Partial Pericardectomy Research Articles

P042 A rare case of constrictive pericarditis with co-existing positive COVID-19: probable autoimmune or immunoglobulin related disease

Background/Aims Constrictive pericarditis occurs most commonly after idiopathic pericarditis (in less than 1%) in the developed world. Other uncommon aetiologies include tuberculosis, rheumatological diseases and post-viral pericarditis. Methods We present a case of an 80-year-old Caucasian man admitted with shortness of breath (NYHA III), skin rash, loss of weight and peripheral oedema. He had no other features of connective tissue disease (CTD) or vasculitis. His past medical history included atrial fibrillation, gout, hiatus hernia and he was on rivaroxaban, ramipril, digoxin, allopurinol, bumetanide, ranitidine and finasteride. Investigations showed NT pro BNP at 6473 ng/L, CRP at 78 mg/ dL and lymphopenia (0.42 10*9/L). He has persistent hyponatraemia at 117 mmol/L with normal kidney function. His liver function test showed alkaline phosphatase of 239 U/L and globulin at 41 g/L. His COVID-19 swab test was positive whereas mycobacterial culture and hepatitis screen were both negative. He had weakly positive ANA at 0.7 but otherwise normal autoimmune profile. The level of immunoglobulin G was 25 g/L and paraprotein of 2 g/L. His electrophoresis showed a monoclonal IgG; Kappa/Lambda ratio was 2.03. CT chest and cardiac MRI: shows constrictive pericarditis, pericardial effusion and thickening, moderate pleural effusion and ground-glass changes scattered throughout the right lung which suggested probably inflammatory origin. Thoracoscopic surgery (RVATS) was done for drainage of pleural effusion, excision of fat pad and anterior partial pericardectomy. The pericardial biopsy concluded chronic fibrous pericarditis with focal submesothelial mononuclear cell infiltrate with numerous plasma cells and lymphocytes .There was no amyloid or immunoglobulin deposition or malignancy. After the operation, there was both clinical and biochemical improvement (CRP- 28 mg/ dL). He did not need any immunomodulatory therapy. Results Cardiac involvement is rapidly emerging in COVID -19 diseases with case reports of myopericarditis, atrial fibrillation, heart failure, Kawasaki disease, thromboembolism, cardiogenic shock and aortitis. The mechanism remains unexplained but it could be related to direct endothelial inflammation or the cytokine storm sequelae. In our case, pericardial biopsy concluded features suggestive of autoimmune or immunoglobulin associated disease, although there was no clinical evidence of autoimmune disease. There were no lytic lesions and MGUS was diagnosed and scheduled for six monthly monitoring. Conclusion We report a case of constrictive pericarditis with COVID-19, although this remained a differential among the co-existed immunoglobulin and autoimmune syndrome. Appropriate imaging, biomarkers and histology investigations need to be considered for rapid evaluation and escalation of treatment. Cardiac manifestations are an important feature of COVID- 19. Further research is required to guide the management plans for similar cases. Disclosure Z. Alkutobi: None. G. Ansari: None. A. Nandagudi: None.

Graft-versus-host disease: a case report of a rare but reversible cause of constrictive pericarditis.

Background Constrictive pericarditis (CP), although an uncommon cause of heart failure, requires specialist multidisciplinary input and multi-modality imaging to identify the underlying aetiology and treat potentially reversible causes.Case summary We report the case of a 74-year-old gentleman referred for assessment of progressive exertional dyspnoea and peripheral oedema, 30 months following treatment of acute myeloid leukaemia with high-dose chemotherapy and allogeneic stem cell transplantation. Clinical examination and cardiac imaging revealed a small pericardial effusion and pericardial thickening with constrictive physiology; however, no aetiology was identified despite diagnostic pericardiocentesis. The patient required recurrent hospital admissions for intravenous diuresis, therefore, following multidisciplinary discussions, surgical partial pericardectomy was performed. Histology suggested graft-vs.-host disease (GvHD) and post-operatively, the patient improved clinically. Following immunomodulatory therapy with ruxolitinib for both pericardial and pulmonary GvHD, his functional status improved further with no subsequent hospital admissions.Discussion Although pericardial disease in cancer patients is common, CP is unusual. Determining the underlying aetiology is important for subsequent management, and here, we describe the use of multi-modality imaging to diagnose a rare cause, GvHD, which responded to surgical treatment and immunomodulatory therapy.

