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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Tahir MH, Sohail S, Shahid D, Hussain I, Malik J, Iqra S, Faraz M. Postcardiac Injury Syndrome After Cardiac Surgery: An Evidence-Based Review. Cardiol Rev 2024:00045415-990000000-00206. [PMID: 38323874 DOI: 10.1097/crd.0000000000000662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Postcardiac injury syndrome (PCIS) serves as a comprehensive term encompassing a spectrum of conditions, namely postpericardiotomy syndrome, postmyocardial infarction (MI) related pericarditis (Dressler syndrome), and post-traumatic pericarditis stemming from procedures like percutaneous coronary intervention or cardiac implantable electronic device placement. These conditions collectively give rise to PCIS, triggered by cardiac injury affecting pericardial or pleural mesothelial cells, leading to subsequent inflammation syndromes spanning from uncomplicated pericarditis to substantial pleural effusion. A thorough literature search conducted on MEDLINE/PubMed utilizing search terms including "postacute cardiac injury syndrome," "postcardiac injury syndrome," "postcardiotomy syndrome," "postpericardiotomy syndrome," and "post-MI pericarditis" was instrumental in collating pertinent studies. To encapsulate the amassed evidence, relevant full-text materials were meticulously selected and amalgamated narratively. The pathophysiology of PCIS is proposed to manifest through an autoimmune-mediated process, particularly in predisposed individuals. This process involves the development of anti-actin and antimyosin antibodies after a cascade of cardiac injuries in diverse forms. Treatment strategies aimed at preventing recurrent PCIS episodes have shown efficacy, with colchicine and nonsteroidal anti-inflammatory drugs, including ibuprofen, demonstrating positive outcomes. Conversely, corticosteroids have exhibited no discernible benefit concerning prognosis or recurrence rates for this ailment. In summary, PCIS serves as a unifying term encompassing a spectrum of cardiac injury-related syndromes. A comprehensive review of relevant literature underscores the autoimmune-mediated pathophysiology in susceptible individuals. The therapeutic landscape involves the proficient use of colchicine and Nonsteroidal anti-inflammatory drugs to deter recurrent PCIS episodes, while corticosteroids do not appear to contribute to improved prognosis or reduced recurrence rates. This nuanced understanding contributes to an enhanced comprehension of PCIS and its multifaceted clinical manifestations, potentially refining its diagnosis and management.
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Affiliation(s)
- Muhammad Hamza Tahir
- From the Department of Cardiovascular Medicine, Cardiovascular Analytics Group, Islamabad, Pakistan
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Pavon AG, Martinez Fernandez R, Arangalage D, Bergamaschi L, Maurizi N, Colombier S, Rotman S, Nowacka A, Bouchardy J, Schwitter J, Kirsch M, Monney P, Rutz T. Prevalence of Pericardial Late Gadolinium Enhancement in Patients After Cardiac Surgery: Clinical and Histological Correlations. Circ Cardiovasc Imaging 2023; 16:e015606. [PMID: 37988447 DOI: 10.1161/circimaging.123.015606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/07/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Pericardial late gadolinium enhancement (LGE) is usually associated with active pericarditis, but it is not infrequently found in patients after cardiac surgery even a long time after the intervention. The clinical relevance of this finding and its histological correlates are unknown. We sought to determine the prevalence of chronic pericardial LGE in patients after cardiac surgery. METHODS All consecutive patients with previous cardiac surgery, who were referred to cardiovascular magnetic resonance between January 2017 and December 2021 were enrolled in the study. Cardiovascular magnetic resonance examination protocol was adapted to clinical indication but always included standard LGE acquisitions. Two independent observers blinded to clinical data assessed the presence of pericardial enhancement on LGE sequences. Fifteen patients underwent cardiac reintervention and pericardial biopsies were obtained. The primary study end point was to assess the prevalence of pericardial enhancement after cardiac surgery and identify possible determinants. The secondary end point was to correlate pericardial enhancement with clinical symptoms and histopathology. RESULTS Two hundred four patients were included in the study. The median time between surgery and cardiovascular magnetic resonance was 160 months (35-226 months). Pericardial LGE was observed in 90 patients (44%). All patients were asymptomatic, and no specific treatment for pericarditis was started. All patients remained asymptomatic at a 1-year clinical follow-up. Pericardial LGE was significantly correlated with the number of previous surgeries (P=0.03). Pericardial fibrosis was detected in all 15 pericardial biopsy specimens; pericardial LGE was present in 7 patients (47%) who underwent biopsy. Histological signs of low-grade inflammation were detected in 6 patients (40%) with severe, circumferential pericardial LGE but in no patient without pericardial enhancement. CONCLUSIONS Pericardial LGE is a frequent finding even several years after cardiac surgery. Its histological correlate is a chronic subclinical post-pericardiotomy inflammation.
