ratio CD4 to CD8 exceed 1.6 in group of 25 patients (57%) with PPS and only in 9 patients (28%) without PPS (p0.05). CD4/CD8 ratio1.6 and increased level of lymphocytes with transferrin receptors was more often observed in PPS patients (18 pts; 41%) in comparison with non-PPS ones (3 pts; 9%). The existence of preoperative antimyocardial antibodies did not effect on the higher risk of PPS.

Successive measurements of cardiac myosin light chain I (MLC), creatine kinase isoenzyme MB (CKMB), and the titer of antimyosin antibody (AMA) were performed prospectively in 19 patients following open heart surgery. Seven of these patients showed the postpericardiotomy syndrome (PPS). No differences in serum concentrations of MLC or CKMB were observed between the patients with and without PPS, and all patients in both groups had abnormal MLC values after surgery. However, only patients with PPS had significantly elevated AMA titers. The maximum AMA titer was significantly correlated with the severity of the effusion. These data suggest that PPS is unrelated to the severity of myocardial injury during operation. Furthermore, the AMA titer may be useful as one of the indicators for determining the patient's clinical condition.

Source Citation Imazio M, Trinchero R, Brucato A, et al. COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial...

Endocardial placement of electrodes for myocardial electrostimulation is a standard procedure. In the past, myocardial electrode placement was not performed routinely mainly because of the trauma of surgical access to the heart. We have developed for the first time an endoscopic approach. It is based on the use of a rigid endoscope with a diameter of 20 mm, which is introduced via a subxyphoideal skin incision into the pericardium. A sutureless, screw-in electrode is positioned via the endoscope. 129 patients were treated successfully without method-related lethality. An advantage especially for our large country is the possibility of performing this procedure in distant hospitals without the need of X-ray facilities. The equipment can be carried in an attaché case. Further developments could include two-chamber ECS using disposable kits ready for on-the-spot use.

A 57-year-old man, who had suffered an anterior Q-wave myocardial infarction complicated with typical post-cardiac injury syndrome (PCIS) 9 years earlier, underwent percutaneous transluminal coronary angioplasty (PTCA) without any immediate clinical, laboratory, or radiological signs of complications. After 4 days he recognized the recurrence of the earlier symptoms of PCIS. The diagnosis was supported by slight fever, elevated inflammatory parameters, and improvement when oral corticosteroids were given. The observations suggest that milder cardiac injury than previously considered, that is, without demonstrated structural damage to pericardium or myocardium, may precipitate PCIS in predisposed individuals. The case adds a differential diagnosis to chest pain and malaise following PTCA.

In a 78-year old woman, pacemaker implantation was complicated by a transient perforation of the endocardial lead. The patient was in stable condition for up to 7 weeks after implantation, after which pericardial effusion and subacute cardiac tamponade developed and pericardiocentesis became necessary. This case illustrates that even after initially uneventful pacemaker lead perforation, careful, long-term follow-up is necessary to recognize the potential development of late postpericardiotomy syndrome.

DOI:€10.1510/icvts.2010.248948A Interact CardioVasc Thorac Surg 2010;11:871- Nikolaos Barbetakis, Christos Asteriou, Athanassios Kleontas and Christos Lafaras Post-pericardiotomy syndrome following lung cancer surgery http://icvts.ctsnetjournals.org/cgi/content/full/11/6/871 located on the World Wide Web at: The online version of this article, along with updated information and services, is

The clinical course of 41 consecutive pediatric patients (mean age 7.6 +/- 5.8 years, weight 27 +/- 22 kg) who underwent percutaneous pericardial drain placement during a 3-year period were reviewed. The most common diagnoses were malignancy (20%), postpericardiotomy syndrome (17%), aseptic pericarditis (12%), and patients recovering from a Fontan type of operation (12%). Indications for drainage included increasing effusion size determined by 2-dimensional echocardiogram (48%), clinical deterioration (33%) and echocardiographic evidence of hemodynamic compromise (12%). Only 3 (7%) patients had clinical evidence of cardiac tamponade. Drainage catheter placement was accomplished percutaneously from the subxiphoid approach. Insertion was successful in all but 1 patient (98%) and successful evacuation of the pericardial space was achieved in 93% of patients. There was 1 death in a critically ill 2-week-old infant and 4 complications, 3 of which occurred in patients aged less than 2 years. Drainage catheters remained in position from 1 to 18 days (mean 3 +/- 3 days) with no late complications. There were 3 instances (7%) of drainage catheter occlusion. These data support the notion that placement of a percutaneous pericardial catheter is safe and effective in providing definitive drainage of the pericardial space in the pediatric age group. Children younger than age 2 years may be at increased risk for complications.

