Isolated Pericardiectomy: Outcomes are Well Worth the Challenge
Through the years, numerous descriptions of clinical presentation have emerged, and pericarditis has ultimately been sub-classified into constrictive and effusive types.1,2 The true incidence of pericarditis in the general population is not known; however, general estimates indicate approximately 6% have signs of pericarditis at autopsy and this diagnosis accounts for approximately one in 1000 hospital admissions.3 The management of patients with pericarditis can be challenging. While some patients may be medically managed successfully, there is a subset of patients with pericardial constriction or medically refractory effusive/chronic relapsing pericarditis who benefit from surgical intervention.3,4 Despite having vastly different pathophysiology, diastolic heart failure from constriction and recurrent chest pain and effusion from effusive/chronic relapsing, both benefit from removal of the pericardium to achieve symptomatic relief and improvement in functional status.3-9 Although there are many reports validating the benefit of pericardiectomy, there remains a poor understanding of which patients derive the most benefit from surgery,4,10-13 what co-morbid conditions contribute most to postoperative morbidity and mortality, the superiority of a particular surgical approach, or, most importantly, the long-term outcomes after intervention.
Historically, pericardiectomy has been reported to have a very high early morbidity and mortality for both constriction (14%) and effusive/chronic relapsing types (5.5-19.4%).14,15 However, postoperative mortality after pericardiectomy can be performed with low early risk in the current era.3,4 Earlier diagnosis and surgical intervention before the onset of irreversible left ventricular dysfunction and end-organ damage has likely contributed to improved outcomes more recently.
The etiology of pericarditis depends on several factors, including region of the world and surgical era.9-11,13,14,16 Further, with the current prevalence of cardiac surgical procedures and increased use of electrophysiological interventions, iatrogenic pericarditis is at an all-time high.17,18 The numerous etiologic factors predisposing to the development of pericarditis poses a challenge in evaluating natural history and outcomes after surgical treatment.
Patients with constrictive pericarditis present with heart failure, which can manifest with broad symptoms depending on the severity of cardiac compromise. Constriction may be progressive, ultimately resulting in end-organ damage and deterioration of cardiac function. Medical therapy is limited in constriction with focus on improving symptoms of heart failure and temporizing measures. Surgery is the only definitive treatment. Effusive/chronic relapsing patients present most commonly with recurring episodes of pain and less commonly with compressive effusions and constriction. Non-steroidal anti-inflammatory drugs and corticosteroids are the mainstay of medical therapy in effusive/chronic relapsing pericarditis. Patients with large effusions additionally benefit from pericardial drainage. In many cases pericardial reaction will improve with aforementioned treatments and patients may successfully be observed. There is a subset of patients who will have recurring episodes of inflammation manifesting with refractory pain and some who progress to demonstrate evidence of constriction due to long standing inflammation.4,5 Patients undergoing surgery for effusive/chronic relapsing pericarditis tended to have fewer relapses and hospitalizations than patients managed medically.
Findings at operation are also unique in these two subgroups of patients. Typically, patients with constrictive pericarditis manifest with a heavily calcified, thickened pericardium which is intimately associated and at times extensions of calcium into the myocardium. The pericardial space is obliterated and separation is tedious. Conversely, effusive/chronic relapsing pericarditis exhibits inflamed, non-calcified pericardium that is generally not adherent to underlying edematous epicardium. In some cases, a thickened pericardium is not present; this does not portend a lesser response to pericardiectomy.19
The extent of pericardiectomy is a much debated topic and therefore lacks standardization. An anterior pericardiectomy removes only the anterior pericardium between both phrenic nerves. A complete pericardiectomy removes not only the anterior pericardium as described above, but also the inferior (diaphragmatic), and left lateral (posterior to left phrenic nerve).20 Of course care is taken to preserve each phrenic nerve with monitoring as indicated.
Pericardiectomy, in the face of severe constriction and heavy calcification can be technically demanding surgery, wrought with potential complications. For this reason, some authors advocate anterior pericardiectomy only in this scenario with acceptable results,21 while others have found that survival and functional outcome are superior with complete pericardiectomy.4 There has been no demonstrable, statistically significant difference in surgical risk between complete pericardiectomy versus a lesser resection.4 Often in difficult pericardiectomies, an outer rind can be easily removed, but a second tight covering over the epicardial surface perpetuates constriction. When complete removal is not possible, the epicardial peel may be quadriculated to produce non-contiguous islands of constricting epicardium. The hemodynamic consequence of remaining pericardium is not felt to compromise end result. Notably, a published report in 2012 demonstrates reoperation with completion pericardiectomy to be independently associated with lower survival on multivariate analysis.22
Median sternotomy is employed most commonly as the surgical approach; however, some surgeons prefer left thoracotomy or clamshell approach. Certainly, it must be noted that a left thoracotomy limits exposure of the right phrenic nerve and could compromise completeness of resection. Cardiopulmonary bypass is typically used less frequently in the effusive/chronic relapsing group for the aforementioned less adherent pericardium which allows for easier removal. The use of cardiopulmonary bypass is associated with a lower late survival in some reports, but only in a univariate manner.23 We believe this is a reflection of a sicker patient population with a more calcified and adherent pericardium.