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Affiliation(s)
- Anna Giulia Pavon
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University hospital, Switzerland (A.G.P., D.A., J.S., P.M., T.R.)
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (A.G.P., L.B.)
| | | | - Dimitri Arangalage
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University hospital, Switzerland (A.G.P., D.A., J.S., P.M., T.R.)
| | - Luca Bergamaschi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (A.G.P., L.B.)
| | - Niccolò Maurizi
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
| | - Sebastien Colombier
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), Switzerland (S.C., A.N., M.K.)
- Department of Cardiac Surgery, Hôpital du Valais (HVS), Sion, Switzerland (S.C.)
| | - Samuel Rotman
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland (S.R.)
| | - Anna Nowacka
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), Switzerland (S.C., A.N., M.K.)
| | - Judith Bouchardy
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
| | - Juerg Schwitter
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University hospital, Switzerland (A.G.P., D.A., J.S., P.M., T.R.)
- University of Lausanne (Unil), Switzerland (R.M.F., J.S., P.M., T.R.)
| | - Matthias Kirsch
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), Switzerland (S.C., A.N., M.K.)
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University hospital, Switzerland (A.G.P., D.A., J.S., P.M., T.R.)
- University of Lausanne (Unil), Switzerland (R.M.F., J.S., P.M., T.R.)
| | - Tobias Rutz
- Department of Cardiology, Lausanne University Hospital (CHUV), Switzerland (A.G.P., D.A., N.M., J.B., J.S., P.M., T.R.)
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University hospital, Switzerland (A.G.P., D.A., J.S., P.M., T.R.)
- University of Lausanne (Unil), Switzerland (R.M.F., J.S., P.M., T.R.)
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Abuhammad A, Nassar O, Atawnah SI. Post-cardiac Injury Syndrome in a Systemic Lupus Erythematosus Patient After an Open-Heart Operation: A Case Report. Cureus 2023; 15:e46077. [PMID: 37900378 PMCID: PMC10610300 DOI: 10.7759/cureus.46077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Post-cardiac injury syndrome (PCIS) is an inflammatory condition caused by a cardiac injury that can affect the pericardium, pleura, or both. We describe a female patient who underwent heart surgery and thereafter developed pericardium and pleural effusion. She was also known to have systemic lupus erythematosus (SLE). Due to the possibility that each of these symptoms could impact the pericardium or pleura, we came to the conclusion that they could be caused by either PCIS, SLE, or both. A 54-year-old woman underwent open heart surgery three weeks ago and required aortic valve replacement and coronary artery bypass grafting (CABG). She presented to the emergency room complaining of fatigue, chest pain, shortness of breath, coughing, and fever for five days. She had a history of SLE for seven years. The patient was found to have a right-side pleural effusion, a pericardial effusion, and a high inflammatory marker based on imaging and laboratory evaluations. A right pleural-side image-guided percutaneous pigtail catheter drainage was inserted. Exudative fluid appeared in the pleural fluid analysis, and a mild pericardial effusion was seen on echocardiography. The patient was diagnosed with pericarditis and treated with prednisone, colchicine, and antibiotics. Six days later, she was discharged in good general condition. In this particular case of SLE with a chronic inflammatory reaction, PCIS developed following valve replacement surgery. The activation and destruction of endothelial cells are frequently seen in both SLE and PCIS, leading us to believe that there may be a possible reciprocal interaction between these two distinct autoimmune illnesses.