Late pericarditis following myocardial infarction, cardiac surgery, or trauma is referred to as postmyocardial infarction syndrome (PMIS) or postcardiotomy syndrome (PCS), respectively. The term postcardiac injury syndrome (PCIS) is used to encompass both these entities. PCIS is characterized by fever, pleuropericardial pain, pericarditis, and pulmonary involvement. Abnormal laboratory findings include leukocytosis, high sedimentation rate, and chest x-ray abnormalities of pleural effusion with or without pulmonary infiltrates. Evidence supports an immunopathic etiology; viruses may play a contributing role. The course is benign but rare complications include tamponade, constriction, anemia, and coronary bypass graft occlusion. Anti-inflammatory agents are helpful; indo-methacin and steroids are preferably avoided. Rarely, PMIS-like syndrome may occur following pulmonary embolism. Anticoagulation and steroids have been used successfully in the latter situation.

One-dimensional sodium dodecyl sulphate polyacrylamide gel electrophoresis of myocardial proteins followed by Western blotting is a sensitive method for the detection of antiheart antibodies after cardiac transplantation. In a previous study we found that the majority of patients made antiheart antibodies after cardiac transplantation. It is possible that these antibodies were formed in response to cardiac damage caused during the surgical procedure rather than being specific to the transplantation situation. In this study we have evaluated the role of open cardiac surgery in the formation of antiheart antibodies for the first 9 months of the postoperative period using the Western blotting technique and correlated that with the development of post-pericardiotomy syndrome. Only 25% (9/36) of patients showed any increase in the pre-existing level of antiheart antibodies or developed antiheart antibodies with new reactivities. None of the patients in the study developed manifestations specific for post-pericardiotomy syndrome during the period of follow-up. The results support the contention that the high incidence of antiheart antibodies formed after cardiac transplantation is due to a humoral immune response to the presence of alloantigens on the grafted heart rather than as a result of the surgical procedure itself.

Three cases are reported that describe acute pulmonary edema as an early manifestation of a postpericardiotomy or postmyocardial infarction syndrome. Each of these cases occurred in the presence of good left ventricular function. The cases suggest this syndrome occurs in immunologically primed patients who have had prior cardiac injury resulting in readily available heart antibody. The first report followed an acute myocardial infarction that required a temporary pacemaker, and the two other cases occurred following coronary artery bypass surgery. Two of the patients had a history of distant myocardial or pericardial injury, and the third patient had an acute anteroseptal myocardial infarction two to three weeks before cardiac surgery. All three patients with pulmonary edema responded dramatically to corticosteroids, having been resistant to diuretic and pre-load and afterload reduction therapy, suggesting an autoimmune capillary injury process. Early recognition of such a syndrome is important since all three patients were successfully treated, and might otherwise have been confused with other causes of pulmonary edema.

The post-pericardiotomy syndrome is a symptom complex which is similar in many respects to the post-myocardial infarction syndrome and these are summarized under the diagnosis of the Post Cardiac Injury Syndrome (PCIS). This condition, which is observed most frequently after open heart surgery, is characterized by pyrexia, pericarditis and increased inflammation parametres. These symptoms develop 2-12 weeks after the trauma. The etiology is unknown but autoimmunity probably plays a part, possibly precipitated by virus infection. PCIS is a diagnosis by exclusion. No definite test is available to identify patients with or without PCIS but demonstration of antimyocardial antibodies may be valuable in the differential diagnostic deliberations. As a rule, the course of the condition is benign and self-limiting but there is a tendency to recurrence. In rare cases, the inflammatory process may encroach on the coronary vessels, with cardiac tamponade and chronic pericardial exudate. In the lighter cases, PCIS may be treated with NSAID and, in the more severe cases, with systemic glucocorticoid which has a prompt effect.

