Post-Cardiac Injury Syndrome (Postpericardiotomy Syndrome)

What happens in post-cardiac injury syndrome

When the heart muscle or pericardium is damaged, by a surgical incision, a heart attack, a pacemaker lead or a burn during ablation, cells release proteins that the immune system had not previously "seen". The immune system makes antibodies against them, and these trigger inflammation in the pericardium and pleura a week or more later. That delay is why PCIS is thought to be autoimmune rather than infectious.

PCIS is an umbrella term for three related conditions:

• Postpericardiotomy syndrome: after surgery that opens the pericardium, such as bypass or valve surgery. The most common type.
• Post-myocardial infarction pericarditis (Dressler syndrome): after a heart attack. Now uncommon because heart attacks are treated quickly and damage is smaller.
• Post-traumatic pericarditis: after chest injury or after catheter procedures such as pacemaker implantation, ablation for atrial fibrillation or coronary stenting.

Symptoms

• Chest pain: sharp, stabbing, worse lying flat, coughing or breathing in, eased by sitting up and leaning forward. It may spread to the shoulders or neck.
• Fever, often low-grade, without another cause
• Shortness of breath, from fluid around the heart or lungs
• Fatigue, aches and feeling generally unwell
• Cough
• a scratchy sound (pericardial rub) heard by the doctor

After surgery, it can be hard to tell PCIS from normal recovery pain. Pain that gets worse after a period of improvement, or that comes with fever and breathlessness, needs assessment.

Diagnosis

The European Society of Cardiology defines PCIS by having at least 2 of the following after cardiac injury:

• fever with no other cause
• pericarditic or pleuritic chest pain
• a pericardial or pleural friction rub
• a new or growing pericardial effusion
• a pleural effusion with raised CRP

Tests include:

1. Echocardiogram: shows pericardial effusion and whether it is affecting heart filling.
2. ECG: may show pericarditis changes, though these are often less typical after surgery.
3. Blood tests: CRP and ESR (inflammation), white cell count, and troponin to check for heart muscle injury.
4. Chest X-ray or CT: shows pleural effusions and lung changes.
5. Tests to exclude other causes: wound and blood cultures for infection, CT for pulmonary embolism, and coronary assessment if a new heart attack is possible.

Treatment

First-line treatment

• Aspirin or an NSAID such as ibuprofen at anti-inflammatory doses, chosen by your doctor. After a heart attack, aspirin is preferred, because other NSAIDs can interfere with heart healing. People on blood thinners need careful monitoring because of bleeding risk.
• Colchicine for about 3 months, which speeds recovery and halves the risk of recurrence.
• Stomach protection with a proton pump inhibitor while taking anti-inflammatories.
• Rest from strenuous activity until symptoms and CRP settle.

Treatment is tapered gradually once symptoms resolve and CRP normalizes.

Second-line treatment

Corticosteroids (prednisone) at low to moderate doses are used if aspirin, NSAIDs and colchicine fail or cannot be used. They are not used first because they can increase the chance of recurrence.

Draining fluid

A large effusion causing cardiac tamponade, where pressure from fluid stops the heart filling, needs urgent drainage with a needle (pericardiocentesis) or surgery. Large pleural effusions may also need draining to ease breathing.

Prevention

Colchicine started around the time of cardiac surgery reduces postpericardiotomy syndrome in studies, although side effects such as diarrhea limit its use. Some surgical teams offer it to selected patients.

Complications

• Cardiac tamponade, particularly in people on blood thinners after valve surgery
• Recurrent pericarditis, returning weeks or months later
• Constrictive pericarditis, a rare late complication in which the pericardium stiffens and scars
• early blockage of bypass grafts has been linked to PCIS in some studies

Outlook

Most people recover fully within a few weeks of treatment. Recurrences happen in a minority and are managed with colchicine and tapering anti-inflammatories. Serious complications are uncommon when PCIS is recognized and treated promptly.

Frequently asked questions

What is postpericardiotomy syndrome?

It is inflammation of the sac around the heart, and often the lining of the lungs, that develops days to weeks after heart surgery that opened the pericardium. It causes chest pain, fever and fluid around the heart or lungs. It is thought to be an immune reaction, not an infection.

How soon after heart surgery does postpericardiotomy syndrome start?

It usually starts 1 to 6 weeks after surgery, but can appear as early as a few days or as late as 3 months. Symptoms that get worse after initial recovery, especially sharp chest pain with fever, should be reported to your cardiac team.

Is post-cardiac injury syndrome serious?

Usually not. Most cases respond well to anti-inflammatory medicines and colchicine within weeks. The main danger is a large buildup of fluid around the heart, called cardiac tamponade, which needs urgent drainage. Breathlessness, fainting or low blood pressure need emergency care.

Is post-cardiac injury syndrome the same as Dressler syndrome?

Dressler syndrome is one type of post-cardiac injury syndrome, occurring after a heart attack. PCIS also includes the more common postpericardiotomy syndrome after heart surgery and pericarditis after procedures such as pacemaker insertion, ablation or chest trauma.

Can it come back?

Yes. A minority of people have recurrences weeks or months later. Taking colchicine for the full course, tapering anti-inflammatories slowly and avoiding strenuous exercise until inflammation has settled reduce the risk.