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Affiliation(s)
| | - Osayd Nassar
- Internal Medicine, Al-Ahli Hospital, Hebron, PSE
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5
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Comentale G, Parisi V, Manzo R, Conte M, Bruzzese D, Pilato E. Impact of posterior pericardial drain and risk factors on late pericardial effusion after coronary artery bypass surgery. J Cardiovasc Med (Hagerstown) 2022; 23:715-721. [PMID: 36166335 DOI: 10.2459/jcm.0000000000001370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The blood retained in posterior pericardium can trigger an inflammatory response that increases postoperative atrial fibrillations (POAFs), and it can complicate postoperative course. We retrospectively investigated the impact of a posterior pericardial drain (PPD) in reducing late postoperative pericardial effusion (pPE) and POAFs during the first 30 postoperative days. METHODS Two hundred and fifty coronary artery bypass grafting patients were divided into two groups according to the presence of a PPD in addition to the anterior one. Perioperative data and the incidence of POAF were compared. Risk factor analysis was used to determine the predictors of pPE and postpericardiotomy syndrome. RESULTS Late pPE was present in 16% of all patients. It proved to be much more frequent in patients with a posterior drain (odds ratio 2.58; 95% confidence interval 1.23-5.79; P = 0.015) where it seemed to be almost mild and anterior. 'Anterior Drain' patients showed an increased rate of moderate (P < 0.001) and posterior effusions (P < 0.001). POAF was much more frequent in patients without a PPD (25.2 vs. 6.3%; P < 0.001). Univariate risk factor analysis revealed a significant association between late pPE and lower preoperative weight (P = 0.003), lower preoperative and postoperative serum albumin (P < 0.001) and a greater amount of blood transfusion (P = 0.02). CONCLUSION Even if a PPD is associated with a higher rate of pPE, the patients with only anterior drains were shown to have a greater amount of pericardial effusion and an increased risk of POAFs. Therefore, a PPD should be considered to improve postoperative course.
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Affiliation(s)
- Giuseppe Comentale
- Department of Advanced Biomedical Sciences, Division of Cardiac Surgery, University of Napoli "Federico II" Napoli
| | - Valentina Parisi
- Department of Translational Medical Sciences, University of Napoli 'Federico II', Napoli
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Division of Cardiac Surgery, University of Napoli "Federico II" Napoli
| | - Maddalena Conte
- Department of Translational Medical Sciences, University of Napoli 'Federico II', Napoli.,Casa di Cura San Michele, Maddaloni
| | - Dario Bruzzese
- Department of Public Health, University of Napoli 'Federico II', Napoli, Italy
| | - Emanuele Pilato
- Department of Advanced Biomedical Sciences, Division of Cardiac Surgery, University of Napoli "Federico II" Napoli
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Campisano M, Celani C, Franceschini A, Pires Marafon D, Federici S, Brancaccio G, Galletti L, De Benedetti F, Chinali M, Insalaco A. Incidence and predictors of pericardial effusion following surgical closure of atrial septal defect in children: A single center experience. Front Pediatr 2022; 10:882118. [PMID: 36016883 PMCID: PMC9395979 DOI: 10.3389/fped.2022.882118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the incidence of pericardial effusion (PE) after surgical atrial septal defect (ASD) closure and to investigate the presence of predictive risk factors for its development. METHODS We collected data from 203 patients followed at Bambino Gesù Children's Hospital of Rome who underwent cardiac surgery for ASD repair between January 2015 and September 2019. RESULTS A total of 200/203 patients with different types of ASD were included. Patients were divided into two groups: Group 1) 38 (19%) who developed PE and Group 2) 162 (81%) without PE. No differences were noted between the two groups with regard to gender or age at the surgery. Fever in the 48 h after surgery was significantly more frequent in group 1 than in group 2 (23.7 vs. 2.5%; p < 0.0001). ECG at discharge showed significant ST-segment elevation in children who developed PE, 24.3 vs. 2.0% in those who did not (p < 0.0001). Group 1 patients were divided into two subgroups on the basis of the severity of PE, namely, 31 (81.6%) with mild and 7 (18.4%) with moderate/severe PE. Patients with moderate/severe PE had a significantly higher BMI value (median 19.1 Kg/m2) (range 15.9-23.4, p = 0.004). CONCLUSION The presence of fever and ST-segment elevation after surgery predicts subsequent development of PE suggesting a closer follow-up for these categories of patients. A higher BMI appears to be associated with a higher risk of moderate/severe PE.
