Real-world performance of postpericardiotomy syndrome diagnostic criteria – an analysis of the prospective CAREBANK database

Objectives Postpericardiotomy syndrome (PPS) is a well-recognized postoperative complication in cardiac surgery. Current diagnostic criteria, however, seem to lack specificity and fail to account for common confounding factors encountered in clinical settings. This study evaluated the real-world performance of current PPS diagnostic criteria and their reliability in the presence of confounding conditions. Methods We examined the performance of current PPS diagnostic criteria in a prospective cohort of 1001 patients from the CAREBANK database who underwent cardiac surgery between 2016–2021 at a tertiary center. Considering clinical relevance together with the evaluation of coexisting confounding conditions, the patients fulfilling the criteria were divided into four categories: ‘Confirmed PPS’, ‘Likely PPS’, ‘Unlikely PPS’, and ‘Ruled out PPS’ (Figure 1). Results The incidence of ‘Confirmed PPS’ and ‘Likely PPS’ was 4.0% each, while ‘Unlikely PPS’ and ‘Ruled out PPS’ accounted for 8.7% and 83.3%, respectively. The median time to diagnosis was 42 (IQR 19–63) days for ‘Confirmed PPS’ and 24 (9–49) days for ‘Likely PPS’. Patients categorized as ‘Likely PPS’ or ‘Unlikely PPS’ exhibited more frequent comorbid conditions, represented by higher EuroSCORE II values (p=0.011), increased incidence of new-onset atrial fibrillation (p=0.007), delayed postoperative ventilation (p=0.011), and postoperative stroke (p=0.045), and elevated first-year mortality (HR 3.00, 95% CI 1.36–6.58, p=0.006, Figure 2). Surgical complexity also affected the occurrence of PPS: the incidence of ‘Confirmed PPS’ was lower among patients undergoing CABG (p=0.022), whereas ‘Likely PPS’ was more frequent in those undergoing MVR (p=0.043). Conclusions Accurate diagnosis of PPS is often challenged by overlapping clinical conditions, especially in patients with multiple comorbidities. The majority of patients fulfilling current PPS diagnostic criteria have confounding explanations rather than genuine inflammatory disease. The diagnostic pathway applied in this study better complies with real-world practice. It also separates the ‘Confirmed PPS’ and ‘Ruled out PPS,’ which allows the comparison between these two groups in future studies, making it possible to investigate more specifically the PPS cases driven by the underlying inflammatory mechanism.Figure 1Figure 2