Cox’s Conference: Post-Pericardiotomy Syndrome

In this week’s Ambulatory Cox’s Conference, Dr. Neela Thangada presented a case of a female with history of hypertension, type 2 diabetes, and adrenal insufficiency secondary to pigmented nodular adrenocortical disease who presented with a chief complaint of shortness of breath, one week in duration. Our expert discussant, Dr. Ian Neeland guided us through the differential diagnosis for acute, progressive shortness of breath.

The young female patient was also experiencing orthopnea, paroxysmal nocturnal dyspnea, and exercise intolerance, all symptoms concerning for heart failure. Exam was pertinent for jugular venous distention, muffled heart sounds, and diffuse crackles. Our differential for acute onset of heart failure included myocarditis, myocardial infarction, valvular disease (acute aortic insufficiency), cardiac tamponade, constrictive pericarditis, infiltrative cardiomyopathies, familial cardiomyopathies, endocrinopathies (hyperthyroidism, hypothyroidism, adrenal insufficiency, and acromegaly), and nutritional deficiencies leading to heart failure. A bedside echocardiogram was performed that revealed a pericardial effusion. The patient had a notable history of recent sternotomy for anterior mediastinal mass resection, which made post-pericardiotomy syndrome the likely diagnosis.

Post-Pericardiotomy Syndrome Pearls:

  • Post-cardiac injury syndrome is pericarditis with or without a pericardial effusion as a result of injury to the pericardium.
  • Commonly occurs post-myocardial infarction, known as Dressler Syndrome.
  • However patients can also develop a similar syndrome after cardiac surgery, thoracic surgery that disturbs the pericardium, cardiovascular interventions (percutaneous coronary intervention, pacemaker lead insertion, and radiofrequency ablation), or trauma.1

Clinical Presentation:

  • Occurs after injury to or invasion of the pericardium or myocardium.
  • Typically there is a latent period, weeks to months, between the injury and the development of pericarditis or pericardial effusion.
  • Symptoms include pleuritic chest pain, fever, but heart failure symptoms can occur in the setting of pericardial effusion. Pericardial tamponade is rare (~ 2%).2

Diagnosis:

  • Suspected based on clinical picture (fever, chest pain, shortness of breath) in the setting of recent myocardial infarction or pericardial injury.
  • Laboratory abnormalities include leukocytosis and elevated erythrocyte sedimentation rate and C-reactive protein.2
  • EKG can have diffuse ST-segment elevation and PR depression.
  • Echocardiogram can reveal pericardial effusion.

Treatment:

  • First-line treatment consists of NSAIDs (if there are no contraindications) and colchicine.
  • In cases of refractory disease, systemic glucocorticoids (prednisone at 0.25 – 0.50 mg/kg/day) can be used.3
  • Colchicine may also be effective in prevention of post-pericardiotomy syndrome after cardiac surgery.4

References:

  1. Wessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J 2006; 99:309.
  2. Imazio M, Brucato A, Rovere ME, et al. Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. Am J Cardiol 2011; 108:1183.
  3. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
  4. Finkelstein Y, Shemesh J, Mahlab K, et al. Colchicine for the prevention of postpericardiotomy syndrome. Herz 2002; 27:791.