Risk factors and prognosis of postpericardiotomy syndrome

Postpericardiotomy syndrome (PPS) is a common complication after cardiac surgery. In most cases it develops within two to three weeks after the surgery and the typical symptoms include dyspnea, chest pain, and fever. An immunological mechanism is suspected as the cause of the disease. The disease process is usually self-limiting. Even though PPS occasionally requires invasive interventions, the prognosis of the disease is considered to be benign. This thesis investigated the incidence of clinically significant PPS, the risk factors for the disease, and the effect of operation type on the occurrence of the disease. Furthermore, the mortality of PPS patients was investigated. The results suggest that although the course of PPS is mostly benign, PPS requiring invasive interventions is associated with increased mortality. The syndrome had no significant impact on the occurrence of atrial fibrillation, cerebrovascular events, or bleeding episodes. The results also demonstrate that the incidence of clinically significant PPS is markedly lower compared to the diagnoses included in previous studies concerning the medical treatment of the disease. The use of red blood cell units, female sex, and younger age were identified as predisposing factors for PPS. Valve procedures and especially aortic procedures represented higher occurrence of the disease when compared to coronary artery bypass surgery. Moreover, PPS was less common in patients with diabetes. The results demonstrate that the majority of the PPS diagnoses included in recent studies are clinically irrelevant. The knowledge concerning the predisposing factors, such as younger age, female sex, and specific operation types, may be useful for the targeting of prophylactic methods. In contrast with the previous conception, PPS requiring the evacuation of pericardial or pleural effusion is associated with higher mortality. The results suggest that PPS patients requiring invasive interventions are in the need of more intensive follow-up and treatment.Postperikardiotomiaoireyhtymä (PPS) on yleinen sydänleikkauksen jälkeinen komplikaatio. Taudin tyypilliseen oireistoon kuuluu kahdesta kolmeen viikkoa sydänleikkauksen jälkeen ilmaantuva hengenahdistus, rintakipu ja lämpöily. Taudin aiheuttajaksi epäillään immunologista mekanismia. Tautiprosessi rajoittuu yleensä itsestään. Vaikka PPS:n hoito vaatii joissain tapauksissa kajoavia hoitotoimenpiteitä, on sen ennustetta pidetty hyvänlaatuisena. Tässä väitöskirjassa tutkittiin kliinisesti merkittävän PPS:n ilmaantuvuutta ja riskitekijöitä sekä leikkaustyypin vaikutusta taudin ilmaantuvuuteen. Lisäksi tutkittiin PPS:n vaikutusta potilaiden ennusteeseen. Tämä tutkimus osoittaa, että vaikka PPS:n ennuste on pääosin hyvänlaatuinen, kajoavaa hoitoa vaativa PPS on yhteydessä lisääntyneeseen kuolleisuuteen. Oireyhtymä ei ollut merkittävästi yhteydessä eteisvärinän, aivotapahtumien tai vuototapahtumien ilmaantuvuuteen. Tulokset osoittavat myös, että kliinisesti merkittävän PPS:n määrä on selvästi pienempi kuin taudin määrä viimeaikaisissa PPS:n lääkehoitoa koskevissa tutkimuksissa. Verituotteiden käytön, naissukupuolen ja nuoremman iän todettiin altistavan taudin kehittymiselle. Leikkaustyypeistä läppäleikkaukset ja erityisesti aortan toimenpiteet olivat yhteydessä taudin lisääntyneeseen ilmaantuvuuteen sepelvaltimoiden ohitusleikkaukseen verrattuna. Lisäksi diabeteksen todettiin merkittävästi vähentävän taudin ilmaantuvuutta. Tulokset osoittavat, että valtaosa viimeaikaisten tutkimusten PPS-diagnooseista on kliinisesti merkityksettömiä. Tieto taudille altistavista tekijöistä, kuten nuorempi ikä, naissukupuoli ja tietyt leikkaustyypit, voi olla hyödyllistä, kun valitaan kohteita taudin ennaltaehkäiseville toimille. Aiemmasta käsityksestä poiketen PPS on yhteydessä lisääntyneeseen kuolleisuuteen. Vaikka löydöksen syitä on tutkittava vielä lisää, tulosten perusteella kajoavaa hoitoa vaativat PPS-potilaat ovat kuolemanvaarassa ja tarvitsevat siksi nykyistä intensiivisempää hoitoa ja seurantaa

Postpericardiotomy syndrome after cardiac surgery

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

Occurrence of Postpericardiotomy Syndrome: Association With Operation Type and Postoperative Mortality After Open-Heart Operations

BackgroundPostpericardiotomy 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 ResultsWe 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; PPPPP=0.014).ConclusionsThe 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.</p

Indications and predictors for pacemaker implantation after isolated aortic valve replacement with bioprostheses : the CAREAVR study

