Pericardiectomy For Chronic Constrictive Pericarditis Research Articles

Does tuberculosis affect surgical outcomes following pericardiectomy for chronic constrictive pericarditis? Twelve years' experience from a tertiary care center in India.

Tuberculosis (TB) is the commonest cause of chronic constrictive pericarditis (CCP) in India, unlike in the western countries. Pericardiectomy is the treatment of choice for CCP. Surgery in TB CCP is considerably more difficult than it is for other etiologies. The role of TB as an independent predictor for adverse surgical outcomes had not been properly evaluated in the Indian scenario. Hence, the aim of this study was to retrospectively analyze our results of surgery for CCP and the pre-operative factors that influenced post-operative outcomes. The data of all adult patients who underwent pericardiectomy for CCP, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analyzed. There were 124 patients in the study. The average age was 32years. The male to female ratio was 3:1. TB was the commonest cause of CCP, identified in 64 (51.6%) patients. Complete anterior pericardiectomy (CAP) was possible in 122 (98.3%) patients. All the patients had significant drop in their central venous pressure (CVP) (10.25 ± 3.47mmHg) after surgery. The operative time (p = 0.008), intra-operative blood loss (p = 0.02), intensive care unit (ICU) stay (p = 0.03), and hospital stay (p = 0.028) were significantly higher in the TB group. Apart from TB, the other pre-operative variables that predicted adverse outcomes were male sex, presence of pleural effusion or ascites, and advanced New York Heart Association (NYHA) class. There were 7 (5.6%) post-operative complications and 3 (2.4%) in-hospital deaths. The high incidence of TB CCP makes a pericardiectomy in developing countries technically more challenging resulting in increased operative time, more blood loss, and prolonged ICU and hospital stay, but did not affect in-hospital mortality or morbidity.

Assessment of Myocardial Mechanics in Patients Undergoing Pericardiectomy for Chronic Constrictive Pericarditis by Tissue Doppler Imaging and 2D Speckled Tracking Echocardiography: A Prospective Obser

Background: This study was designed to prospectively evaluate the changes in tissue Doppler imaging (TDI) at mitral and tricuspid annuli and two dimensional speckle tracking echocardiography in patients undergoing pericardiectomy for chronic constrictive pericarditis and identify the relationship if any of the tissue Doppler imaging and speckle echocardiographic derived variables with patient’s symptomatic status following surgery. Patients and Methods: Twelve patients undergoing pericardiectomy for constrictive pericarditis aged 7 years to 70 years (median 21; IQR: 19.75-26.5 years) were studied for 2-36 months (median 19 months). They underwent Doppler flow velocity, TDI, and 2D-speckle echocardiographic studies. Friedman’ test was used to test the changes in TDI-derived mitral and tricuspid annular velocities and speckle derived parameters in postoperative period from baseline. Results: Despite congestive heart failure, all patients had normal left ventricular ejection fraction and increased medial mitral and tricuspid early diastolic septal velocity (e¢) with “annulus reversus”. This pattern of annular velocity improved maximally in the immediate postoperative period. At closing interval, 2 (16.7%) patients continued to be in New York Heart Association class II and both of them continued to remain in atrial fibrillation. There was statistical significant improvement in the Global cirumferential strain than in global longitudinal and global radial strain after pericardiectomy. Conclusions: We conclude that tissue Doppler imaging and speckle tracking echocardiography are useful investigative modalities for serial evaluation of patients undergoing pericardiectomy. It can be performed serially with a high degree of reproducibility.

Total Pericardiectomy Using a Modified Left Anterolateral Thoracotomy Without Cardiopulmonary Bypass

We sought to ascertain the short- and long-term results of total pericardiectomy for chronic constrictive pericarditis using a modified left anterolateral thoracotomy without cardiopulmonary bypass on postoperative low cardiac output, normalization of intracardiac pressures, survival, and reoperations. Between January 2005 and December 2019 a series of 127 consecutive patients (91 male patients) between ages 4 and 72 years (median, 25 years; interquartile range, 18-38) underwent radical total pericardiectomy using a modified left anterolateral thoracotomy without cardiopulmonary bypass. Operative and late mortalities were 3.1% and 1.6%, respectively. Thirty-one patients (24.4%) had postoperative low cardiac output, and none required reoperations. At a median follow-up of 99 months (interquartile range, 56-141) the actuarial survival was 97.6% ± 0.01% months (95% confidence interval, 92.8-99.2). At their last follow-up 113 (93.4%) and 8 (6.6%) survivors were in New York Heart Association class I and II, respectively. Total pericardiectomy is associated with lower perioperative and late mortality and decreased low cardiac output syndrome and confers significant long-term advantage of superior hemodynamics.

