Chronic Postpericardiotomy Syndrome and Cardiac Tamponade Lasting for Two Years After Open Heart Surgery
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Case Reports Acta Cardiol Sin 2006;22:170-4 Chronic Postpericardiotomy Syndrome and Cardiac Tamponade Lasting for Two Years after Open Heart Surgery Nai-Chuan Chien and Ta-Chung Shen Postpericardiotomy syndrome (PPS) is a major cause of morbidity after cardiac surgery and may cause bypass graft closure and fatal cardiac tamponade. Treatment modalities include nonsteroidal antiinflammatory drugs, corticosteroids, diuresis, drainage, and pericardiectomy in severe cases. Usually the syndrome lasts weeks only, and persistence beyond six months is exceptional. We describe a 64-year-old male patient of chronic PPS, with persistent pericardial effusions and tamponade lasting for two years after an initial open heart surgery. The patient was treated successfully with thoracoscopic partial pericardiectomy and low-dose maintenance steroids and colchicine for two months. Key Words: Cardiac tamponade · Open heart surgery · Pericardiectomy · Postpericardiotomy syndrome · Thoracoscopic surgery INTRODUCTION Postpericardiotomy syndrome (PPS), also named postcardiotomy syndrome, can be classified as a specific Chronic (> 3 months) pericarditis includes effusive form of traumatic pericarditis, and is characterized by (inflammatory or hydropericardium in heart failure), ad- pericardial and/or pleural effusion days to weeks after an hesive, and constrictive forms. Chronic pericardial effu- open heart surgery. Well known to all cardiac surgeons, sions are sometimes encountered in patients without an it is one of the most common complications after open antecedent history of acute pericarditis. Symptoms of heart surgery. PPS usually only lasts weeks; persistence chronic pericarditis are usually mild (chest pain, palpita- beyond six months is exceptional.2 Failure to identify the tions, fatigue), related to the degree of cardiac compres- relationship between the antecedent cardiac operation sion. The etiologies of pericarditis include infectious and the occurrence of the pericardial effusion often re- pericarditis, pericarditis in systemic autoimmune dis- sults in misdiagnosis. eases, type 2 (auto)immune process, pericarditis and Here we present a rare case of chronic PPS and car- pericardial effusion in diseases of surrounding organs, diac tamponade lasting for two years after an initial open pericarditis in metabolic disorders, traumatic pericar- heart surgery. ditis, neoplastic pericardial disease, and idiopathic pe- ricarditis.1 CASE REPORT Received: December 8, 2005 Accepted: April 19, 2006 A 64-year-old man was admitted to the cardiology Department of Surgery, Buddhist Dalin Tzu Chi General Hospital, service presenting with congestive heart failure, NYHA Chiayi, Taiwan. Address correspondence and reprint requests to: Dr. Ta-Chung Fc III. He had undergone a mitral valve repair because of Shen, Department of Surgery, Buddhist Dalin Tzu Chi General severe mitral regurgitation with congestive heart failure Hospital, No. 2, Min Sheng Road, Dalin, Chiayi, Taiwan. Tel: 886-5-264-8000 ext. 5200; Fax: 886-5-264-8006; E-mail: frederick_ 25 months prior to this admission in another hospital. He [email protected] was discharged home with good symptomatic relief three Acta Cardiol Sin 2006;22:170-4 170 Chronic Postpericardiotomy Syndrome months after the operation and was lost to follow-up one He was referred to the cardiac surgical service one month later. The patient started to suffer exercise intoler- month later presenting with massive pericardial effu- ance and leg edema several months after his discharge. sion and cardiac tamponade. Thoracoscopic partial The symptoms waxed and waned, and he sought medical pericardiectomy (without thoracotomy) through the attention only when the symptoms were severe and into- right thorax was carried out, and 1000 mL of serosan- lerable. He had been informed that there was some degree guinous pericardial fluid was evacuated. The pericardial of pericardial effusion. No definite diagnosis was achi- fluid was an exudates, and the pathology of the peri- eved, and the treatment consisted of aggressive diuresis cardium was chronic inflammation. Since there was an only. Though he had hypertension and chronic atrial fi- antecedent open heart operation and there had been brillation, he didn’t receive antihypertensive agents and chronic pericarditis and pericardial effusion, we con- was not anticoagulated. cluded that the final diagnosis was “chronic PPS”. The The physical