Suspected electrically induced ventricular fibrillation during thoracoscopic partial pericardectomy in two dogs

Partial removal of the pericardium is the recommended treatment for dogs suffering from recurrent pericardial effusion. An electrosurgical unit is often used for tissue dissection in the thorax, especially with...

Pericardiectomia parcial toracoscópica em um cão

The pericardial effusion in dogs is frequently idiopathic or secondary to neoplasia. Fluid accumulation causes increased intrapericardial pressure and hemodynamic alterations. A surgical treatment through thoracoscopic partial pericardect omy in a dog with recurrent pericardial effusion is described. To the authors’ knowledge, this technique has not been reported for clinical use in Brazil. An 11-year-old male Akita was presented at the Hospital de Clinicas Veterinarias of UFRGS with clinical signs compatible to pericardial effusion, which was confirmed through complementary exams (thoracic radiography, electrocardiography and echocardiography). After two pericardiocentesis with recurrence of fluid accumulation, the patient was submitted to intercostal thoracoscopy for performing partial pericardectomy. The patient died 76 days post-surgery; however it was not due to pericardial effusion. The procedure was technically successful. In the present report, the minimally invasive su rgery was easy and rapid to perform, and with no significant postoperative complications.

Cardiac herniation following right lower lobectomy—a rare clinical entity

Cardiac herniation and torsion may rarely occur following lobectomy with partial pericardectomy. High index of suspicion is required to diagnose this near fatal event. We report an unusual case of acute right sided cardiac dextroversion with torsion in a 58-year-old female following a right lower lobectomy, pericardectomy, and excision of infiltrated part of right hemi diaphragm for recurrent soft tissue fibrosarcoma.

Unusual Presentation of a Primary Pericardial Malignant Mesothelioma: Constrictive Pericarditis A Case Report and Review of the Literature

Primary malignant pericardial mesothelioma is an extremely rare tumor with high lethality. We report the case of a 30 year-old female without medical history, who was admitted in the department of cardiology for a dyspnea and chest pain due to a large pericardial effusion. A tamponade was confirmed by echocardiography, and emergent pericardial drainage was performed. Twelve months later, the patient developed a hemodynamically relevant pericardial constriction. She underwent a partial pericardectomy. The pericardium was thick and adherent. The histological examination revealed a pericardial infiltration by malignant mesothelioma. After surgery, five cycles of chemotherapy with carboplatine were beginned. The treatment methods of primary pericardial mesothelioma are limited. Chemotherapy in addition to surgery seems to improve symptoms in case of constriction and non-response to pericardectomy.

Primary chylopericardium treated by surgery: Report of two cases

Primary chylopericardium is a rare condition. The etiology and the treatment remain unclear. We report two cases of primary chylopericardium successfully treated by surgery. Both cases were asymptomatic young women and were found to have cardiomegaly on chest X-ray at a routine annual health examination. An echocardiography demonstrated massive pericardial effusion and chylous fluid was obtained with pericardiocentesis. Lymphoscintigraphy demonstrated abnormal communication between the pericardial sac and the thoracic duct. Because of reaccumulation of chylous pericardial effusion after conservative treatment, we performed surgical ligation of thoracic duct and partial pericardectomy by video-assisted thoracic surgery (VATS) in one case and by thoracotomy in another case. After surgery, both patients are doing well without recurrence of pericardial effusion. Surgical treatment including VATS is effective and should be performed in case of primary chylopericardium.