OBJECTIVES: We sought to study the indications, long-term occurrence, and predictors of permanent pacemaker implantation (PPI) after isolated surgical aortic valve replacement with bioprostheses. METHODS: The CAREAVR study included 704 patients (385 females, 54.7%) without a preoperative PPI (mean +/- standard deviation age 75 +/- 7years) undergoing isolated surgical aortic valve replacement at 4 Finnish hospitals between 2002 and 2014. Data were extracted from electronic patient records. RESULTS: The follow-up was median 4.7years (range 1day to 12.3years). Altogether 56 patients received PPI postoperatively, with the median 507days from the operation (range 6days to 10.0years). The PPI indications were atrioventricular block (31 patients, 55%) and sick sinus syndrome (21 patients, 37.5%). For 4 patients, the PPI indication remained unknown. A competing risks regression analysis (Fine-Gray method), adjusted with age, sex, diabetes, coronary artery disease, preoperative atrial fibrillation (AF), left ventricular ejection fraction, New York Heart Association class, AF at discharge and urgency of operation, was used to assess risk factors for PPI. Only AF at discharge (subdistribution hazard ratio 4.34, 95% confidence interval 2.34-8.03) was a predictor for a PPI. CONCLUSIONS: Though atrioventricular block is the major indication for PPI after surgical aortic valve replacement, >30% of PPIs are implanted due to sick sinus syndrome during both short-term follow-up and long-term follow-up. Postoperative AF versus sinus rhythm conveys >4-fold risk of PPI.Peer reviewe

Preoperative paroxysmal atrial fibrillation predicts high cardiovascular mortality in patients undergoing surgical aortic valve replacement with a bioprosthesis: CAREAVR study

Background Preoperative permanent atrial fibrillation (AF) is associated with impaired outcome after surgical aortic valve replacement (SAVR). The impact of preoperative paroxysmal AF, however, has remained elusive. Purpose We assessed the impact of preoperative paroxysmal AF on outcome in patients undergoing SAVR with bioprosthesis. Methods A total of 666 patients undergoing isolated AVR with a bioprosthesis were included. Survival data was obtained from the national registry Statistics Finland. Patients were divided into three groups according to the preoperative rhythm: sinus rhythm (n = 502), paroxysmal AF (n = 90), and permanent AF (n = 74). Results Patients in the sinus rhythm and paroxysmal AF groups did not differ with respect to age (P = .484), gender (P = .402) or CHA(2)DS(2)-VASc score (P = .333). At 12-month follow-up, AF was present in 6.2% of sinus rhythm patients and in 42.4% of paroxysmal AF patients (P <.001). During follow-up, incidence of fatal strokes in the paroxysmal AF group was higher compared to sinus rhythm group (1.9 vs 0.4 per 100 patient-years, HR 4.4 95% Cl 1.8-11.0, P = .001). Cardiovascular mortality was higher in the paroxysmal AF group than in the sinus rhythm group (5.0 vs 3.0 per 100 patient-years, HR 1.70 95% CI 1.05-2.76, P = .03) and equal to patients in the permanent AF (5.0 per 100 patient-years). Conclusion Patients undergoing SAVR with bioprosthesis and history of paroxysmal AF had higher risk of developing permanent AF, cardiovascular mortality and incidence of fatal strokes compared to patients with preoperative sinus rhythm. Life-long anticoagulation should be considered in patients with a history of preoperative paroxysmal AF.Peer reviewe

Adverse events and survival with postpericardiotomy syndrome after surgical aortic valve replacement

Peer reviewe

Late incidence and recurrence of new-onset atrial fibrillation after isolated surgical aortic valve replacement

Publisher Copyright: © 2021 The AuthorsObjectives: Atrial fibrillation (AF) is a common complication after cardiac surgery. More knowledge is needed about long-term AF recurrence and adverse outcomes related to new-onset AF (NOAF) during the index hospitalization. Methods: A total of 1073 patients underwent isolated surgical aortic valve replacement at the 4 participating hospitals (2002-2014). After the exclusion of patients with a history of any preoperative AF, the final study population included 529 patients in the bioprosthetic and 253 patients in the mechanical valve prosthesis cohort. Median follow-up time was 5.4 (interquartile range, 3.4-8.2) years in the combined cohort. Results: Altogether 333 (42.6%) patients had in-hospital NOAF and 250 (32.0%) AF after hospital discharge. In the mechanical cohort, 64 (25.3%) experienced in-hospital NOAF and 74 (29.2%) AF after hospital discharge, whereas in the bioprosthetic cohort, 269 (50.9%) patients had in-hospital NOAF and 176 (33.3%) AF after hospital discharge. Patients with NOAF during the index hospital stay had a multifold risk of AF after hospital discharge in the combined cohort (hazard ratio [HR], 3.68; 95% confidence interval [CI], 2.82-4.81; P <.0001) as well as in both cohorts separately (bioprosthetic: HR, 4.35; 95% CI, 3.05-6.22; P <.001; mechanical: HR, 2.54; 95% CI, 1.59-4.03; P <.001). Patients with an in-hospital NOAF also had a significantly higher adjusted risk of death during the follow-up in the mechanical (HR, 2.05; 95% CI, 1.10-3.82; P =.025) and bioprosthetic (HR, 1.63; 95% CI, 1.17-2.28; P =.004) valve prosthesis cohorts. Conclusions: NOAF during the index hospitalization is associated with a 2- to 4-fold risk of later AF and 1.6- to 2.0-fold risk of all-cause mortality after mechanical and bioprosthetic surgical aortic valve replacement.Peer reviewe

