WORKUP	Section 5 of 10
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Lab Studies:

• Complete blood cell count: The expected findings are leukocytosis with a leftward shift.

• As with other patients with suspected inflammatory versus infectious conditions, obtain blood cultures early in the workup. The results of the blood cultures should be negative.

• Acute phase reactants, such as an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, show an elevation.

• Antiheart antibodies are usually present in a high titer.

• Cardiac enzyme testing is usually not helpful because the results vary; also, studies have reported no difference in enzyme levels compared with patients who underwent cardiopulmonary bypass that do not have clinical signs of PPS.

• If a pericardial drain is placed, the fluid should be sent for cell count, differential, cytology, culture, gram stain, triglycerides, and total protein.

Imaging Studies:

• Chest radiography may be helpful in diagnosing PPS.

• The chest radiograph usually reveals blunting of the costophrenic angles due to a pleural effusion. A pericardial effusion enlarges the cardiac silhouette.

• The cardiac silhouette enlarges in proportion to the amount of fluid contained in the pericardial sac.

• Echocardiography is the diagnostic standard. It is a much more sensitive imaging study than plain radiography.

• In the early stages of PPS, a small amount of fluid may be detected posterior to the left ventricle during systole.

• With increasing fluid accumulation, detection by means of echocardiography becomes easier.

• Specific echocardiographic criteria indicate impending or established cardiac tamponade.

• Echocardiography assists in differentiating suspected PPS from congestive heart failure. Echocardiography is particularly helpful in evaluating ventricular contractility.

• Cardiac magnetic resonance imaging has been used more frequently to evaluate cardiac dynamics and pericardial abnormalities.

• Cardiac magnetic resonance imaging may be more helpful in identifying posterior pericardial fluid collections that may have become loculated and not easily viewed with trans-thoracic echocardiography.

Other Tests:

• Electrocardiography (ECG) produces abnormal findings in PPS. Initial findings may simulate pericarditis, with global ST segment elevation and T-wave inversion.

• Subepicardial injury, resulting from myocardial inflammation, causes ST segment elevation.

• The ECG may also demonstrate low QRS amplitude, especially with a large pericardial effusion.

Procedures:

• Tamponade is a life-threatening condition that can result from PPS. The inflammatory changes seen with PPS may cause pericardial adhesions resulting in a localized tamponade.

• Pericardiocentesis may be required emergently if cardiac tamponade is present.

• The standard subxiphoid approach is recommended. Because of the possible localized nature of the tamponade, using echocardiographic guidance is recommended. Echo-guided pericardiocentesis with extended catheter drainage is considered the primary management for patients with clinically significant pericardial effusions. The drainage tube is usually left in place for 24-48 hours, during which anti-inflammatory treatment is initiated.

	TREATMENT	Section 6 of 10
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Medical Care: Evaluation of patients with suspected PPS is usually performed in an outpatient setting. The workup and treatment may continue on an outpatient basis if the patient is not hemodynamically affected. Patients with symptoms indicating tamponade must be admitted to hospital for definitive care.

Surgical Care: Immediate pericardiocentesis is necessary to relieve life-threatening cardiac tamponade. A surgically placed pericardial window may be necessary in patients with persistent symptoms or relapse after medical therapy. Involvement of a cardiothoracic surgeon is indicated in patients with symptoms refractory to medical management.

Consultations:

• Consult a pediatric cardiologist to diagnose and treat as well as to follow care of patients with PPS.

• Consult a pediatric cardiothoracic surgeon in cases of patients with persistent symptoms or relapse after medical therapy. These patients may require a pericardial window.

Diet:

• Patients usually have decreased appetite.

• Special dietary restrictions are usually not required in patients with PPS.

Activity:

• Patients with suspected or confirmed PPS should avoid strenuous activity.

• Bed rest alone may be adequate to treat mild cases. Enforce strict bed rest until the fever has resolved and chest radiography and ECG represent near baseline studies.

	MEDICATION	Section 7 of 10
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The mainstay of medical therapy is use of anti-inflammatory agents. A variety of drugs are available, all having similar efficacy. Corticosteroids are often used in more severe or refractory cases. Corticosteroids have resulted in rapid improvement in clinical symptoms and decrease in antiheart antibodies. No evidence exists that pre-cardiopulmonary bypass steroids reduce the risk of developing PPS. One case has been reported of low-dose methotrexate used in PPS refractory to standard therapy but has not been further supported.

	MISCELLANEOUS	Section 9 of 10
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Medical/Legal Pitfalls:

• Failure to diagnose or adequately treat PPS

• Failure to diagnose or treat impending or manifest cardiac tamponade