Occult pleural cryptococcosis in an immunocompromised patient

Sir: Cryptococcosis is a rare opportunistic, invasive, fungal, lifethreatening infection, which occurs in both immunocompetent and immunocompromised patients. In immunocompromised patients, the signs of cryptococcosis can easily be confused by the symptoms of the primary disease, which may delay adequate treatment [1]. We recently treated a 47-year-old woman with a thymoma WHO type B1 in the left hemithorax treated with three cycles of cisplatin/etoposide. Simultaneously, she developed a recurrent right-sided pleural effusion, which was drained four times and tested by an India ink and gramstained smear, bacterial culturing, Cryptococcus serum and pleural punctuate antigen testing and a cytological stain, which were all negative for microorganisms including Cryptococcus neoformans. The broncheoalveolar lavage (BAL) material was also negative. The transudate contained lymphocytes and mesothelial cells. Eight days following the last cycle of chemotherapy, the patient was admitted because of fever, headache, neck pain, and cognitive changes during chemotherapyinduced pancytopenia. Three months after pleural effusion development, C. neoformans meningitis was diagnosed in the cerebral spinal fluid. The infection was successfully treated with amphotericin B (0.7 mg/kg/day) and flucytosine (100 mg/kg/day) for 2 weeks, followed by 8 weeks amfotericin B (0.7 mg/kg/day) with flucanozole (800 mg/kg/day). Despite the diagnosis of meningeal cryptococcosis, pleural abnormalities remained attributed to the thymoma. Two weeks after cryptococcosis diagnosis, the patient underwent surgery for staging. Histology of the right middle lobe and pleura revealed a granulomatous necrotizing infection with C. neoformans (Fig. 1). One month later, a thymectomy was performed with partial pericardectomy, followed by ICU admission for 1 month. In summary, our patient showed pulmonary cryptococcosis which, due to negative bacteriological testing, was not recognized as such. Pulmonary signs were, therefore, attributed to her thymoma. Despite repeated testing for fungi of the pleural effusion and BAL, these tests remained negative during a substantial part of the disease progression. Whether the initial pleural transuduate was caused by cryptococcal infection or that secondary infection of pre-existent pleural fluid occurred, remains unclear. Microbiologic examination of specimens for cryptococci is not always conclusive: the appearance of cryptococci may vary considerably

Limited Cardiotoxicity after Extensive Thoracic Surgery and Intraoperative Hyperthermic Intrathoracic Chemotherapy with Doxorubicin and Cisplatin

Recently, pleural mesothelioma has been treated by cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy with doxorubicin and cisplatin. The well-established cardiotoxicity of doxorubicin and distressing data from an animal study raised concern about its impact on cardiac function. In the present study, early cardiotoxicity of this treatment modality was prospectively analyzed. In 13 pleural mesothelioma patients, cardiotoxicity was monitored by clinical examination, electrocardiography, Troponin levels, cardiac ultrasonography, and estimation of left ventricular ejection fraction (LVEF) by radionuclide ventriculography before and during the first 6 months after cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy with doxorubicin (25-54 mg/m(2)) and cisplatin (65-120 mg/m(2)). No clinical cardiac failure or treatment-related death was observed. In two patients transient atrial fibrillation was noted; one associated with pulmonary emboli. Early posttreatment Troponin release was not of predictive value. Ultrasonography did not reveal significant alterations. LVEF decreased significantly (mean 0.07 or 11%, P = .001) during the first 3 months and remained stable thereafter. In univariate analysis, the degree of LVEF reduction was statistically related to maximal intrathoracic doxorubicin concentration (P = .031) and total cisplatin dose (P = .029). Direct exposure of the heart to the drugs as a result of partial pericardectomy was not associated with greater LVEF decrease. On the contrary, partial pericardectomy seemed to be associated with a smaller LVEF decline than when the pericardium remained intact (P = .045). In this small series, no statistically significant correlation between other treatment or pharmacokinetic parameters and LVEF decline was found. Notably, higher doxorubicin plasma concentrations and exposure were not associated with increased LVEF reduction. Early cardiotoxicity is limited after this treatment modality using substantial doses of doxorubicin and cisplatin. Hence, this study suggests that intrathoracic chemotherapy with doxorubicin and/or cisplatin may be used for primary and secondary pleural malignancies, even immediately after extensive thoracic surgery, without concern of severe early cardiotoxicity.

Pericardial lipoma in a geriatric dog with an incidentally discovered thoracic mass

An intrathoracic mass was discovered as an incidental finding in a 14-year-old, spayed, female Rottweiler cross during evaluation of urinary incontinence. Computed tomography suggested a pericardial or pleural location and high adipose content of the mass. The mass was removed via lateral thoracotomy with partial pericardectomy and was diagnosed as a pericardial lipoma. The dog recovered well, and there was no evidence of recurrence approximately one year later. Adipose tumours of the heart and its associated structures are rare in dogs and have been associated with both successful and fatal outcomes.

Pericardiocutaneous Fistula: Presentation With Acute Hemorrhage 8 Years Following Aortic Valve Replacement

Pericardiocutaneous fistula is a rare complication of cardiac surgery. A 35-year-old female presented with acute severe hemorrhage from a pericardiocutaneous fistula eight years following aortic valve replacement. Computed tomography showed a large, pericardial collection causing tamponade, connected to a smaller subcutaneous cavity, with a tract leading to the skin. The patient underwent emergency surgical exploration with removal of hematoma, hemostasis, and partial pericardectomy. One year following the operation, the patient remains stable. Factors in the development of pericardiocutaneous fistula were valve replacement, infection, and warfarin anticoagulation.

