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.

References

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