Postpericardiotomy syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]

Synonyms and keywords:Postcommissurotomy syndrome; PCS; PPS; Dressler syn; Post cardiac injury syndrome; Post heart injury syndrome; Post pericardial injury syndrome


The postpericardiotomy syndrome is inflammation of the pericardium following cardiac surgery. Symptoms can occur from days to weeks after the operation. The syndrome is thought to have an autoimmune basis. Postcardiac injury was first discovered by soloff, in 1953. Later Itoh in 1958 ,was first discovered same syndrome and labelled it postpericardiotomy syndrome. In 1956, Dressler described PMIS, and therefore referred to as Dressler syndrome. It has been postulated that the syndrome is an autoimmune response to pericardial and/or pleural bleeding or surgical trauma. Persistance of Various viral agents,such as coxsackie B, adenovirus, and cytomegalovirus ,suggesting autoimmune response associated with a viral infection. It is thought that postpericardiotomy syndrome is mediated by development of antibodies againts heart. The progression to postpericardiotomy syndrome usually secondary to cell-mediated immunity.

Historical Perspective


There is no established system for the classification of postpericardiotomy syndrome.



The most important causes of the postpericardiotomy syndrome:

Differentiating Postpericardiotomy Syndrome from other Conditions

Postpericardiotomy syndrome should be distinguished from Dressler's syndrome which is an autoimmune process that occurs 2-10 weeks following ST elevation MI.[14] It should also be differentiated from the much more common post myocardial infarction pericarditis that occurs between days 2 and 4 after myocardial infarction. Postpericardiotomy syndrome should also be differentiated from pulmonary embolism, another cause of pleuritic chest pain in people who have been hospitalized and/or undergone surgical procedures within the preceding weeks.

Epidemiology and Demographics

It is estimated that anywhere from 2000-30,000 out of 100,000 of patients who undergo heart surgery who have had their pericardium opened will develop postpericardiotomy syndrome.


The risk of postpericardiotomy syndrome increases with age.

  • Infants: Uncommon
  • Children: Not uncommon
  • Adults: Common, occurs in 30% of patients following surgery in which the pericardium is opened

Risk Factors

Natural History, Complications, Prognosis

Natural History

The onset of symptoms is 1 to 6 weeks after cardiac surgery. In general the disease is self-limited and the symptoms and signs are mild and resolve in 2 to 3 weeks.



Prognosis is generally good.[15]


Diagnostic Study of Choice

The diagnosis of postpericardiotomy syndrome is made when at least two of the following five diagnostic criteria are met: New or worsening pleural effusion, new or worsening pericardial effusion, fever, pleural chestpain, pleural or pericardial rubbing.[16]

History and Symptoms

Common symptoms of postpericardiotomy syndrome include fever, chest pain, dyspenea. Less symptoms of postpericardiotomy syndrome are malaise, decrease appetite, arthralgia.[16]

Physical Examination

Vital signs

Tachycardia may be present hypoxemia may be present.


Pericardial friction rub is often present, an enlarged heart may be present.


Signs of a pleural effusion may be present.

Abdominal Exam

Hepatomegaly may be present.


Pedal edema may be present if pericardial constriction or a pericardial effusion is present.

Laboratory Findings


An ECG may be helpful in the diagnosis of postpericardiotomy syndrome. Findings on an ECG diagnostic of pericarditis include ST-segment elevation and T-wave inversion and PR depression in multiple leads.[17]

Chest X Ray

Echocardiography or Ultrasound

CT scan


Cardiac MRI may be helpful in the diagnosis of postpericardiotomy syn. Findings on MRI suggestive of pericardial effusion is pericardial thickening.[18]

Other Imaging Findings

There are no other imaging findings associated with postpericardiotomy syndrome.

Other Diagnostic Studies

There are no other diagnostic studies associated with postpericardiotomy syndrome.


Medical Therapy


Primary Prevention

Secondary Prevention

There are no established measures for the secondary prevention of postpericardiotomy syndrome.

ACC/AHA Treatment Guidelines (DO NOT EDIT)[24]

Class I

1. Aspirin is recommended for treatment of pericarditis after STEMI. Doses as high as 650 mg orally (entericcoated) every 4 to 6 hours may be needed. (Level of Evidence: B)

2. Anticoagulation should be immediately discontinued if pericardial effusion develops or increases. (Level of Evidence: C)

Class IIa

1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following:

a. Colchicine 0.6 mg orally every 12 hours (Level of Evidence: B)
b. Acetaminophen 500 mg orally every 6 hours. (Level of Evidence: C)

Class IIb

1. Corticosteroids might be considered only as a last resort in patients with pericarditis refractory to aspirin or NSAIDs. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. (Level of Evidence: C)

2. Nonsteroidal anti-inflammatory drugs may be considered for pain relief; however, they should not be used for extended periods because of their effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion. (Level of Evidence: B)

Class III

1. Ibuprofen should not be used for pain relief because it blocks the antiplatelet effect of aspirin and it can cause myocardial scar thinning and infarct expansion. (Level of Evidence: B)


  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [24]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [25]


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  25. Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter |month= ignored (help)

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