Early experience with pericardiectomy for constrictive pericarditis in Ile-Ife, Nigeria: a retrospective analysis

Invited commentary

RARE CASE OF CONSTRICTIVE PERICARDITIS SECONDARY TO METASTATIC SQUAMOUS CELL CARCINOMA

Contemporary Etiologies, Risk Factors, and Outcomes After Pericardiectomy

Background: Patients with constrictive pericarditis can be treated by pericardiectomy by either left anterolateral thoracotomy or median sternotomy. The terms “radical,” “total,” “extensive,” “complete,” “subtotal,” “adequate,” “near-total,” and partial pericardiectomy have been used often without much clarity. We describe our experience with a radical pericardiectomy technique via modified left anterolateral thoracotomy and compare the same to total pericardiectomy via median sternotomy. Methods: In this study, 67 (54.9%) patients underwent radical pericardiectomy via modified left anterolateral thoracotomy (Group I), and 55 (45.1%) patients underwent total pericardiectomy via median sternotomy (Group II). Results: The operative mortalities were 2.9% and 7.2% for the radical and total pericardiectomy groups, respectively. The time taken for normalization to Class I/II in Groups I and II was 30 ± 11 and 36 ± 14 days, respectively (P = 0.009). Surgical techniques did not affect the outcome of atrial fibrillation (P = 0. 77). Reoperation was not required for any patient. The radical pericardiectomy was also associated with less postoperative low cardiac output state as compared to patients undergoing total pericardiectomy (P < 0.001). There was no difference in mean duration of hospitalization; however, the radical pericardiectomy group achieved the New York Heart Association I and II Status quicker than the total pericardiectomy group (P = 0. 009). Conclusions: We conclude that using several technical modifications of pericardial excision, it is possible to achieve radical pericardiectomy via modified left anterolateral thoracotomy, particularly removing the constricting pericardium over the anterolateral, diaphragmatic surfaces of left ventricle and the anterior and diaphragmatic surfaces of the right ventricle until the right atrioventricular groove without using cardiopulmonary bypass in the great majority of patients undergoing pericardiectomy for chronic constrictive pericarditis. Although the surgical approach for pericardiectomy is based on surgeon's preference, left anterolateral thoracotomy is the preferred and noncontroversial approach in the setting of purulent pericarditis and effusive constrictive pericarditis to prevent sternal infection. We recommend median sternotomy approach with or without cardiopulmonary bypass, in the setting of calcific pericardial patches, pericardial masses, reoperations, and calcific pericardial “cocoon” and for those with predominant right-sided and annular involvement.

Although rare, constrictive pericarditis is a serious condition with debilitating symptoms and often severe heart failure. Total pericardiectomy is the most effective treatment and is traditionally performed via median sternotomy. With the increasing use of minimally invasive techniques, there have been reports of partial pericardiectomy via thoracoscopy but with suboptimal exposure and difficulty identifying both phrenic nerves. Robotic surgery offers both small incisions and enhanced visualization. We present four cases of robotic endoscopic off-pump total pericardiectomy for constrictive pericarditis. Four patients underwent off-pump total pericardiectomy with robotic assistance for constrictive pericarditis. All had constrictive physiology demonstrated by right heart catheterization and/or echocardiogram. One was also found to have coronary artery disease and underwent concurrent totally endoscopic coronary artery bypass grafting left internal mammary artery to left anterior descending artery. Ports were placed in the left second, fourth, and sixth intercostal spaces. The left lung was isolated and deflated with CO2 insufflation, aiding in exposure. With the use of electrocautery, the pericardium was removed first posterior to the left phrenic nerve, then anteriorly all the way to the right phrenic nerve, and caudally from the diaphragmatic reflection to the great vessel cephalad. A stabilizer in the subcostal fourth robotic arm was used to assist in the dissection. Two of four patients were extubated within 6 hours after surgery and transferred to the floor on postoperative day 1. Both were discharged home by postoperative day 5. Two of four patients had preoperative sequelae from chronic constriction and necessitated longer hospital and intensive care unit stays but had improvement in symptoms and were discharged home within 3 weeks. Total pericardiectomy for constrictive pericarditis can be performed using a robotic approach. In contrast to thoracoscopy, it offers better visualization of both phrenic nerves, avoids injury, and allows a thorough pericardial dissection. In our experience, the robotic left chest approach has proven more efficacious in removing the posterior pericardium than is allowed with median sternotomy.

