Contemporary series of postpericardiotomy syndrome (PPS) are lacking. The aim of this study was to evaluate the incidence, time course, features at presentation, risk factors, and prognosis of PPS. The study population consisted of 360 consecutive candidates to cardiac surgery enrolled in a prospective cohort study. PPS was diagnosed in 54 patients (15.0%; mean age 66 ± 12 years, 48.1% women): 79.6% in the first month, 13.0% in the second month, and 7.4% in the third month. Specific symptoms, signs, or features were pleuritic chest pain (55.6%), fever (53.7%), elevated markers of inflammation (74.1%), pericardial effusion (88.9%), and pleural effusion (92.6%). Cardiac tamponade was rare at presentation (1.9%). Female gender (hazard ratio 2.32, 95% confidence interval 1.22 to 4.39, p = 0.010), and pleura incision (hazard ratio 4.31, 95% confidence interval 2.22 to 8.33, p <0.001) were identified as risk factors in multivariate analysis. Patients with PPS had longer cardiac surgery stays (11.5 ± 4.6 vs 9.9 ± 4.7 days, p = 0.021) and rehabilitation stays (16.4 ± 6.7 vs 12.4 ± 6.2 days, p <0.001) and more readmissions (13.0% vs 0%, p <0.001). Adverse events after a mean follow-up period of 19.8 months were recurrences (3.7%), cardiac tamponade (<2%), but no cases of constriction. In conclusion, despite advances in cardiac surgery techniques, PPS is a common postoperative complication, generally occurring in the first 3 months after surgery. Severe complications are rare, but the syndrome is responsible for hospital stay prolongation and readmissions. Female gender and pleura incision are risk factors for PPS.
There is a relative lack of contemporary series evaluating the features, risk factors, and prognosis of postpericardiotomy syndrome (PPS). PPS may have a troublesome course and complicate the postoperative period, with even life-threatening events such as cardiac tamponade; moreover, it may prolong the hospital stay and increase management costs.
The aim of the present study was to analyze the incidence, time course, clinical presentation features, possible risk factors, and prognosis of PPS after cardiac surgery. Additional analyses will evaluate the hospital stay and hospital readmission rate of patients with or without the syndrome. This study is a planned prospective cohort substudy of the Colchicine for the Prevention of the Post-Pericardiotomy Syndrome (COPPS) trial.
Methods
The study population consisted of 360 consecutive patients enrolled at 6 general hospitals from urban areas of Italy (Maria Vittoria Hospital, Turin; Ospedali Riuniti, Bergamo; Mauriziano Hospital, Turin; Niguarda Hospital, Milan; San Maurizio Regional Hospital, Bolzano; and Ospedale Degli Infermi, Rivoli). All patients were adults and candidates for cardiac surgery for any reason, including coronary artery bypass grafting, valvular diseases, congenital heart disease, or aortic disease. The study is an independent work founded and performed within the Italian national health care system. The research protocol was approved by the relevant institutional review boards or ethics committees, and all human participants gave written informed consent.
According to published clinical trials in this area, the following diagnostic criteria were adopted : (1) fever lasting beyond the first postoperative week without evidence of systemic or focal infection, (2) pleuritic chest pain, (3) friction rub, (4) evidence of pleural effusion, and (5) evidence of new or worsening pericardial effusion. The diagnosis of PPS was based on the presence of ≥2 criteria.
The incidence, time course, and presentation clinical features of PPS were studied as well as treatments and hospital stay. Potential risk factors for PPS were analyzed. Follow-up data were collected by clinical visits, electrocardiography, echocardiography, and chest x-ray. The following clinical events were considered “adverse events” during follow-up: recurrent pericarditis, cardiac tamponade, constrictive pericarditis, and rehospitalization.
Criteria for the diagnosis of recurrence included recurrent pain and ≥1 of the following signs: fever, pericardial friction rub, electrocardiographic changes, echocardiographic evidence of pericardial effusion, and an elevation in the white blood cell count, erythrocyte sedimentation rate, or C-reactive protein. The diagnosis of cardiac tamponade and constrictive pericarditis was formulated following the combination of clinical and echocardiographic data according to current available guidelines. For constrictive pericarditis the clinical suspicion on the basis of initial physical and echocardiographic evaluation was confirmed by additional imaging studies (computed tomography, cardiac magnetic resonance) and cardiac catheterization.
Data are expressed as mean ± SD. Comparisons between patient groups were performed using Mann-Whitney U tests for continuous variables and chi-square tests for categorical variables. Time-to-event distributions were estimated by the Kaplan-Meier method and compared using the log-rank test. The Cox proportional-hazards model was used to identify independent risk factors for recurrence. A stepwise selection procedure was adopted. A p value <0.05 was considered the significance level for variable entry for stepwise selection.
A p value of <0.05 was considered to indicate statistical significance. Analyses were performed using SPSS version 13.0 (SPSS, Inc., Chicago, Illinois).
Results
PPS was diagnosed in 54 of 360 patients (15.0%) <12 months after cardiac surgery. The time course of PPS occurrence was as follows: 28 cases (51.9%) in week 1, 9 cases (16.7%) in week 2, 4 cases (7.4%) in week 3, and 2 cases (3.7%) in week 4. Most cases occurred in the first month (79.6%), while the remaining cases were all confined to the first 3 months after cardiac surgery: 7 (13.0%) during the second month and 4 (7.4%) in the third month after cardiac surgery ( Figures 1 and 2 ).