Cellular, hemostatic, and inflammatory parameters of the surgical stress response in pigs undergoing partial pericardectomy via open thoracotomy or thoracoscopy

Thoracoscopy has been shown to reduce the inflammatory and immunologic response to surgical stress, as compared with corresponding open procedures in humans. The influence on the hemostatic system, however, has not been thoroughly evaluated. The current study aimed to compare the perioperative and immediate postoperative changes in cellular, hemostatic, and inflammatory parameters after a partial pericardectomy performed by either thoracoscopy or thoracotomy. For this study, 16 pigs were randomly assigned to have a partial pericardectomy performed thoracoscopically or by thoracotomy. Blood was collected intraoperatively, then 10 min, 3 h, and 6 h after surgery. Whole ethylenediaminetetraacetic acid (EDTA)-stabilized blood and plasma were examined for cellular, hemostatic, and inflammatory parameters, respectively, and thromboelastography (TEG) was performed on citrated whole blood. No significant difference in any of the parameters measured was found between the two groups except for the TEG parameter R-time, which was significantly shorter in the thoracoscopic group 3 h postoperatively. In both groups, a significant postoperative state of hypercoagulability and increase in inflammatory parameters was found. Additionally, pig blood showed a high degree of hypercoagulability in preoperative measurements, as compared with other species. Partial pericardectomy performed by thoracotomy or thoracoscopy in pigs produces a surgical stress response of equal magnitude, as measured by cellular, hemostatic, and inflammatory changes.

Stiff Man Syndrome With Thymoma

Paraneoplastic stiff man syndrome with a thymoma is rare disease. We treated a 57-year-old woman with a type B1 thymoma, based on the World Health Organization classification, who had stiff man syndrome. Her symptoms were alleviated after a thymectomy. Herein we report a case of stiff man syndrome with a thymoma and also review three cases reported previously.

Thoracoscopic versus open partial pericardectomy in dogs: comparison of postoperative pain and morbidity.

To evaluate postoperative pain and morbidity in dogs undergoing open thoracotomy and partial pericardectomy versus thoracoscopic pericardectomy. Research study in normal dogs. Fourteen mixed breed healthy dogs. Seven dogs had a partial pericardectomy through a standard left lateral thoracotomy at the fifth intercostal space. The remaining seven dogs underwent selective lung ventilation and thoracoscopic partial pericardectomy. Surgery sites in both groups were bandaged and each dog received a single postoperative dose of morphine (0.2 mg/kg, intramuscularly [i.m.]). Postoperative pain was evaluated using a standard pain score table at 1, 5, 9, 17, 29, and 53 hours after surgery. Dogs receiving a pain score of six or greater received an additional dose of morphine. At each observation point, blood samples were taken to measure blood glucose and plasma cortisol concentrations. Pain scores, blood glucose, and plasma cortisol concentrations were compared between the two groups using two-way ANOVA. Blood glucose concentrations, plasma cortisol concentrations, and pain scores were significantly different between the two groups, with the thoracotomy dogs having higher values at 1, 5, and 9 hours postoperatively. Three of the open thoracotomy dogs required additional analgesia after the initial dose of morphine. In addition, two dogs that underwent open thoracotomy were lame in the left forelimb and two others developed dehiscence of their wounds. Thoracoscopic partial pericardectomy has several advantages over open partial pericardectomy including decreased postoperative pain, fewer wound complications, and more rapid return to function.

Cardiac torsion after lobectomy with partial pericardectomy

Cardiac herniation and torsion after intrapericardial pneumonectomy without closure of the pericardium is widely recognized. However, such a complication occurring after lobectomy has been rarely discussed in the literature. We describe a case of cardiac torsion of late onset that developed in a woman who had undergone left upper lobectomy as part of a resection for a malignant thymoma.

Late cardiac effects of mediastinal radiotherapy in patients with Hodgkin's disease.