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Affiliation(s)
- Martina Campisano
- Division of Pediatric Cardiology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Camilla Celani
- Division of Rheumatology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alessio Franceschini
- Division of Pediatric Cardiology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Denise Pires Marafon
- Division of Rheumatology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Silvia Federici
- Division of Rheumatology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gianluca Brancaccio
- Division of Pediatric Cardiology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Lorenzo Galletti
- Division of Pediatric Cardiology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Fabrizio De Benedetti
- Division of Rheumatology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Marcello Chinali
- Division of Pediatric Cardiology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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Malik J, Zaidi SMJ, Rana AS, Haider A, Tahir S. Post-cardiac injury syndrome: An evidence-based approach to diagnosis and treatment. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 12:100068. [PMID: 38559602 PMCID: PMC10978175 DOI: 10.1016/j.ahjo.2021.100068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 10/12/2021] [Accepted: 10/22/2021] [Indexed: 04/04/2024]
Abstract
Post-cardiac injury syndrome (PCIS) is an umbrella term used for the post-pericardiotomy syndrome, post-myocardial infarction (MI) related pericarditis (Dressler syndrome), and post-traumatic pericarditis (percutaneous coronary intervention (PCI) or cardiac implantable electronic device (CIED) placement). All these conditions give rise to PCIS due to an inciting cardiac injury to pericardial or pleural mesothelial cells, leading to subsequent inflammation syndromes ranging from uncomplicated pericarditis to massive pleural effusion. We did a literature search on MEDLINE/PubMed for relevant studies using the terms "post-acute cardiac injury syndrome", "post-cardiac injury syndrome", "post-cardiotomy syndrome", "post-pericardiotomy syndrome", "post-MI pericarditis" and to summarize the body of evidence, all relevant full texts were selected and incorporated in a narrative fashion. Pathophysiology of PCIS is suggested as autoimmune-mediated in predisposed patients who develop anti-actin and anti-myosin antibodies following a cascade of cardiac injury in various forms. Colchicine and NSAIDs including ibuprofen are demonstrated as efficacious in preventing recurrent attacks of PCIS while corticosteroids show no benefit on prognosis and recurrence of the disease.
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Affiliation(s)
- Jahanzeb Malik
- Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi 46000, Pakistan
| | | | - Abdul Sattar Rana
- Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi 46000, Pakistan
| | - Ali Haider
- Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi 46000, Pakistan
| | - Saleha Tahir
- Department of Respiratory Medicine, Shifa International Hospital, Islamabad 44000, Pakistan
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8
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Maranta F, Cianfanelli L, Grippo R, Alfieri O, Cianflone D, Imazio M. Post-pericardiotomy syndrome: insights into neglected postoperative issues. Eur J Cardiothorac Surg 2021; 61:505-514. [PMID: 34672331 DOI: 10.1093/ejcts/ezab449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/01/2021] [Accepted: 07/27/2021] [Indexed: 12/20/2022] Open
Abstract
ABSTRACT OBJECTIVES Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge. METHODS A literature review was performed that included relevant prospective and retrospective studies on the subject. RESULTS PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention. CONCLUSIONS Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies.
