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need of additional medication and the risk of recurrence and severe complications&#44; such as cardiac tamponade&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This complication is treated with colchicine&#44; nonsteroidal anti-inflammatory drugs and steroids&#44; reserving intravenous immunoglobulin &#40;IVIG&#41; therapy for refractory cases&#46; A growing body of evidence in patients with recurrent idiopathic pericarditis demonstrates the usefulness of anakinra&#44; an antagonist of the receptor of interleukin-1&#946;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> a proinflammatory cytokine involved in innate immunity&#46; However&#44; this drug has not been used for treatment of severe refractory PPS to date&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present two cases of refractory postoperative PPS that required pericardiocentesis or drainage on account of the favourable outcomes associated with treatment with anakinra&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 1</span>&#58; boy aged 9 years with congenitally corrected transposition of the great arteries and complete heart block&#46; The patient underwent an initial surgery at age 4 years &#40;pulmonary artery banding and epicardial pacing&#41; and developed PPS&#44; which was treated with 2 cycles of prednisone &#40;2&#8239;mg&#47;kg&#47;day&#41;&#46; At 8 years he underwent a second surgery &#40;hemi-Mustard procedure&#44; band removal&#44; arterial switch and Glenn procedure&#41;&#44; and once again developed PPS&#46; The patient received ibuprofen and colchicine&#44; and on day 20 required addition of prednisone &#40;2&#8239;mg&#47;kg&#47;day&#41;&#46; The effusion progressed&#44; requiring performance of pericardiocentesis &#40;day 35 post surgery&#41; and leading to administration of IVIG &#40;2&#8239;g&#47;kg&#41;&#44; with no improvement after 3 doses&#46; On day 65 post surgery&#44; anakinra was added&#44; delivered by the subcutaneous route &#40;100&#8239;mg&#47;24&#8239;h&#8239;&#61;&#8239;2&#8239;mg&#47;kg&#47;day&#41;&#44; which achieved a significant reduction in the effusion&#46; Tapering off of anakinra started after 2 months of treatment&#44; with addition of prednisone at a low dose &#40;0&#46;1&#8239;mg&#47;kg&#47;day&#41;&#46; At 3 months&#44; anakinra and prednisone were discontinued&#44; followed by discontinuation of colchicine 4 months after&#46; The patient has attended follow-up visits at regular intervals and has not experienced a recurrence in 3 years&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 2</span>&#58; boy aged 10 years with severe mitral valve stenosis and mixed aortic valve disease &#40;moderate aortic valve and subaortic stenosis and mild regurgitation&#41;&#46; After cardiac surgery &#40;mitral and aortic valvuloplasty&#44; subaortic membrane resection&#41;&#44; the patient developed bilateral pleural effusion and pericardial effusion&#44; with a prolonged need of pleural drainage with removal of up to 1900&#8239;mL&#47;day&#46; He was treated with ibuprofen and colchicine&#46; During the postoperative period&#44; he developed severe mitral insufficiency due to a suture tear that required reintervention on day 22 post surgery&#46; Due to the persistence of pleural and pericardial effusion&#44; prednisone &#40;2&#8239;mg&#47;kg&#47;day&#41; and IVIG were added&#44; which were not effective&#46; Due to the lack of improvement&#44; anakinra was initiated on day 37 post surgery&#44; delivered subcutaneously at a dose of 100&#8239;mg per 24&#8239;h &#40;4&#8239;mg&#47;kg&#47;day&#41;&#44; which achieved resolution of pericardial effusion and a significant reduction of pleural effusion&#44; allowing removal of the drains and hospital discharge&#46; On month 3 post surgery&#44; prednisone was discontinued and tapering of anakinra started&#44; which was followed by an increase in the left-sided pleural effusion that required readmission to hospital&#46; We increased the dose of anakinra &#40;100&#8239;mg&#47;12&#8239;h&#41;&#44; which achieved a favourable response&#46; At present &#40;11 months post surgery&#41; mild pleural effusion persists in the left hemithorax&#44; and the patient remains in treatment with colchicine and low-dose prednisone&#44; tolerating the tapering of anakinra without complications &#40;current dose&#44; 100&#8239;mg&#47;72&#8239;h&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Both patients tolerated the drug well&#44; as they only developed local reactions at the site of injection in the first doses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Several hypotheses have been formulated to explain the pathogenesis of PPS&#44; including a