What is the management of post cardiotomy syndrome?

Management of Post Cardiotomy Syndrome

Anti-inflammatory therapy with NSAIDs plus colchicine is the first-line treatment for post cardiotomy syndrome (PPS), with treatment duration typically extending for several weeks to months, even after disappearance of effusion. 1

Definition and Clinical Features

• Post cardiotomy syndrome (also called post-pericardiotomy syndrome) is characterized by fever, pleuritic chest pain, pericardial/pleural friction rub, and pericardial/pleural effusions occurring days to months after cardiac surgery 2, 3
• Diagnosis requires at least 2 of 5 criteria: fever without infection, pericardial/pleuritic chest pain, pericardial/pleural friction rub, pleural effusion, and pericardial effusion (within 60 days after surgery), with elevated inflammatory markers like CRP 3, 4
• PPS is more common after valve surgery than coronary artery bypass grafting alone 2

First-Line Treatment

• NSAIDs plus colchicine is the recommended first-line therapy for symptomatic PPS 1, 5
• Ibuprofen and indomethacin have shown 90.2% and 88.7% effectiveness respectively in resolving symptoms within 48 hours (significantly better than placebo at 62.5%) 5
• Colchicine dosing: 0.5 mg twice daily for patients ≥70 kg or 0.5 mg once daily for patients <70 kg, continued for at least 3 months 1
• Colchicine reduces recurrence rates by approximately 50% and is associated with reduced odds of adverse events requiring procedural intervention 1, 4

Treatment Duration and Tapering

• Anti-inflammatory therapy should be continued for several weeks to months, even after disappearance of effusion 2
• Gradual tapering is recommended: decrease NSAID doses first (e.g., aspirin by 250-500 mg every 1-2 weeks), then gradually discontinue colchicine over several months in difficult cases 1

Management of Pleural Effusions

• For symptomatic pleural effusions with estimated volume >400 mL, ultrasound-guided thoracentesis is the initial intervention of choice 2
• Dedicated follow-up and drainage protocols for pleural effusions can enhance recovery rates by up to 15% 2

Treatment of Refractory Cases

• For refractory PPS, options include:
  • Long-term oral corticosteroids (3-6 months) 2, 1
  • Pericardiocentesis with intrapericardial instillation of triamcinolone (300 mg/m²) 2, 1
• Redo surgery and pericardiectomy are rarely needed 2

Special Considerations

• Younger age, early-onset PPS, and postoperative constrictive physiology are associated with higher risk of requiring procedural intervention 4
• Cardiac tamponade occurring in the first hours after cardiac surgery is usually due to hemorrhage and requires surgical reintervention 2
• Asymptomatic postoperative pericardial effusions should not be treated with NSAIDs, as studies have shown this to be ineffective and potentially associated with increased risk of side effects 2
• Patients with pericardial effusion >10 mm thickness should be investigated for possible subacute rupture 2

Prevention

• Prophylactic colchicine has shown effectiveness in preventing PPS, but perioperative use is associated with increased gastrointestinal side effects compared to postoperative use 2
• Prophylactic ibuprofen has not been shown to reduce the rate of PPS following surgical atrial septal defect repair 6

Prognosis

• Complication rates are generally low: <4% for recurrences, <2% for cardiac tamponade 2
• Development of constrictive pericarditis has been reported in approximately 3% of cases 2