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Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Rocco Grippo
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Udine, Italy
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Mangileva TA, Kazantseva OA, Karaseva IV. Peculiarity of clinical course of postpericardiotomy syndrome in different methods of surgery and postoperative antithrombotic therapy. ACTA ACUST UNITED AC 2021; 61:53-59. [PMID: 33998409 DOI: 10.18087/cardio.2021.4.n1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022]
Abstract
Aim To compare features of the disease course and the effectiveness of nonsteroidal anti-inflammatory drug (NSAID) treatment of postpericardiotomy syndrome (PPS) in patients after coronary bypass (CB) surgery who were treated with antiplatelet drugs and in patients after surgical correction of heart valve disease (CHVD) who received the anticoagulant warfarin for prevention of thrombotic complications. Material and methods This study included 89 patients of whom 53 patients had underwent CB and 36 patients had underwent CHVD. At 15 [13; 15] days after surgery, the severity of inflammatory response, the state of coagulation hemostasis, and hematocrit were studied. At 5 days after the first test, blood count and measurement of C-reactive protein were repeated. Echocardiography was used to determine the presence and volume of pleural effusion. For prevention of thrombotic complications, antiplatelet drugs were administered after CB and warfarin was administered after CHVD. PPS was detected in 35 (66 %) patients after CB and 18 (50 %) patients after CHVD. The ibuprofen treatment (600 mg twice a day) was administered to all patients with PPS. If positive changes in inflammatory markers were absent during the NSAID treatment, ibuprofen was replaced with prednisolone 0.5 mg/kg body weight with subsequent laboratory and instrumental monitoring. Results Patients after CHVD treated with warfarin had higher values of international normalized ratio (INR) and activated partial thromboplastin time (aPPT) and lower values of prothrombin index (PTI), fibrinogen (p<0.001 for all), hemoglobin (p=0.0016), and hematocrit (p=0,0032) than patients after CB treated with antiplatelet drugs. 21 (40 %) patients with PPS required changing the anti-inflammatory therapy from ibuprofen to prednisolone. These patients displayed hypocoagulation, which was evident as reduced PTI (p=0.0023) and fibrinogen (p=0.0209), increased INR (p=0.0291) and aPPT (p=0.0416), and a higher incidence of pericardial effusion (p=0.0080). The insufficient effectivity of NSAIDs that required administration of prednisolone was more frequently observed in patients after CHVD (61 % vs. 29 %, р=0.037).Conclusion Hypocoagulation observed in patients after CHVD due to the anticoagulant treatment with warfarin was associated with more severe course of PPS and lower effectiveness of the NSAID treatment compared to patients after CB. This results in more frequent replacement of NSAIDs with glucocorticoids in the treatment of patients after CHVD.
