We read the report by Alraies et al published in a recent issue of AJC . Their work is laudable as they have conducted one of the largest observational studies of patients with postpericardiotomy syndrome (PPS) to identify the clinical features associated with adverse events in this cohort. The investigators found younger age, time to PPS, and early postoperative constrictive physiology as some of the key factors associated with need for procedural intervention in patients who developed PPS. The lack of pathognomonic features for PPS makes the diagnosis challenging, and the investigators have used the criteria proposed by Finkelstein et al to define PPS.

The existing literature on PPS demonstrates clear benefit in the use of colchicine to prevent PPS and the association of younger age with higher incidence of PPS. We scrutinized the result depicting lower age with higher incidence of PPS in the study by Alraies et al, as we believe treatment differences to have some role to play in this association. Although there is no doubt that they found a clear statistical difference of PPS in younger patients (55 ± 15 years) as opposed to their older counterparts (60 ± 16 years), one cannot ignore the more aggressive medical treatment strategies used for the older patients in their cohort. The p values for treatment with colchicine and ≥2 anti-inflammatory medications (including colchicine) are 0.06 and 0.07, respectively, with higher percentages of treatment for the elderly, and although they do not reach statistical significance with p ≤0.05, they probably play a role in confounding the results of age. Although we would like to see all age groups be treated aggressively with anti-inflammatory agents to prevent PPS, it also leads us to question whether medical therapy alone can prove superior to surgical techniques even in treating complications of PPS, with the exception of constrictive pericarditis and cardiac tamponade. We might even venture and propose a mantra of “less is more” especially in older patients who seem to do better with medical therapy alone. This remains a question for future prospective studies, as the current design is unable to evaluate whether repetitive surgical trauma causes more inflammation and predisposes the pericardium to constrictive evolution.

Per some of the previous studies and in the personal experience of the senior author, an increased incidence of PPS is found in certain groups of patients such as those undergoing surgery for the congenital heart disease, aortic valve repair, and interestingly in those with B-negative blood type. If this can be confirmed by a subanalysis in the present study, it might lead to formulation of better preventive strategies (such as aggressive use of colchicine in the perioperative period) in these specific cohorts for prevention of PPS and its related complications.