systemic inflammatory response triggered by exposure of pericardial&#47;pleural structures to the immune system&#44; the presence of blood in the pericardial&#8211;pleural space or perioperative tissue hypoxia&#46; Tissue necrosis or mesothelial damage associated to traumatic injury or heart surgery may stimulate the release of autoantigens&#46; Patients that develop PPS exhibit elevation of various cytokines&#44; including interleukins 1&#44; 8 and 6&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Since interleukin 1 plays a key role in the development of inflammation&#44; blocking its activity could contribute to inhibiting the mechanisms involved in the pathogenesis of PPS&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although anakinra has proven effective in the management of recurrent idiopathic pericarditis&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> our literature search did not yield any studies that assessed its role in the management of severe refractory PPS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In our experience&#44; anakinra was effective and safe for treatment of patients with severe refractory PPS&#46; In the future&#44; performance of multicentre studies with larger samples will determine its efficacy for this indication&#46;</p></span>"
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Scientific Letter
Usefulness of interleukin 1 receptor antagonist (anakinra) in refractory post-pericardiotomy syndrome
Utilidad del bloqueo de interleucina 1 con anakinra en el síndrome pospericardiotomía refractario
Marta Flores Fernándeza,
Corresponding author
martafloresfdez@outlook.com

Corresponding author.
, Ana Caro Barria, Elena Montañés Delmása, Belén Toral Vázqueza, Jaime de Inocencio Arocenab
a Instituto Pediátrico del Corazón, Hospital Universitario 12 de Octubre, Madrid, Spain
b Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, Spain
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        "titulo" => "Utilidad del bloqueo de interleucina 1 con anakinra en el s&#237;ndrome pospericardiotom&#237;a refractario"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Postpericardiotomy syndrome &#40;PPS&#41; is an inflammation of the pericardium or pleura following a pericardial lesion&#44; which may result from&#44; among others&#44; heart surgery&#44; acute myocardial infarction or chest trauma&#46; It is defined based on the presence of at least 2 of the following criteria&#58; a&#41; fever with no alternative explanation&#59; b&#41; pleuritic&#47;pericardial chest pain&#59; c&#41; pericardial friction rub&#59; d&#41; pericardial effusion and e&#41; pleural effusion with elevation of C-reactive protein&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is considered persistent or refractory when the symptoms last longer than 4 weeks&#46; The incidence of pericarditis post pericardiotomy is of 10&#37;&#8211;25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its development entails a prolonged stay&#44; need of additional medication and the risk of recurrence and severe complications&#44; such as cardiac tamponade&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This complication is treated with colchicine&#44; nonsteroidal anti-inflammatory drugs and steroids&#44; reserving intravenous immunoglobulin &#40;IVIG&#41; therapy for refractory cases&#46; A growing body of evidence in patients with recurrent idiopathic pericarditis demonstrates the usefulness of anakinra&#44; an antagonist of the receptor of interleukin-1&#946;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> a proinflammatory cytokine involved in innate immunity&#46; However&#44; this drug has not been used for treatment of severe refractory PPS to date&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present two cases of refractory postoperative PPS that required pericardiocentesis or drainage on account of the favourable outcomes associated with treatment with anakinra&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 1</span>&#58; boy aged 9 years with congenitally corrected transposition of the great arteries and complete heart block&#46; The patient underwent an initial surgery at age 4 years &#40;pulmonary artery banding and epicardial pacing&#41; and developed PPS&#44; which was treated with 2 cycles of prednisone &#40;2&#8239;mg&#47;kg&#47;day&#41;&#46; At 8 years he underwent a second surgery &#40;hemi-Mustard procedure&#44; band removal&#44; arterial switch and Glenn procedure&#41;&#44; and once again developed PPS&#46; The patient received ibuprofen and colchicine&#44; and on day 20 required addition of prednisone &#40;2&#8239;mg&#47;kg&#47;day&#41;&#46; The effusion progressed&#44; requiring performance of