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Affiliation(s)
- T A Mangileva
- Medical Academy named after S.I. Georgievsky, СFU named after V.I. Vernadsky, Simferopol, Russia
| | - O A Kazantseva
- Republican Clinical Hospital named after N.A.Semashko, structural unit «Cardiological dispensary», Simferopol, Russia
| | - I V Karaseva
- Republican Clinical Hospital named after N.A.Semashko, structural unit «Cardiological dispensary», Simferopol, Russia
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10
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Lehto J, Gunn J, Björn R, Malmberg M, Airaksinen KJ, Kytö V, Nieminen T, Hartikainen JE, Biancari F, Kiviniemi TO. Adverse events and survival with postpericardiotomy syndrome after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2020; 160:1446-1456. [DOI: 10.1016/j.jtcvs.2019.12.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/29/2019] [Accepted: 12/31/2019] [Indexed: 11/26/2022]
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11
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Lee YJ, Mubasher M, Zainal A, Syed T, Mohamed MFH, Ferrantino M, Hoefen R. Pacemaker-Associated Post-cardiac Injury Syndrome Presenting with Tamponade and Recurrent Pleural Effusion. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2020; 13:1179547620965559. [PMID: 33192113 PMCID: PMC7607781 DOI: 10.1177/1179547620965559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/20/2020] [Indexed: 11/24/2022]
Abstract
Post-cardiac injury syndrome (PCIS) is presumed to be an immune-mediated process. It affects the pericardium and, to a lesser extent, the epicardium, myocardium, and pleura. It has been rarely reported following pacemaker insertion with an estimated incidence of 1% to 2%. We present the case of a 62-year-old female who developed PCIS 8 weeks following pacemaker insertion. She presented with impending cardiac tamponade requiring pericardiocentesis; recurrent pleural effusions subsequently complicated her condition. The pleural effusion recurred despite trials of steroids, eventually requiring talc pleurodesis. This case highlights the need to consider PCIS as a possible etiology of recurrent pleural effusion following pacemaker insertion.
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Affiliation(s)
- Young Ju Lee
- Unity Hospital, Rochester Regional Health, Rochester, New York, USA
| | - Mahmood Mubasher
- Unity Hospital, Rochester Regional Health, Rochester, New York, USA
| | - Abir Zainal
- Unity Hospital, Rochester Regional Health, Rochester, New York, USA
| | - Tausif Syed
- Unity Hospital, Rochester Regional Health, Rochester, New York, USA
| | | | | | - Ryan Hoefen
- Unity Hospital, Rochester Regional Health, Rochester, New York, USA
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12
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Abstract
Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.
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Affiliation(s)
- Joonas Lehto
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Lehto J, Kiviniemi T, Gunn J, Airaksinen J, Rautava P, Kytö V. Occurrence of Postpericardiotomy Syndrome: Association With Operation Type and Postoperative Mortality After Open-Heart Operations. J Am Heart Assoc 2019; 7:e010269. [PMID: 30571490 PMCID: PMC6404434 DOI: 10.1161/jaha.118.010269] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Postpericardiotomy syndrome (PPS) is a common complication after cardiac surgery. However, large‐scale epidemiological studies about the effect of procedure type on the occurrence of PPS and mortality of patients with PPS have not yet been performed. Methods and Results We studied the association of PPS occurrence with operation type and postoperative mortality in a nationwide follow‐up analysis of 28 761 consecutive patients entering coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or ascending aortic surgery. Only PPS episodes severe enough to result in hospital admission or to contribute as a cause of death were included. Data were collected from mandatory Finnish national registries between 2005 and 2014. Of all the patients included, 493 developed PPS during the study period. The occurrence of PPS was significantly higher after aortic valve replacement (hazard ratio, 1.97; 95% confidence interval, 1.58–2.46; P<0.001), mitral valve replacement (hazard ratio, 1.62; 95% confidence interval, 1.22–2.15; P<0.001), and aortic surgery (hazard ratio, 3.06; 95% confidence interval, 2.24–4.16; P<0.001), when compared with coronary artery bypass grafting in both univariable and multivariable analyses. The occurrence of PPS decreased significantly with aging (P<0.001). The occurrence of PPS was associated with an increased risk of mortality within the first year after the surgery (adjusted hazard ratio, 1.78; 95% confidence interval, 1.12–2.81; P=0.014). Conclusions The occurrence of PPS was higher after aortic valve replacement, mitral valve replacement, and aortic surgery when compared with the coronary artery bypass grafting procedure. Aging decreased the risk of PPS. The development of PPS was associated with higher mortality within the first year after cardiac or ascending aortic surgery. See Editorial by https://doi.org/10.1161/JAHA.118.011118.