The mean age was 66 ± 12 years; most patients were >65 years of age (59%). The predominant symptom was pleuritic chest pain (56%). Fever was recorded in 54% of patients and elevated markers of inflammation in >70% of cases. Most patients had pericardial effusions (89%), generally mild (83%). Cardiac tamponade was rare at presentation (<2%). Concomitant pleural effusions were present in most cases (92%). A detailed list of clinical features at presentation is reported in Table 1 .
| Variable | Value |
|---|---|
| Mean age (years) | 66.4 ± 12.2 |
| Age < 45 years | 6 (11%) |
| Age > 65 years | 32 (59%) |
| Female gender | 26 (48%) |
| Pleuritic chest pain | 30 (56%) |
| Fever | 29 (54%) |
| Pericardial rub | 17 (32%) |
| Elevated C-reactive protein or erythrocyte sedimentation rate | 40 (74%) |
| Electrocardiographic changes ⁎ | 13 (24%) |
| Chronic atrial fibrillation | 4 (7%) |
| Pericardial effusion | 48 (89%) |
| Mild (<10 mm) | 40/48 (83%) |
| Moderate (10–20 mm) | 6/48 (13%) |
| Large (>20 mm) | 2/48 (4%) |
| Cardiac tamponade | 1 (2%) |
| Pericarditis † | 28 (52%) |
| Pleural effusion | 50 (93%) |
| Coronary artery bypass grafting | 21 (38.9%) |
| Mean number of bypass | 1.15 |
| Valvular surgery | 13 (24%) |
| Surgery of aorta | 3 (6%) |
| Coronary artery bypass grafting plus other surgery | 17 (32%) |
⁎ Electrocardiographic changes suggestive of pericarditis.
† Criteria for pericarditis were fulfilled (≥2 of chest pain, pericardial rub, electrocardiographic changes, and pericardial effusion).
Compared to patients without the complication, patients with PPS more frequently had combined cardiac surgery (31.5% vs 16.3%, p = 0.013), pleural incision (66.7% vs 34.6%, p <0.001), fever (54.0% vs 11.8%, p <0.001), and pericardial (88.9% vs 5.2%, p <0.001) and pleural (92.5% vs 5.8%, p <0.001) effusions. There was also a predominance of female gender (48.1% vs 31.1%, p = 0.019; Table 2 ). Female gender (hazard ratio 2.32, 95% confidence interval 1.22 to 4.39, p = 0.010) and pleural incision (hazard ratio 4.31, 95% confidence interval 2.22 to 8.33, p <0.001) were identified as risk factors for PPS in multivariate analysis ( Table 3 ).
| Variable | PPS (n = 306) | No PPS (n = 54) | p Value |
|---|---|---|---|
| Age (years) | 65.6 ± 12.4 | 66.4 ± 12.2 | 0.690 |
| Women | 95 (31%) | 26 (48%) | 0.019 |
| Medical history | |||
| Hypertension | 204 (67%) | 42 (78%) | 0.152 |
| Diabetes mellitus | 69 (23%) | 15 (28%) | 0.390 |
| Chronic obstructive pulmonary disease | 22 (7%) | 4 (7) | 0.998 |
| Tobacco use | 84 (28%) | 11 (20%) | 0.318 |
| Previous myocardial infarction | 65 (21%) | 9 (17%) | 0.584 |
| Previous cardiac surgery | 20 (6%) | 1 (2%) | 0.339 |
| Previous pericarditis | 3 (1%) | 1 (2%) | 0.489 |
| Preoperative data | |||
| Creatinine clearance <60 ml/min | 49 (16%) | 6 (11%) | 0.418 |
| Ejection fraction (%) | 53.4 ± 11.5 | 54.7 ± 9.8 | 0.827 |
| Ejection fraction <40% | 39 (13%) | 6 (11%) | 0.917 |
| New York Heart Association class III or IV | 91 (30%) | 16 (30%) | 0.895 |
| Cardiac surgery type | |||
| Coronary artery bypass grafting | 148 (48%) | 21 (39%) | 0.254 |
| Valvular surgery | 93 (30%) | 13 (24%) | 0.439 |
| Aorta surgery | 9 (3%) | 3 (6%) | 0.542 |
| Combined surgery | 50 (16%) | 17 (32%) | 0.013 |
| Other | 6 (2%) | 0 (0%) | 0.633 |
| Pleural incision | 106 (35%) | 36 (67%) | <0.001 |
| Postoperative data | |||
| Fever | 36 (12%) | 29 (54%) | <0.001 |
| Pericardial effusion | 16 (5%) | 48 (89%) | <0.001 |
| Pleural effusion | 18 (6%) | 50 (93%) | <0.001 |
| Medical therapy | |||
| β blockers | 159 (52%) | 25 (46%) | 0.464 |
| Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers | 110 (36%) | 27 (50%) | 0.067 |
| Oral anticoagulant therapy | 28 (9%) | 3 (6%) | 0.598 |
| Colchicine | 164 (54%) | 16 (30%) | 0.002 |
| Factor | HR | 95% CI | p Value |
|---|---|---|---|
| Female gender | 2.32 | 1.22–4.39 | 0.010 |
| Pleural incision | 4.31 | 2.22–8.33 | <0.001 |
| Colchicine use | 0.34 | 0.18–0.67 | 0.002 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
