Challenges in the management of post-pericardiotomy syndromes

We thank Aldajani for the insightful comments on our paper regarding the diagnosis and management of post-pericardiotomy constrictive pericarditis.1 Post-pericardiotomy syndrome (PPS) is a subgroup of post-cardiac injury syndrome (PCIS) and is an independent risk factor for the development of constrictive pericarditis (CP). There is limited data within the literature to provide clear consensus on the treatment of PPS given heterogeneity in severity, clinical recognition, and prognosis in the postoperative period. Indeed, the prognosis of PPS is often good2 which may contribute to the lack of clinical recognition. However, a small number of cases can progress to developing CP which can be life-threatening. As highlighted by Aldajani, the ESC guidelines3 recommend anti-inflammatory therapy for PCIS. There are a number of limitations which should be considered when interpreting these guidelines. Firstly, the recommendations offer a treatment algorithm similar to that of idiopathic pericarditis and the efficacy/safety of these treatments within the PPS subgroup is assumed but not proven. In fact, the recommendations for anti-inflammatory use in PPS are driven by studies on other forms of PCIS or other aetiologies of acute, recurrent, or persistent pericarditis. Differences within the pathogenesis and underlying mechanisms between these sub-groups exist and further data are required before a definitive treatment algorithm can be formulated for PPS. Secondly, varying severity within the PPS subgroup is another consideration. While most cases of PPS carry a relatively benign course, there are a number of cases which may progress to clinically severe disease. Surgery is not recommended for patients with mild or end-stage disease with end-organ consequences such as cachexia.4 For patients with severe cases, such as in our patient, it is recommended that surgery should be considered earlier to reduce mortality.3,4 The work of Andreis et al.5 studied Anakinra in 39 patients with incessant or recurrent pericarditis concluding that ‘anakinra may have a role in CP reversal’. These results must be interpreted with caution given the relatively small cohort and only five of the studied patients were within the PCIS subgroup. Additionally, the safety of anakinra within the postoperative setting has not been established. In summary, there are limited data guiding management for patients with PPS complicated by CP. Surgical intervention is high risk and should be reserved for patients with severe cases of CP. Discussion within a local heart team could help guide management according to local expertise. Funding: The work reflected in this manuscript was the independent work of the involved authors.