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Affiliation(s)
- Joonas Lehto
- 1 Heart Center Turku University Hospital Turku Finland.,3 University of Turku Finland
| | - Tuomas Kiviniemi
- 1 Heart Center Turku University Hospital Turku Finland.,3 University of Turku Finland
| | - Jarmo Gunn
- 1 Heart Center Turku University Hospital Turku Finland.,3 University of Turku Finland
| | - Juhani Airaksinen
- 1 Heart Center Turku University Hospital Turku Finland.,3 University of Turku Finland
| | - Päivi Rautava
- 2 Clinical Research Center Turku University Hospital Turku Finland.,4 Department of Public Health University of Turku Finland
| | - Ville Kytö
- 1 Heart Center Turku University Hospital Turku Finland.,3 University of Turku Finland.,5 Research Center of Applied and Preventive Cardiovascular Medicine University of Turku Finland
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14
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Tombetti E, Giani T, Brucato A, Cimaz R. Recurrent Pericarditis in Children and Adolescents. Front Pediatr 2019; 7:419. [PMID: 31681717 PMCID: PMC6813188 DOI: 10.3389/fped.2019.00419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022] Open
Abstract
Recurrent pericarditis (RP) is a clinical syndrome characterized by recurrent attacks of acute pericardial inflammation. Prognosis quoad vitam is good, although morbidity might be significant, especially in children and adolescents. Multiple potential etiologies result in RP, in the vast majority of cases through autoimmune or autoinflammatory mechanisms. Idiopathic RP is one of the most frequent diagnoses, that requires the exclusion of all known etiologies. Therapeutic advances in the last decade have been significant with the recognition of the effectiveness of anti IL1 therapy, but a correct diagnostic and therapeutic algorithm is of key importance. Unfortunately, most of evidence comes from studies in adult patients. Here we review the etiopathogenesis, diagnosis and management of RP in pediatric patients.
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Affiliation(s)
- Enrico Tombetti
- Department of Medicine, Azienda Socio Sanitaria Territoriale (ASST) Fetebenefratelli-Sacco and Department of "Biomedical and Clinical Sciences Luigi Sacco", Milan University, Milan, Italy
| | - Teresa Giani
- Rheumatology Unit, Department of Pediatrics, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Antonio Brucato
- Department of Medicine, Azienda Socio Sanitaria Territoriale (ASST) Fetebenefratelli-Sacco and Department of "Biomedical and Clinical Sciences Luigi Sacco", Milan University, Milan, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Azienda Socio Sanitaria Territoriale (ASST) G.Pini, Milan, Italy
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15
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Tuck BC, Townsley MM. Clinical Update in Pericardial Diseases. J Cardiothorac Vasc Anesth 2019; 33:184-199. [DOI: 10.1053/j.jvca.2018.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Indexed: 01/15/2023]
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16
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Abstract
See Article by https://doi.org/10.1161/JAHA.118.010269.
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Affiliation(s)
- Gregory Pattakos
- 1 Department of Cardiothoracic Surgery and Department of Transcatheter Heart Valves Hygeia Hospital Athens Greece
| | - Shuab Omer
- 2 Division of Cardiothoracic Surgery Baylor College of Medicine Michael E DeBakey VA Medical Center Houston TX
| | - Ernesto Jimenez
- 2 Division of Cardiothoracic Surgery Baylor College of Medicine Michael E DeBakey VA Medical Center Houston TX
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17
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Wamboldt R, Bisleri G, Glover B, Haseeb S, Tse G, Liu T, Baranchuk A. Primary prevention of post-pericardiotomy syndrome using corticosteroids: a systematic review. Expert Rev Cardiovasc Ther 2018; 16:405-412. [PMID: 29745734 DOI: 10.1080/14779072.2018.1475231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Rachel Wamboldt
- Division of Cardiology, Kingston Health Science Center, Queen’s University, Kingston, Canada
| | - Gianluigi Bisleri
- Division of Cardiovascular Surgery, Kingston Health Science Center, Queen’s University, Kingston, Canada
| | - Benedict Glover