Serial semi-invasive hemodynamic assessment following pericardiectomy for chronic constrictive pericarditis

Objectives:This study was designed to prospectively investigate the effects of pericardiectomy via median sternotomy on intra- and postoperative hemodynamics by a new semi-invasive device (Flotrac/VigileoTM monitor) using arterial pressure waveform analysis.Patients and Methods:Thirty consecutive patients aged 15 to 55 years (mean+SD, 31.73 + 13.53 years), who had undergone total pericardiectomy via median sternotomy underwent serial hemodynamic evaluation. FlotracTM Sensor – derived stroke volume, stroke volume variation, systemic vascular resistance index (SVRI), cardiac index and right atrial pressure were measured just before and after pericardiectomy, at 12 hours, 24 hours, 48 hours, 72 hours and at discharge postoperatively.Results:Majority of patients (73.33%) exhibited statistically significant reduction of right atrial pressure and SVRI along with improvement in cardiac index and oxygen delivery in the immediate and late postoperative period. However, the stroke volume and stroke volume variation did not increase proportionately on completion of surgery. Patients with low cardiac output syndrome exhibited persistently high central venous pressure with reduced cardiac index and echocardiographically abnormal diastolic filling characteristics.Conclusions:We conclude that there is early normalization of hemodynamics following pericardiectomy via median sternotomy and the adequacy of pericardiectomy can be accurately assessed by the new semi-invasive arterial pressure waveform analysis device. Stroke volume variation is a non-predictor of fluid requirement during and after pericardiectomy.

Pulmonary Artery Perforation: Rare reported Complication of Pericardiectomy for Chronic Constrictive Pericarditis recorded on Transesophageal Echocardiography

ABSTRACT Major vessel injury is a possible complication during pericardiectomy for chronic constrictive pericarditis (CCP). We present a case of CCP, who while undergoing radical pericardiectomy incurred an iatrogenic injury of a major vessel with profuse bleeding. A rent in main pulmonary artery (MPA) was detected by the surgical team and simultaneously confirmed on transesophageal echocardiography (TEE), and a timely intervention was done. Importance of monitoring TEE in a patient undergoing pericardiectomy for CCP is highlighted. How to cite this article Makhija N, Narula J, Kumar S, Taneja S, Hote MP. Pulmonary Artery Perforation: Rare reported Complication of Pericardiectomy for Chronic Constrictive Pericarditis recorded on Transesophageal Echocardiography. J Perioper Echocardiogr 2016;4(1):17-18.

Indications, timing and techniques of radical pericardiectomy via modified left anterolateral thoracotomy (ukc's modification) and total pericardiectomy via median sternotomy (holman and willett) without cardiopulmonary bypass

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.

Risk factors for mortality after pericardiectomy for chronic constrictive pericarditis in a large single-centre cohort.

Constrictive pericarditis (CP) is an uncommon disease with multiple causes and unclear clinical outcomes. To date, few publications have clearly defined risk factors of poor outcomes after surgery for CP. We performed a retrospective analysis of almost 100 patients undergoing surgical treatment for CP at a single institution in order to identify risk factors for perioperative and long-term mortality. A total of 97 consecutive patients (67.0% male) undergoing surgery for CP at our institution from 1995 to 2012 were included in the study. CP was diagnosed either preoperatively by cardiac catheterization and appropriate imaging or during surgery. Preoperative and intraoperative risk factors for 30-day and late mortality were analysed using stepwise multivariate logistic and Cox regression analyses. Median follow-up was 1.23 ± 3.96 years (mean 3.08 ± 3.96 years). The mean patient age was 60.0 ± 12.5 years and the underlying aetiology was idiopathic (50.5%), prior cardiac surgery (15.5%), prior mediastinal radiation (9.3%), and miscellaneous (24.7%). All patients underwent either radical (55.2%) or partial (44.8%) pericardiectomy. Concomitant procedures were performed in 54 (55.7%) patients. The total procedure time was 197.0 ± 105.0 min. Cardiopulmonary bypass (CPB) was used in 62 patients with a corresponding CPB time of 124.8 ± 68.4 min. In those patients who underwent CPB, cardioplegic arrest was performed in 53.2% of patients with a mean cross-clamp time of 74.9 ± 41.9 min. Overall 30-day, 1-year and 5-year survival rates were 81.4, 66.5 and 51.6%, respectively, without significant differences according to the underlying aetiology. Multivariate analysis revealed patients with reduced left ventricular ejection fraction (LVEF) [P = 0.01, odds ratio (OR) 3.6] and preoperative right ventricular dilatation (P = 0.04, OR 3.5) to be at significant risk of early mortality. Long-term mortality was independently predicted by the presence of coronary artery disease (CAD) [P < 0.001, hazard ratio (HR) 6.44], chronic obstructive pulmonary disease (P = 0.001, HR 4.21) and preoperative renal insufficiency (P = 0.012, HR 1.8). Concomitant tricuspid valve repair (TVR) appeared to provide protective effect on the long-term survival (P = 0.07). Surgery for CP is associated with a significant risk based on the poor preoperative patient status. Whenever justified, partial over radical pericardiectomy should be preferred and TVR should be indicated liberally. Reduced LVEF and right ventricular dilatation were independent predictors for early mortality, whereas CAD, chronic obstructive pulmonary disease and renal insufficiency were risk factors for late mortality. Thus, an optimal timing for surgery on CP remains crucial to avoid secondary morbidity with an even worse natural prognosis.