pericardiocentesis &#40;day 35 post surgery&#41; and leading to administration of IVIG &#40;2&#8239;g&#47;kg&#41;&#44; with no improvement after 3 doses&#46; On day 65 post surgery&#44; anakinra was added&#44; delivered by the subcutaneous route &#40;100&#8239;mg&#47;24&#8239;h&#8239;&#61;&#8239;2&#8239;mg&#47;kg&#47;day&#41;&#44; which achieved a significant reduction in the effusion&#46; Tapering off of anakinra started after 2 months of treatment&#44; with addition of prednisone at a low dose &#40;0&#46;1&#8239;mg&#47;kg&#47;day&#41;&#46; At 3 months&#44; anakinra and prednisone were discontinued&#44; followed by discontinuation of colchicine 4 months after&#46; The patient has attended follow-up visits at regular intervals and has not experienced a recurrence in 3 years&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 2</span>&#58; boy aged 10 years with severe mitral valve stenosis and mixed aortic valve disease &#40;moderate aortic valve and subaortic stenosis and mild regurgitation&#41;&#46; After cardiac surgery &#40;mitral and aortic valvuloplasty&#44; subaortic membrane resection&#41;&#44; the patient developed bilateral pleural effusion and pericardial effusion&#44; with a prolonged need of pleural drainage with removal of up to 1900&#8239;mL&#47;day&#46; He was treated with ibuprofen and colchicine&#46; During the postoperative period&#44; he developed severe mitral insufficiency due to a suture tear that required reintervention on day 22 post surgery&#46; Due to the persistence of pleural and pericardial effusion&#44; prednisone &#40;2&#8239;mg&#47;kg&#47;day&#41; and IVIG were added&#44; which were not effective&#46; Due to the lack of improvement&#44; anakinra was initiated on day 37 post surgery&#44; delivered subcutaneously at a dose of 100&#8239;mg per 24&#8239;h &#40;4&#8239;mg&#47;kg&#47;day&#41;&#44; which achieved resolution of pericardial effusion and a significant reduction of pleural effusion&#44; allowing removal of the drains and hospital discharge&#46; On month 3 post surgery&#44; prednisone was discontinued and tapering of anakinra started&#44; which was followed by an increase in the left-sided pleural effusion that required readmission to hospital&#46; We increased the dose of anakinra &#40;100&#8239;mg&#47;12&#8239;h&#41;&#44; which achieved a favourable response&#46; At present &#40;11 months post surgery&#41; mild pleural effusion persists in the left hemithorax&#44; and the patient remains in treatment with colchicine and low-dose prednisone&#44; tolerating the tapering of anakinra without complications &#40;current dose&#44; 100&#8239;mg&#47;72&#8239;h&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Both patients tolerated the drug well&#44; as they only developed local reactions at the site of injection in the first doses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Several hypotheses have been formulated to explain the pathogenesis of PPS&#44; including a systemic inflammatory response triggered by exposure of pericardial&#47;pleural structures to the immune system&#44; the presence of blood in the pericardial&#8211;pleural space or perioperative tissue hypoxia&#46; Tissue necrosis or mesothelial damage associated to traumatic injury or heart surgery may stimulate the release of autoantigens&#46; Patients that develop PPS exhibit elevation of various cytokines&#44; including interleukins 1&#44; 8 and 6&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Since interleukin 1 plays a key role in the development of inflammation&#44; blocking its activity could contribute to inhibiting the mechanisms involved in the pathogenesis of PPS&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although anakinra has proven effective in the management of recurrent idiopathic pericarditis&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> our literature search did not yield any studies that assessed its role in the management of severe refractory PPS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In our experience&#44; anakinra was effective and safe for treatment of patients with severe refractory PPS&#46; In the future&#44; performance of multicentre studies with larger samples will determine its efficacy for this indication&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Flores Fern&#225;ndez M&#44; Caro Barri A&#44; Monta&#241;&#233;s Delm&#225;s E&#44; Toral V&#225;zquez B&#44; de Inocencio Arocena J&#46; Utilidad del bloqueo de interleucina 1 con anakinra en el s&#237;ndrome pospericardiotom&#237;a refractario&#46; An Pediatr &#40;Barc&#41;&#46; 2021&#59;95&#58;199&#8211;200&#46;</p>"
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ISSN: 23412879
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