Although the postpericardiotomy syndrome is a common complication of cardiac operations, the most effective drug regimen for the treatment of this condition has not been established. The present study was designed to evaluate the effectiveness of nonsteroidal antiinflammatory drugs (NSAIDs) in the treatment of postpericardiotomy syndrome, in a double-blind, placebo-controlled randomized trial with a 10-day course of ibuprofen or indomethacin. Of 1019 adult patients undergoing cardiac operations during a 14-month period, a diagnosis of postpericardiotomy syndrome was made in 187, and 149 were enrolled in the study. Diagnosis was based on the presence of at least two of the following: fever, anterior chest pain, and friction rub. Drug efficacy was defined as the resolution of at least two of these criteria within 48 hours of drug initiation. Ibuprofen and indomethacin were 90.2% and 88.7% effective, respectively, and both were significantly more effective than placebo (62.5%, p = 0.003). The occurrence of side effects, including nausea, vomiting, renal failure, and fluid retention, was low in all groups (13.1% for ibuprofen, 16.1% for indomethacin, and 16.7% for placebo [p = not significant). Length of hospital stay, incidence of ischemic events, and accumulation of significant pericardial effusions were similar in all groups. The results of this study demonstrate that both ibuprofen and indomethacin provide safe and effective symptomatic treatment for postpericardiotomy syndrome.

The postpericardiotomy syndrome occurs frequently after cardiac surgery, and shows a strong tendency to recur. It is characterized by febrile illness with an elevated erythrocyte sedimentation rate, leucocytosis, and symptoms of pulmonary and pleuro-pericardial inflammation. Pleural effusion is a common manifestation of this syndrome, and is usually left-sided. We describe a patient who shows a periodic left-sided pleural effusion with an interval of 5 to 6 weeks 18 months after cardiac surgery. This is the first description of a 'cyclic' pleural effusion due to the postpericardiotomy syndrome. On the basis of this case report and the literature, we discuss the pathogenesis, therapy and clinical outcome of this syndrome.

factor I in cultured bovine articular cartilage. Biochem J 1986;240:423-30. 11. Saxne T, Hayford J, Heinegard D, et al. Serum levels of the proteoglycan core protein and keratan sulfate correlate in juvenile rhemnatoid arthritis. Arthritis Rheum 1989;32(4):S 105. 12. Trivedi P, Hindmarsh P, Risteli J, Risteli L, Mowat AP. Growth velocity, growth hormone therapy, and serum concentrations of the amino-terminal propeptide of type lIl procollagen. J PEDIATR 1989;114:225-30. 13. Danne T, Gruters A, Schuppan D, Quanta N, Enders I, Weber B. Relationship of procollagen type III propeptide-related 14.

A laminar color Doppler flow was discovered in the pericardial space in a 35-year-old man with postpericardiotomy effusive constrictive pericarditis. The flow was detected by transesophageal color Doppler echocardiography. A further pulsed Doppler study revealed a to-and-fro flow, which was synchronized with the cardiac rhythm. We hypothesized that this flow was generated by the rhythmic cardiac contraction. It was then augmented by hard fibrous pericardium and became detectable by color Doppler echocardiography. Pericardial effusion is a frequent echocardiographic finding but little attention has been paid to the flow in it. The laminar flow in the pericardial space in our patient is related to his hard pericardium and can aid in making the diagnosis of effusive constrictive pericarditis. We suggest that flow in the pericardial space deserves more attention and may provide valuable diagnostic aid.

We report on the development of features of the postpericardiotomy syndrome following coronary perforation during balloon angioplasty, in a patient that was managed conservatively. The case illustrates that while cardiac tamponade does not invariably follow coronary perforation, late consequences derived from this complication may occur. It also widens the spectrum of conditions where the postpericardiotomy syndrome has been observed.