Twenty-eight patients younger than age 40 years, treated for Hodgkin's disease with mediastinal irradiation, were examined no less than 5 years after the irradiation in order to evaluate the frequency of cardiac abnormalities. Twelve patients (43%) had had some pericardial event after radiation: a diagnosed pericarditis, remarkably increased heart volume, or a conspicuous change of cardiac silhouette, suggesting pericardial fluid. On evaluation, 50% of the patients complained of symptoms, and 13 patients had to stop the exercise test on a low level because of chest pain, dyspnea, or general fatigue. In 13 patients some of the following abnormalities in the electrocardiogram (ECG) was found: right bundle branch block (four), first-degree atrioventricular block (four), abnormal P terminal force (five), or a low voltage (two). In ten patients (38%) an increase of the pericardial fluid was seen in the echocardiogram, and in nine patients the right ventricle wall thickness had increased. In two patients a severe coronary artery disease was found. One died suddenly after an acute myocardial infarction (AMI), and the other had a large anterior AMI. Two patients with chronic pericardial fluid underwent partial pericardectomy. Two cases of mild pulmonary valve stenosis, one pulmonary subvalvular stenosis and two aortic valve deformities were discovered. Eight patients went through cardiac catheterization, and in all but one case the pressures were slightly elevated suggesting diminished diastolic compliance. In summary, 19 of 28 patients had some abnormal cardiac findings, but only three of them were serious ones.

Post-Pneumonectomy Shock

A 61-year-old man with squamous cell carcinoma of the lung underwent radical right pneumonectomy with partial pericardectomy. Two hours after transfer to the recovery room, he developed severe hypotension, marked jugular venous distention, cyanosis, and electrocardiographic changes consistent with right ventricular ischemia. The chest tube pressure that had been maintained on the negative side was corrected to ambient pressures and an AP portable roentgenogram was obtained (Fig 1).

Primary osteogenic sarcoma of the mediastinum

Ikeda, T., Ishihara, T., Yoshimatsu, H., Kikuchi, K., Murakami, M., Kobayashi, K., Inoue, H., and Kasahara, M. (1974) . Thorax , 582-588. Primary osteogenic sarcoma of the mediastinum . A 22-year-old man with primary osteogenic sarcoma of the superior mediastinum is reported. This case is the second instance of primary osteogenic sarcoma of the mediastinum and the first case of superior mediastinal origin to be reported. The patient had local recurrence one year after the first operation. After resection of the recurrent tumour with left upper lobectomy and partial pericardectomy followed by radiation, he has been well for more than five years without recurrence. Extraosseous osteogenic sarcoma of soft tissue is very rare and has been reported in 103 patients. The five-year survival of patients with extraosseous osteogenic sarcoma is 22·4%. The distribution and prognosis of this tumour are similar to those of rhabdomyosarcoma in soft tissue. Primary amputation or wide excision is the treatment of choice.

Pericardial tamponade in chronic-hemodialysis patients treatment by pericardectomy

Uremic pericarditis, often with cardiac tamponade, is an infrequent but difficult problem, since the number of uremic patients kept alive by maintenance hemodialysis has increased. Some believe that aggressive dialysis with pericardiocentesis is the best therapy. Our experience suggests that this is not always adequate. Increasing experience indicating that uremic patients on hemodialysis tolerate major surgical procedures well has prompted an early and aggressive surgical approach when tamponade is not quickly relieved by conservative methods. Five patients on chronic hemodialysis developed pericarditis and tamponade after 1, 6, 7, 13 and 15 months of dialysis. All were subjected to a partial pericardectomy with the objectives of (1) eliminating the tamponade, and (2) preventing recurrence or constriction. All are alive and active from 6 to 23 months after the surgical procedure.

Pericardial Tamponade in Chronic-Hemodialysis Patients

Uremic pericarditis, often with cardiac tamponade, is an infrequent but difficult problem, since the number of uremic patients kept alive by maintenance hemodialysis has increased. Some believe that aggressive dialysis with pericardiocentesis is the best therapy. Our experience suggests that this is not always adequate. Increasing experience indicating that uremic patients on hemodialysis tolerate major surgical procedures well has prompted an early and aggressive surgical approach when tamponade is not quickly relieved by conservative methods. Five patients on chronic hemodialysis developed pericarditis and tamponade after 1, 6, 7, 13 and 15 months of dialysis. All were subjected to a partial pericardectomy with the objectives of (1) eliminating the tamponade, and (2) preventing recurrence or constriction. All are alive and active from 6 to 23 months after the surgical procedure.