Cardiac Cirrhosis May Present Ten Years after Pericardiectomy for Chronic Constrictive Pericarditis

A 51 year old male, presented to us with progressive abdominal distention and jaundice since 1 month, and a single episode of hematemesis. He had undergone pericardiectomy 10 years back for chronic constrictive pericarditis (CCP) and had completed a course of anti-tubercular therapy following the surgery. Physical examination revealed normal vital signs and mild icterus, moderate ascites, splenomegaly, and mild ankle edema. On endoscopy, he found to have large esophageal varices and endoscopic variceal ligation (EVL) was performed. Thyroid function tests, hepatitis serologies, autoimmune assays (ANA, AMA) ASMA, ferritin, ceruloplasmin, and α1-AT, level were unremarkable. Liver biopsy showed cirrhosis. After extensive evaluation, a diagnosis of cardiac cirrhosis was made.

Pericardiectomy for chronic constrictive pericarditis: risks factors and predictors of survival

Objective We have performed this study to (1) evaluate the major etiological factors of chronic constrictive pericarditis in this geographical region, (2) evaluate the effect of preoperative optimization, (3) find the best surgical approach, (4) assess the extent of decortication required, (5) evaluate the management of immediate postoperative low cardiac output and (6) determine the predictors of early and long-term survival.

Successful Surgical Management for Severe Mitral Regurgitation Unmasked After Pericardiectomy for Chronic Constrictive Pericarditis

A 78-year-old cachectic woman who previously had repair of atrial septal defect was admitted to the hospital for congestive heart failure. Cardiac workup revealed chronic constrictive pericarditis; no evidence of coronary or valvular disease was found. She underwent corrective surgery for pericardiectomy. Intraoperative transesophageal echocardiography after pericardiectomy demonstrated acute development of severe mitral regurgitation, which was not preoperatively observed. She eventually required mitral valve replacement and tricuspid valve repair after conservative management failed. She recovered from the operation and was discharged. We believe that this is the first report of successful surgical management of mitral regurgitation that developed acutely after pericardiectomy.

Radical Pericardiectomy for Chronic Constrictive Pericarditis

A retrospective analysis was undertaken in 79 patients who underwent pericardiectomy for chronic constrictive pericarditis from January 1985 to February 1999. Most operations (77) were carried out with cardiopulmonary bypass, with subtotal pericardiectomy in 75 patients, and concomitant operations in 25. Postoperative complications occurred in 8 patients: cerebrovascular accident in 2, renal insufficiency in 5, bleeding in 2, low output syndrome in 4, and respiratory insufficiency in 2. The operative mortality was 5%; causes of death were cardiac-related in all cases. Actuarial survival at 1, 5, and 10 years was 89.9% ± 3.4%, 74.9% ± 5.7%, and 55.4% ± 13.5%, respectively. Regression analysis was performed using 53 clinical variables. Female gender, renal insufficiency, concomitant coronary artery bypass grafting, and preoperative right ventricular end-diastolic pressure &gt; 20 mm Hg were found to be predictors of poor survival. At follow-up, improved functional status was noted in 88% of patients. Subtotal pericardiectomy can be performed on cardiopulmonary bypass with low mortality and good long-term survival.

Atrial natriuretic peptide and hemodynamic response to pericardiectomy for chronic constrictive pericarditis

A trial compliance, intraluminal pressure, transmural pressure and atrial stretch have been suggested as major stimuli for the production of atrial natriuretic peptide (ANP). These assumptions are mainly based on observations showing good correlations between pressures and ANP levels in heart failure due to heart diseases of various etiology. 1 Increasing pressure in the left and/or right atrium is followed by an increased stretch of the atrial wall in most heart diseases, except in cardiac tamponade and constrictive pericarditis. In an experiment with dogs, the rise of ANP during rapid volume expansion was decreased in the presence of cardiac tamponade, even if the right atrial pressure and the left end-diastolic pressure increased during the induced tamponade. 2 This indicates that pressure is not the only determinant, as has been presumed previously. To investigate this relation, we studied the relation between ANP and some important hemodynamic parameters in a patient during exercise before and after pericardiectomy.

Release of atrial natriuretic factor after pericardiectomy for chronic constrictive pericarditis

The mechanism by which atrial natriuretic factor (ANF) is released has been variably attributed to a number of stimuli including atrial distension, 1,2 stretch, 3 compliance 4 and atria1 hypertension. 5,6 In constrictive pericarditis, atrial pressures are markedly elevated in conjunction with fluid retention and diminished myocardial distensibility. Release of pericardial constriction would therefore allow increased distensibility at the same time atrial pressures are lowered. We describe a patient with severe calcific constrictive pericarditis in whom for the first time ANF levels and physiologic parameters were measured before and after pericardiectomy.