Etiologic spectrum of constrictive pericarditis in our era and correlations with its clinical presentation

Constrictive pericarditis (CP) is characterized by impaired diastolic cardiac function leading to heart failure. Pericardiectomy is considered effective treatment for CP, but data on long-term clinical outcomes after pericardiectomy are limited. We retrospectively investigated 45 consecutive patients (mean age, 59±14 years) who underwent pericardiectomy for CP. Preoperative clinical factors, parameters of cardiac catheterization, and cardiac events were examined. Cardiac events were defined as hospitalization owing to heart failure or cardiac death.Median follow-up was 5.7 years. CP etiology was idiopathic in 16 patients, post-cardiac surgery (CS) in 21, tuberculosis-related in 4, non-tuberculosis infection-related in 2, infarction-related in 1, and post-radiation in 1. The 5-year event-free survival was 65%. Patients with idiopathic CP and tuberculosis-related CP had favorable outcomes compared with post-CS CP (5-year event-free survival: idiopathic, 80%; tuberculosis, 100%; post-CS, 52%). Higher age (hazard ratio: 2.51), preoperative atrial fibrillation (3.25), advanced New York Heart Association class (3.92), and increased pulmonary artery pressure (1.06) were predictors of cardiac events. Patients with postoperative right-atrial pressure ≥9 mmHg had lower event-free survival than those with right-atrial pressure <9 mmHg (39% vs. 75% at 5 years, P=0.013). Long-term clinical outcomes after pericardiectomy among a Japanese population were related to the underlying etiology and the patient's preoperative clinical condition. Postoperative cardiac catheterization may be helpful in the prediction of prognosis after pericardiectomy.

Chronic constrictive pericarditis treated with pericardiectomy

Constrictive pericarditis is a rare disease with a challenging diagnosis and treatment. Tuberculous pericarditis accounts to 1-2% of the cases in the United States, but is the most common cause in other countries. We report a 17-year-old male presenting with right heart failure. His initial work up that included an Electrocardiogram, chest roentgenogram and echocardiogram suspected constrictive pericarditis. Right heart catheterization and cardiac MRI confirmed the diagnosis. Total Pericardiectomy was performed. Tissue PCR showed tuberculous pericarditis and the patient was treated with anti-tuberculous drugs for 9 months. Tuberculosis is a common cause of constrictive pericarditis especially in developing countries, whereas in developed countries most cases are idiopathic. To note that the diagnosis of tuberculous pericarditis can be difficult especially in negative PPD patients However It remains a common cause of constrictive pericarditis in some parts of the world where a high index of suspicion is requested. The treatment is curative and thus an aggressive approach in diagnosis and treatment is indicated.

