Peculiarity of clinical course of postpericardiotomy syndrome in different methods of surgery and postoperative antithrombotic therapy

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.

1.

2. Imazio M, Brucato A, Ferrazzi P, Spodick DH, Adler Y. Postpericardiotomy syndrome: a proposal for diagnostic criteria. Journal of Cardiovascular Medicine. 2013;14(5):351–3. DOI: 10.2459/JCM.0b013e328353807d

3. van Osch D, Dieleman JM, Bunge JJ, van Dijk D, Doevendans PA, Suyker WJ et al. Risk factors and prognosis of postpericardiotomy syndrome in patients undergoing valve surgery. The Journal of Thoracic and Cardiovascular Surgery. 2017;153(4):878-885.e1. DOI: 10.1016/j.jtcvs.2016.10.075

4. Imazio M, Brucato A, Rovere ME, Gandino A, Cemin R, Ferrua S et al. Contemporary Features, Risk Factors, and Prognosis of the Post-Pericardiotomy Syndrome. The American Journal of Cardiology. 2011;108(8):1183–7. DOI: 10.1016/j.amjcard.2011.06.025

5. 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. Journal of the American Heart Association. 2018;7(22):e010269. DOI: 10.1161/JAHA.118.010269

6. Boyle EM, Gillinov AM, Cohn WE, Ley SJ, Fischlein T, Perrault LP. Retained Blood Syndrome after Cardiac Surgery: A New Look at an Old Problem. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2015;10(5):296–303. DOI: 10.1097/imi.0000000000000200

7. Valgimigli M, Bueno H, Byrne R, Collet J, Costa F, Jeppsson A et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Russian Journal of Cardiology. 2018;23(8):113–63. DOI: 10.15829/1560-4071-2018-8-113-163

8. Baumgartner H, Falk V, Bax J, De Bonis M, Hamm C, Holm PJ et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Russian Journal of Cardiology. 2018;23(7):103–55. DOI: 10.15829/1560-4071-2018-7-103-155

9. Ministry of Health of Russian Federation. Clinical guidelines. Postcardiotomy syndrome. I97.0. Av. at: https://racvs.ru/clinic/files/2020/postcardiotomy_syndrome.pdf. 2020.

10. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Russian Journal of Cardiology. 2016;21(5):117–62. DOI: 10.15829/1560-4071-2016-5-117-162

11. Lehto J, Gunn J, Björn R, Malmberg M, Airaksinen KEJ, Kytö V et al. Adverse events and survival with postpericardiotomy syndrome after surgical aortic valve replacement. The Journal of Thoracic and Cardiovascular Surgery. 2020;160(6):1446–56. DOI: 10.1016/j.jtcvs.2019.12.114

12. Lehto J, Gunn J, Karjalainen P, Airaksinen J, Kiviniemi T. Incidence and risk factors of postpericardiotomy syndrome requiring medical attention: The Finland postpericardiotomy syndrome study. The Journal of Thoracic and Cardiovascular Surgery. 2015;149(5):1324–9. DOI: 10.1016/j.jtcvs.2015.01.031

13. Van Osch D, Nathoe HM, Jacob KA, Doevendans PA, van Dijk D, Suyker WJ et al. Determinants of the postpericardiotomy syndrome: a systematic review. European Journal of Clinical Investigation. 2017;47(6):456–67. DOI: 10.1111/eci.12764

14. Köhler I, Saraiva PJ, Wender OB, Zago AJ. Behavior of inflammatory markers of myocardial injury in cardiac surgery: laboratory correlation with the clinical picture of postpericardiotomy syndrome. Arquivos Brasileiros de Cardiologia. 2003;81(3):285–90. DOI: 10.1590/S0066-782X2003001100008

15. Nishimura M, Goda N, Hatazawa K, Sakaguchi K. Delayed diagnosis of postcardiac injury syndrome. BMJ Case Reports. 2019;12(2):e228877. DOI: 10.1136/bcr-2018-228877

16. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Russian Journal of Cardiology. 2017;22(6):7–85. DOI: 10.15829/1560-4071-2017-6-7-85

17. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al. 2016 ESC Guidelines on management of atrial fibrillation developedin collaboration with EACTS. Russian Journal of Cardiology. 2017;22(7):7–86. DOI: 10.15829/1560-4071-2017-7-7-86

18. Nakatseva E.V., Moiseeva O.M., Titarenko O.T., Androsova M.V., Nikulina V.P. Postpericardiotomy syndrome after open heart surgery: modern diagnostic methods. Arterial Hypertension. 2008; 14(S1-2):23–8.

19. Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ et al. Dabigatran versus Warfarin in Patients with Mechanical Heart Valves. New England Journal of Medicine. 2013;369(13):1206–14. DOI: 10.1056/NEJMoa1300615