Isolated pericardiectomy for constriction or for effusive/chronic relapsing pericarditis can be performed safely with low morbidity and mortality. Although the surgical approach and use of cardiopulmonary bypass differs between providers, neither of these factors prove significant in assessing outcomes. Although late outcome is superior in patients with effusive/chronic relapsing subtype of pericarditis, symptomatic benefit is seen in the majority of patients at follow-up with a statistically significant reduction in NYHA Functional class.
- Fowler NO. Constrictive pericarditis: its history and current status. Clin Cardiol 1995;18:341-50.
- Churchill E. Decortication of the heart (Delorme) for adhesive pericarditis. Arch Surg 1929;19:1457-69.
- Syed FF, Schaff HV, Oh JK. Constrictive pericarditis – a curable diastolic heart failure. Nat Rev Cardiol 2014;11:530-44.
- Khandaker MH, Schaff HV, Greason KL, et al. Pericardiectomy vs. medical management in patients with relapsing pericarditis. Mayo Clin Proc 2012;87:1062-70.
- Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999;100:1380-6.
- Chowdry UK, Subramaniam GK, Sampath Kumar, et al. Pericardiectomy for constrictive pericarditis: a clinical echocardiographic, and hemodynamic evaluation of two surgical techniques. Ann Thorac Surg 2005;81:522-9.
- Ghavidel AA, Gholampour M, Kyavar M, Mirmesdagh Y, Tabatabaie MB. Constrictive pericarditis treated by surgery. Tex Heart Inst J 2012;39:199-205.
- Yetkin U, Kestelli M, Yilik L, et al. Recent surgical experience in chronic constrictive pericarditis. Tex Heart Inst J 2003;30:27-30.
- Szabo G, Schmack B, Bulut C, et al. Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy: 24 years of experience. Eur J Cardiothorac Surg 2013;44:1023-8.
- Mutyaba AK, Balkaran S, Cloete R, et al. Constrictive pericarditis requiring pericardiectomy at Groote Schuur Hospital, Capetown, South Africa: causes and perioperative outcomes in the HIV era (1990-2012). J Thorac Cardiovasc Surg 2014;148:3058-65.
- Avgerinos D, Rabitnokov Y, Worku B, Neragi-Miandoab S, Girardi LN. Fifteen-year experience and outcomes of pericardiectomy for constrictive pericarditis. J Card Surg 2014;4:434-8.
- Buyukbayrak F, Aksoy E, Tas S, Kirali K. Surgical management of effusive constrictive pericarditis. Cardiovasc J Afr 2013;8:303-7.
- Tokuda Y, Miyata H, Motomura N, et al. Outcome of pericardiectomy for constrictive pericarditis in Japan: a nationwide outcome study. Ann Thorac Surg 2013;2:571-6.
- McCaughan BC, Schaff HV, Piehler JM, et al. Early and late results of pericardiectomy for constrictive pericarditis. J Thorac Cardiovasc Surg 1985;85:340-50.
- Piehler JM, Pluth JR, Schaff HV, Danielson GK, Orszulak TA, Puga FJ. Surgical management of effusive pericardial disease. Influence of extent of pericardial resection on clinical course. J Thorac Cardiovasc Surg 1985;90:506-16.
- Ling LH, et al. Detection of constrictive pericarditis: a single-center experience of 523 surgically confirmed cases. J Am Coll Cardiol 2009;53:A176.
- Bartus K, Han FT, Bednarek J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol 2013;62:108-18.
- Jahaveri A, Glassberg HL, Acker MA, Callans DJ, Goldberg LR. Constrictive pericarditis presenting as a late complication of epicardial ventricular tachycardia ablation. Circ Heart Fail 2012;5:e22-3.
- Taljera DR, Edwards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation 2003;108:1852-7.
- Villavicencio MA, Dearani JA, Sundt TM. Pericardiectomy for constrictive or recurrent inflammatory pericarditis. Oper Techniq Thorac Cardiovasc Surg 2008;13:2-13.
- Nataf P, Cacoub P, Dorent R, et al. Results of subtotal pericardiectomy for constrictive pericarditis. Eur J Cardiothorac Surg 1993;7:252-6.
- Cho YH, Schaff HV, Dearani JA, et al. Completion pericardiectomy for recurrent constrictive pericarditis: importance of timing of recurrence on late clinical outcome of operation. Ann Thorac Surg 2012;93:1236-41.
- Gillaspie EA, Stulak JM, Daly RC, et al. A 20-year experience with isolated pericardiectomy: analysis of indications and outcomes. J Thorac Cardiovasc Surg 2016;152:448-58.
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