Case Reports1 February 1957CONSTRICTIVE PERICARDITIS AS SEQUEL TO HEMOPERICARDIUM: REPORT OF A CASE FOLLOWING ANTICOAGULANT THERAPYMAURICE H. LASZLO, M.D.MAURICE H. LASZLO, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-46-2-403 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe various causes of constrictive pericarditis have as yet not been thoroughly elucidated. Indeed, there is a wide divergence in various studies with respect to the incidence of the several known etiologic factors.1-4Undoubtedly tuberculous pericarditis is a fairly common precursor of constrictive pericarditis; pyogenic agents, polyserositis and previous nonspecific acute pericarditis are also at times implicated as causative factors. In addition, there still remains a large group of cases of indeterminate cause where the pathology of the pericardium, as found at surgery or autopsy, throws no light on the etiology. For example, no etiologic agent could be demonstrated in...Bibliography1. PaulCastlemanWhite OBPD: Chronic constrictive pericarditis: a study of 53 cases, Am. J. M. Sc. 216: 361, 1948. CrossrefMedlineGoogle Scholar2. AndrewsPickeringSellors GWGWTH: The aetiology of constrictive pericarditis with special reference to tuberculous pericarditis, together with a note on polyserositis, Quart. J. Med. 17: 291, 1948. MedlineGoogle Scholar3. ChamblissJaruszewskiBrofmanMartinFeil JREJBLJFH: Chronic cardiac compression (chronic constrictive pericarditis), Circulation 4: 816, 1951. CrossrefMedlineGoogle Scholar4. Moschcowitz E: Pathogenesis of constrictive pericardium, J. A. M. A. 153: 194, 1953. CrossrefMedlineGoogle Scholar5. Nichol ES: The risk of hemorrhage in anticoagulant therapy, Ann. West. 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OverholtBurwellWoodburyWalker RHCSJWJH: Constrictive pericarditis and constrictive pleuritis treated by pericardiectomy and pulmonary decortication, J. Thoracic Surg. 23: 1, 1952. CrossrefGoogle Scholar21. ElkinCampbell DCRE: Cardiac tamponade: treatment by aspiration, Ann. Surg. 133: 623, 1951. CrossrefMedlineGoogle Scholar22. MaguireGage CHM: A discussion of cardiac tamponade: treatment by aspiration, by Elkin, D. C., and Campbell, R. E.21 Google Scholar23. EhrenhaftTaber JLRE: Hemopericardium and constrictive pericarditis, J. Thoracic Surg. 24: 355, 1952. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: New York, N. Y.*Received for publication February 24, 1956.From the Medical Service of the United States Public Health Service Hospital, Memphis, Tennessee. The opinions expressed are those of the author and do not necessarily reflect those of the U. S. Public Health Service.Requests for reprints should be addressed to Maurice H. Laszlo, M. D., Montefiore Hospital, New York 67, N. Y. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byLeserbreif zum Artikel: Kardiogener Schock 4 Stunden nach akut-PTCA bei HinterwandinfarktEarly constrictive pericarditis and anemia after Dressler's syndrome and inferior wall myocardial infarction.Constrictive pericarditis after myocardial infarction.Constrictive pericarditis after myocardial infarction. 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Thirty year experience of constrictive pericarditis: one-hundred and forty cases with a long-term follow-up

Constrictive pericarditis is a slow progressive fibrosis of the pericardium leading to a variety of symptoms and signs over time. The disease poses a diagnostic challenge; restrictive cardiomyopathy and other syndromes associated with right-sided pressure abnormalities share similar symptoms and clinical findings. Pericardiectomy is considered the treatment of choice for constrictive pericarditis. Here we studied the effects of total radical pericardiectomy on hemodynamics in 37 patients diagnosed with constrictive pericarditis. Between 2005 and 2012 thirty-seven patients, 31 males and 6 females, age range 15 to 69 years, underwent total pericardiectomy for constrictive pericarditis. Diagnosis was made on the basis of clinical, pathological and diagnostic modalities-ECG, x-rays, magnetic resonance imaging, computed tomography and echocardiogram. The surgical approach was median sternotomy and surgery was conducted without cardiopulmonary bypass. Postoperative outcomes showed overall improvement in the majority of patients. Hemodynamics-stroke volume, cardiac output, ejection fraction, central venous pressure-were all measurably improved postoperatively. There was no postoperative mortality. Radical pericardiectomy is a demonstrably useful procedure for correction of hemodynamic abnormalities and improvement of overall heart function in symptomatic patients with constrictive pericarditis.

The operative mortality of pericardiectomy still is high. This retrospective study was conducted to determine the risk factors of early mortality and multiorgan failure. We retrospectively analyzed patients undergoing pericardiectomy from January 2009 to June 2020 at our hospital. Pericardiectomy was performed via sternotomy. Histopathologic studies of pericardium tissue from every patient were done. All survivors were monitored to the end date of the study. Ninety-two consecutive patients undergoing pericardiectomy for constrictive pericarditis were included in the study. Postoperatively, central venous pressure significantly decreased, and left ventricular end diastolic dimension and left ventricular ejection fractions significantly improved. The overall mortality rate was 5.4%. The common postoperative complications include acute renal injury (27.2%), and multiorgan failure (8.7%). Analyses of risk factors showed that fluid balance of the second day following operation is associated with early mortality and multiorgan failure. In this series from Guangxi, China, characteristic histopathologic features of tuberculosis (60/92, 65.2%) of pericardium were the most common histopathologic findings, and 32 patients (32/92, 34.8%) had the histopathologic findings of chronic nonspecific inflammatory changes. The functional status of the patients improved after pericardiectomy; 6 months later postoperatively 85 survivors were in class I (85/87, 97.7%) and two were in class II (2/87, 2.3%). Tuberculosis is the most common cause of constrictive pericarditis in Guangxi, China. Fluid balance of the second day following operation is associated with early mortality and multiorgan failure after pericardiectomy for constrictive pericarditis in our study.

