Postpericardiotomy Syndrome

What is Postpericardiotomy Syndrome?

Postpericardiotomy syndrome (PPS) is an inflammatory complication of cardiac surgery in which the pericardium, the sac around the heart, becomes inflamed.^[1] It is one of the common causes of pericarditis after cardiac procedures, and it usually appears in the days to weeks after the operation.^[2]

Common symptoms

PPS typically causes sharp chest pain that gets worse when breathing in or lying flat, often with fever.^[2] Fluid can collect around the heart (pericardial effusion) or the lungs (pleural effusion), which may cause shortness of breath. Tiredness and a general unwell feeling are also common.

In most people the course is mild and settles with treatment. A large effusion can occasionally press on the heart (cardiac tamponade), which is an emergency.^[2]

Causes and risk factors

The exact cause is not settled, but the syndrome is thought to be an inflammatory, immune-related response to surgical injury, with bleeding and clotting also possibly involved.^[3] Reviews of risk factors found that younger age, a pleural incision, and valve or aortic procedures were linked to a higher risk than bypass grafting.^[1] Reported rates range widely because studies have used different definitions: one review found a median of 16 percent, and prospective studies report 21 to 29 percent.^{[1, 3]}

How it is diagnosed and treated conventionally

Doctors diagnose PPS from your recent surgery, symptoms, a physical examination, blood markers of inflammation such as C-reactive protein, and imaging such as an echocardiogram.^{[1, 2]} Your surgical or cardiology team makes this diagnosis.

Treatment follows the approach for other pericarditis. High-dose NSAIDs are the first step and are tapered over several weeks, and a course of colchicine is added to relieve symptoms and lower the risk of recurrence.^[2] Corticosteroids are used if these do not work, and anti-interleukin-1 drugs are an option for repeated episodes.^{[2, 4]} A meta-analysis of 10 trials found colchicine reduced the incidence of PPS and recurrence of pericarditis, though it caused more side effects, mostly stomach upset.^[5] Fluid that threatens the heart is drained.^[2]

Why Postpericardiotomy Syndrome calls for a whole-person approach

PPS is a medical complication that needs medical treatment, yet recovery from heart surgery involves more than the pericardium. Pain, poor sleep, anxiety, low energy and medication side effects all affect how a person feels during the weeks of treatment.

Supportive care can address those parts of recovery. It does not treat the inflammation itself, and it cannot replace anti-inflammatory therapy or monitoring.

Inflammation and the immune response

Inflammation is central. Risk studies link PPS to markers of the inflammatory response and complement activation after surgery, and a review suggests that C-reactive protein and other inflammatory markers may help identify patients at higher risk.^{[3, 6]}

Bleeding and healing after surgery

Bleeding and clotting around the time of surgery may also play a part: blood transfusion and lower pre-operative hemoglobin were linked to a higher risk of PPS.^[3] This is one reason bleeding-related cautions matter for herbs and acupuncture after cardiac surgery.

Pain, sleep and recovery

Pain after chest surgery is common and can limit breathing and sleep, and sleep problems are common after illness. Both are reasonable targets for supportive care while the medical treatment continues.^{[7, 8]}

Acupuncture as supportive care in Postpericardiotomy Syndrome

What the research shows

We found no clinical trials of acupuncture in postpericardiotomy syndrome, so we cannot say it helps the syndrome. Evidence in related situations is limited.

Two meta-analyses of trials in which electroacupuncture was added to anesthesia during heart surgery found shorter ventilation and intensive care time and lower levels of some inflammatory markers. These came from 7 trials with 321 patients and 14 trials with 836 patients, and the authors of the larger review noted that most evidence was of low or moderate quality.^{[9, 10]} These treatments were given by hospital teams during surgery. They do not show that acupuncture prevents or treats PPS.

For pain, a trial of 100 patients after thoracoscopic (keyhole chest) surgery found that acupressure at two wrist points lowered pain scores compared with routine care alone, with no sham control.^[7] For sleep, a review of 24 trials in insomnia included a meta-analysis of 15 trials that suggested acupuncture improved sleep scores more than medication after about three weeks, with large variation between studies.^[8] These findings come from other patient groups and may not apply to PPS.

How acupuncture may work

In the cardiac surgery trials, electroacupuncture was associated with lower levels of tumor necrosis factor-alpha, an inflammatory marker, and of a marker of oxidative stress, though the certainty of evidence for these findings was low to moderate.^[10] This is an observed association, not a shown mechanism, and it has not been shown to work against PPS.