Red blood cell transfusion induces abnormal HIF-1 alpha response to cytokine storm after adult cardiac surgery

Patients undergoing cardiac surgery develop a marked postoperative systemic inflammatory response. Blood transfusion may contribute to disruption of homeostasis in these patients. We sought to evaluate the impact of blood transfusion on serum interleukin-6 (IL-6), hypoxia induced factor-1 alpha (HIF-1 alpha) levels as well as adverse outcomes in patients undergoing adult cardiac surgery. We prospectively enrolled 282 patients undergoing adult cardiac surgery. Serum IL-6 and HIF-1 alpha levels were measured preoperatively and on the first postoperative day. Packed red blood cells were transfused in 26.3% of patients (mean 2.93 +/- 3.05 units) by the time of postoperative sampling. Postoperative IL-6 levels increased over 30-fold and were similar in both groups (p = 0.115), whilst HIF-1 alpha levels (0.377 pg/mL vs. 0.784 pg/mL, p = 0.002) decreased significantly in patients who received red blood cell transfusion. Moreover, greater decrease in HIF-1 alpha levels predicted worse in-hospital and 3mo adverse outcome. Red blood cell transfusion was associated with higher risk of major adverse outcomes (stroke, pneumonia, all-cause mortality) during the index hospitalization. Red blood cell transfusion induces blunting of postoperative HIF-1 alpha response and is associated with higher risk of adverse thrombotic and pulmonary adverse events after cardiac surgery.Peer reviewe

Adverse events and survival with postpericardiotomy syndrome after surgical aortic valve replacement

ObjectivesPostpericardiotomy syndrome (PPS) is a relatively common complication after cardiac surgery. However, long-term follow-up data on the adverse events and mortality of PPS patients requiring invasive interventions are scarce.MethodsWe sought to assess the occurrence of mortality, new-onset atrial fibrillation (AF), cerebrovascular events, and major bleeds in PPS patients requiring medical attention in a combination database of 671 patients who underwent isolated surgical aortic valve replacement with a bioprosthesis (n = 361) or mechanical prosthesis (n = 310) between 2002 and 2014 (Cardiovascular Research Consortium—A Prospective Project to Identify Biomarkers of Morbidity and Mortality in Cardiovascular Interventional Patients [CAREBANK] 2016-2018). PPS was defined as moderate if it resulted in delayed hospital discharge, readmission, or medical therapy because of the symptoms; and severe if it required interventions for the evacuation of pleural or pericardial effusion.ResultsThe overall incidence of PPS was 11.2%. Median time to diagnosis was 16 (interquartile range, 11-36) days. Severe PPS was diagnosed in 3.6% of patients. Severe PPS seemed to be associated with higher mortality (hazard ratio, 2.01; 95% confidence interval, 1.03-3.91; P = .040). Moderate or severe PPS increased the risk of new-onset AF during the early postoperative period (hazard ratio, 1.72; 95% confidence interval, 1.12-2.63; P = .012). No significant associations were found between PPS and cerebrovascular events or major bleeds during the follow-up.ConclusionsPatients with PPS requiring invasive interventions are at increased risk for mortality unlike those with mild to moderate forms of the disease. PPS requiring medical attention is associated with a higher AF rate during the early postoperative period but has no significant effect on the occurrence of major stroke, stroke or transient ischemic attack, or major bleeds during long-term follow-up.</div

Red blood cell transfusion induces abnormal HIF-1 alpha response to cytokine storm after adult cardiac surgery

Patients undergoing cardiac surgery develop a marked postoperative systemic inflammatory response. Blood transfusion may contribute to disruption of homeostasis in these patients. We sought to evaluate the impact of blood transfusion on serum interleukin-6 (IL-6), hypoxia induced factor-1 alpha (HIF-1 alpha) levels as well as adverse outcomes in patients undergoing adult cardiac surgery. We prospectively enrolled 282 patients undergoing adult cardiac surgery. Serum IL-6 and HIF-1 alpha levels were measured preoperatively and on the first postoperative day. Packed red blood cells were transfused in 26.3% of patients (mean 2.93 +/- 3.05 units) by the time of postoperative sampling. Postoperative IL-6 levels increased over 30-fold and were similar in both groups (p = 0.115), whilst HIF-1 alpha levels (0.377 pg/mL vs. 0.784 pg/mL, p = 0.002) decreased significantly in patients who received red blood cell transfusion. Moreover, greater decrease in HIF-1 alpha levels predicted worse in-hospital and 3mo adverse outcome. Red blood cell transfusion was associated with higher risk of major adverse outcomes (stroke, pneumonia, all-cause mortality) during the index hospitalization. Red blood cell transfusion induces blunting of postoperative HIF-1 alpha response and is associated with higher risk of adverse thrombotic and pulmonary adverse events after cardiac surgery