The optimal extent of pericardial resection in constrictive pericarditis (CP) remains a subject of surgical debate. This study compared perioperative outcomes, postoperative right ventricular (RV) function, functional status, and long-term survival between total and partial pericardiectomy in a contemporaneous single-centre cohort. A retrospective analysis was performed on 102 consecutive patients undergoing pericardiectomy for CP at a single tertiary cardiac surgical centre between 2005 and 2025. Patients were stratified by operative extent into total pericardiectomy (n = 89) and partial pericardiectomy (n = 13). Preoperative, operative, and postoperative variables were compared. Long-term survival was assessed by Kaplan-Meier analysis with log-rank testing. Patients in the partial group were older (67 ± 11 vs 63 ± 12 years; P = .240) with higher operative risk by EuroSCORE II (7.2 ± 4.6 vs 4.9 ± 2.7; P = .010) and logistic EuroSCORE (14.5 ± 19.3 vs 5.6 ± 6.8; P <0.001). Urgent/emergency cases were more frequent in the partial group (61.5% urgent, 15.4% emergency vs 43.8% and 4.5%). Preoperative NYHA III-IV distribution was comparable (51.9% total vs 46.2% partial), as was preoperative RV function (P = .353). Despite greater operative complexity, total pericardiectomy confers significantly superior long-term survival and functional recovery compared with partial resection. These data support total pericardiectomy as the standard of care for durable relief of CP, with appropriately selected use of cardiopulmonary bypass to facilitate complete biventricular decortication.

Objective To evaluate the effect of anesthesia management based on regional cerebral oxygen saturation (rSO2)-bispectral index (BIS)-goal-directed hemodynamic multi-modal monitoring on acute kidney injury (AKI) after cardiac valve replacement. Methods A total of 238 patients of both sexes, aged 18-75 yr, weighing 45-95 kg, of American Society of Anesthesiologists physical status Ⅲ or Ⅳ (New York Heart Association class Ⅱ or Ⅲ ), undergoing elective cardiac valve replacement, were assigned into routine experience group (group C, n=122) and multi-mode monitoring group (group M, n=116) using a random number table method.After admission to the operating room, the invasive blood pressure of radial artery, central venous pressure, electrocardiogram, SpO2 and end-tidal pressure of carbon dioxide were recorded in group C, and rSO2, BIS, stroke volume variation, cardiac index and stroke volume index were monitored based on the monitoring in group C. The patients were tracheally intubated when BIS value was about 50.BIS value was maintained between 45 and 55, rSO2 was maintained not less than 20% of the baseline value or the absolute value not less than 55%, and fluctuation in mean arterial pressure did not exceed 20% of the baseline value, and stroke volume index was maintained >25 ml/m2 and cardiac index>2.5 L·min-1 ·m-2, maintaining not lower than the baseline value before induction in special conditions.The intraoperative volume of fluid infused, infusion of allogeneic blood, consumption of propofol, time of cardiopulmonary bypass, aortic cross-clamping time, anesthesia time, operation time, occurrence of AKI within 48 h after operation, renal replacement therapy, extubation time, duration of intensive care unit stay, postoperative length of hospital stay, development of other serious postoperative complications and fatality rate at day 30 after operation were recorded. Results Compared with group C, the incidence of AKI was significantly decreased, the volume of plasma infused and consumption of propofol were reduced, the extubation time, duration of intensive care unit stay and postoperative length of hospital stay were shortened (P 0.05). Conclusion Anesthesia management based on rSO2-BIS-goal-directed hemodynamic multi-modal monitoring can decrease the occurrence of AKI after cardiac valve replacement. Key words: Heart valve prosthesis implantation; Acute kidney injury; Monitoring, intraoperative; Brain; Oxygen; Electroencephalography; Hemodynamics