findings included jugular vein engor- patient was treated postoperatively with 5 mg of pre- gement, a remote heart sound and marked leg edema. dnisolone twice daily, 25 mg of indomethacin and 5 mg The heart rhythm was irregularly irregular, and there was of colchicine daily for two months. It’s now 6 months no heart murmur. The chest film showed a flask-shaped after the operation, and there is no evidence of re- silhouette (Figure 1). Echocardiography demonstrated a currence of pericardial effusion (Figure 1). The latest la- competent mitral valve, a left ventricular ejection frac- boratory data suggested improved renal function (BUN tion (LVEF) of 43%, and large amount of pericardial 26 mg/dL and Cre 2.0 mg/dL). effusion. The hemogram and blood chemistry study were normal except for the elevated serum blood urea nitro- gen and creatinine level (BUN 43 mg/dL and Cre 2.7 DISCUSSION mg/dL). Pericardiocentesis revealed 2000 mL of serosan- Postpericardiotomy syndrome (PPS) with pericardial guinous pericardial fluid. The laboratory studies were and/or pleural effusion, well known to all cardiac sur- consistent with an exudate, and the bacterial and tu- geons, is one of the most common complications after berculosis cultures were negative. Cytology study was ne- open heart surgery. It is a complication of any cardiac gative for malignancy. The patient was diagnosed with surgery or procedure involving entry into the pericar- chronic effusive pericarditis and was discharged pre- dium. The syndrome presents as a delayed pleural or scribed 10 mg of prednisolone twice daily. pericardial reaction, characterized by fever, chest pain, Figure 1. Left: a preoperative flask-shaped cardiac silhouette; Right: a postoperative chest film. 171 Acta Cardiol Sin 2006;22:170-4 Nai-Chuan Chien et al. and a friction rub.3-5 The incidence of PPS varies a lot. Briefly speaking, our patient underwent a mitral Though early works by Miller et al. following 944 con- valve repair for severe mitral regurgitation and con- secutive patients undergoing open heart surgery between gestive heart failure. He had good symptomatic relief November 1984 and November 1985 suggested an over- when he was discharged, but started to have exercise all incidence of 17.8%,6 Kuvin et al. demonstrated in intolerance several months later. Because of the insidi- their large series that few pericardial effusions progress ous course, no definite diagnosis was achieved until to become hemodynamically significant and result in frank cardiac tamponade overwhelmed 25 months af- cardiac tamponade. Only 1% of their 4,561 patients were ter the initial open heart surgery. Once the diagnosis found to have echocardiographic evidence of a moderate was confirmed and definite treatments (pericardiec- or large pericardial effusion, and of these 1% of patients, tomy, nonsteroid anti-inflammatory drugs, steroids, 74% had evidence of cardiac tamponade. They also and colchicines) were administered, the patient recov- showed that cardiac tamponade after open heart surgery ered soon. In conclusion, we have reported a rare case is more common following valve surgery than coronary in which the postoperative pericardial inflammation artery bypass surgery.7 process persisted for 25 months. This suggests that Although the disease is self-limiting, its duration is PPS should always be considered as an important dif- highly variable, with a median of 22 days and a range of ferential diagnosis once there is pericardial effusion 2 to 100 days in a study by Nishimura and colleagues. after an open heart surgery. They also indicated that PPS is a benign but often recur- rent clinical entity, presumably related to viral and/or immunologic factors. Five out of their 34 patients had REFERENCES recurrences at an interval of 3 to 30 months.8 Usually, 1. Maisch B, Seferoviƒ PM, Ristiƒ AD, Erbel R, et al. Guidelines on PPS only lasts for weeks, and persistence beyond six 2 the diagnosis and management of pericardial disease: executive months is exceptional. Nevertheless, failure to identify summary. Eur Heart J 2004;25:587-610. the relationship between the antecedent operation and 2. Zucker N, Levitas A, Zalzstein E. Methotrexate in recurrent the occurrence of the pericardial effusion often results in postpericardiotomy syndrome. Cardiol Young 2003;13(2):206- misdiagnosis. 8. The pain and effusions are often relieved by bed rest 3. Kronick-Mest C. Postpericardiotomy syndrome: etiology, mani- and aspirin or nonsteroidal antiinflammatory drugs. When festations, and interventions. 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