- Division of Cardiology, Kingston Health Science Center, Queen’s University, Kingston, Canada
| | - Sohaib Haseeb
- Division of Cardiology, Kingston Health Science Center, Queen’s University, Kingston, Canada
| | - Gary Tse
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, P.R., China
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University, Tianjin, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen’s University, Kingston, Canada
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18
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Noma M, Matsubara M, Tokunaga C, Nakajima T, Mathis BJ, Sakamoto H, Hiramatsu Y. Predictors of Pericardial Effusion in Patients Undergoing Pulmonary Artery Banding. World J Pediatr Congenit Heart Surg 2018; 9:201-205. [PMID: 29544417 DOI: 10.1177/2150135118754523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although pulmonary artery banding (PAB) is a common palliative procedure for pediatric heart malformation, there are concerns of pressure overload and concomitant immune reactions in the right ventricle causing postsurgical complications such as pericardial effusion. At this time, no clear guidelines as to potential risk factors or procedural contraindications have been widely disseminated. Therefore, a study was undertaken to examine wide-ranging factors to find potential biomarkers for postsurgical pericardial effusion formation risk. METHODS A retrospective study was conducted on all cardiac surgeries performed over an eight-year period, and the main inclusion criterion was pericardial effusion development after PAB that required surgical drainage. Nine cases were then analyzed against a control group of 45 cases with respect to body measurements, concomitant surgeries, genetic screens, laboratory tests results, and cardiac function parameters. RESULTS Trisomy 21 was strongly associated with the development of severe pericardial effusion after PAB, and postoperative serum albumin levels in patients with trisomy 21 were associated with pericardial effusion development. Other parameters showed no significant correlation with pericardial effusion development. CONCLUSIONS Our data indicate a strong association between trisomy 21 and pericardial effusion requiring drainage after PAB, which is in line with translational research findings. Pressure overload from PAB may play a role in the formation of severe pericardial effusion that is exacerbated by cardiac structural defects commonly associated with trisomy 21. Surgical teams should therefore use caution and plan to implement drainage in PAB cases, and postoperative serum albumin may serve as a useful biomarker for pericardial effusion formation.
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Affiliation(s)
- Mio Noma
- 1 Department of Cardiovascular Surgery, University of Tsukuba Hospital, Amakubo, Tsukuba, Japan
| | - Muneaki Matsubara
- 1 Department of Cardiovascular Surgery, University of Tsukuba Hospital, Amakubo, Tsukuba, Japan
| | - Chiho Tokunaga
- 1 Department of Cardiovascular Surgery, University of Tsukuba Hospital, Amakubo, Tsukuba, Japan
| | - Tomomi Nakajima
- 1 Department of Cardiovascular Surgery, University of Tsukuba Hospital, Amakubo, Tsukuba, Japan
| | - Bryan James Mathis
- 2 Medical English Communications Center, Faculty of Medicine, University of Tsukuba, Tennodai, Tsukuba, Japan
| | - Hiroaki Sakamoto
- 1 Department of Cardiovascular Surgery, University of Tsukuba Hospital, Amakubo, Tsukuba, Japan
| | - Yuji Hiramatsu
- 1 Department of Cardiovascular Surgery, University of Tsukuba Hospital, Amakubo, Tsukuba, Japan
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19
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Pleural effusions in acute idiopathic pericarditis and postcardiac injury syndrome. Curr Opin Pulm Med 2017; 23:346-350. [DOI: 10.1097/mcp.0000000000000383] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Pulido JN. The significance of postpericardiotomy syndrome: A real threat or a simple nuisance? J Thorac Cardiovasc Surg 2016; 153:886-887. [PMID: 28131509 DOI: 10.1016/j.jtcvs.2016.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Juan N Pulido
- Cardiovascular Intensive Care Unit, Cardiothoracic Anesthesiology and Critical Care Medicine, Swedish Heart and Vascular Institute, Physicians Anesthesia Services, Seattle, Wash.
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