What treatment involves

Treatment uses fine, sterile, single-use needles at selected points, typically left in place for about 20 to 40 minutes. A course involves several visits with reassessment. Points on the arms, legs and ears are often used, and needling over the chest is not required.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[11] A review of case reports describes cardiac tamponade when needles were placed close to the heart, which is why anyone with pericardial effusion should tell the practitioner and avoid needling over the chest.^[12] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Tell the practitioner about any surgical wound that is still healing.

Ayurvedic medicine as supportive care in Postpericardiotomy Syndrome

The Ayurvedic view

Ayurveda has no classical name for this surgical complication. Traditional practitioners describe inflammation, fever and chest pain in terms of aggravated Pitta, and recovery after surgery in terms of rebuilding strength and digestion (agni). These are traditional frameworks, not biomedical diagnoses.

Therapies that may be used

Within a supportive role, care might include:

• Simple diet and daily routine advice, such as regular warm meals and steady sleep hours, in line with any heart or fluid restrictions from your physician
• Gentle relaxation and breathing practices for stress and sleep, if your cardiac team agrees
• Gentle oil massage away from surgical wounds once they have healed

Panchakarma procedures are not appropriate during recovery from surgery, acute illness, fever or frailty, so they are not a sensible option for PPS.

What the research shows

We found no studies of Ayurvedic medicine in postpericardiotomy syndrome or in recovery from cardiac surgery. The evidence is therefore none for this condition.

Product quality is a documented concern: about one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[13] Ayurvedic herbs are also herbal medications, so the perioperative cautions in the herbal section below apply to them as well.^[14]

Herbal medicine as supportive care in Postpericardiotomy Syndrome

Herbs and formulas that have been studied

We found no clinical studies of any herb or formula for PPS. Some herbs, such as turmeric, are traditionally used for inflammation, but a general reputation is not evidence for this syndrome.

What the research shows

There is no clinical evidence that herbal medicine treats PPS or eases its symptoms. We do not suggest herbs to replace NSAIDs, colchicine or other prescribed anti-inflammatory therapy.

Safety and herb-drug interactions

Safety comes first with herbs after heart surgery. Many herbs affect clotting and heart rhythm, and a review of perioperative herbal use reported that 50 to 70 percent of surgical patients do not tell their doctors about herbs.^[14] Guidance from anesthesia societies cited in that review is to stop herbal medicines 1 to 2 weeks before elective surgery, so any herb should be discussed with your surgeon.^[14]

Case reports describe bleeding when warfarin is combined with herbs such as Salvia miltiorrhiza (dan shen), garlic or ginkgo, and the same concern applies to antiplatelet drugs.^[15] NSAIDs also raise bleeding risk with blood thinners.^[16] A systematic review found that 45 herbs, foods and supplements were reported to potentiate warfarin.^[17] Tell us about all medicines, including NSAIDs, colchicine, steroids and blood thinners, and about pregnancy, breastfeeding, and liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine might describe the chest pain and fever of this syndrome as stagnation of qi and blood, or heat in the chest, while Ayurveda would speak of Pitta. Researchers instead describe an immune-driven inflammatory response after surgical injury, with complement activation, inflammatory markers, bleeding and effusion.^{[1, 3]}

The only loose parallel studied is anti-inflammatory: electroacupuncture around heart surgery was associated with lower levels of some inflammatory markers.^[10] No study has shown that a traditional pattern matches a measurable process in PPS.

How this care fits with your medical care

PPS needs your surgical or cardiology team. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. We offer supportive care only after the condition is under medical management.

Keep taking the medicines prescribed for you and keep your follow-up visits, echocardiograms and blood tests. Please bring your surgical report, diagnosis, recent test results and full medication and supplement list. We do not diagnose PPS, prescribe or change drugs, or advise on stopping colchicine, NSAIDs or steroids.

When to seek urgent medical care

Pericardial inflammation can cause serious complications, so call your care team promptly for new or worsening symptoms.^[2]

• New or worsening chest pain, especially sharp pain that changes with breathing or position
• Fever, or redness, drainage or opening of your surgical wound
• Increasing shortness of breath, or needing to sit upright to breathe
• Dizziness, fainting, a racing heartbeat or very low blood pressure
• Swelling of the legs, abdomen or neck veins
• Black stools or vomiting blood while taking anti-inflammatory medicines

If you have severe chest pain, fainting or severe breathlessness, call 911 or go to the nearest emergency department.