Pericardiectomy for Intractable Recurrent Pericarditis: When and Why?

Note: Drs. Singh and Tsutsui share co-first authorship.

A 52- year-old woman with history of paroxysmal atrial fibrillation and recurrent pericarditis with recurrent pericardial effusion presented with sharp chronic chest pain affecting her daily activities. Her ESR was 40 mm/hr and CRP was 33.3 mg/dl. Other investigative workup was negative for infection, autoimmune disorders, and malignancy. She had undergone one pericardiocentesis and two pericardial windows over the past 2 years for her recurrent pericardial effusions. She had been treated with ibuprofen, colchicine, azathioprine, methotrexate, and chronic corticosteroids. She was on 20mg of prednisone daily with failure to taper. She had significant side effects from steroids including cushingoid features, cataract, and severe osteoporosis.

Her initial cardiac magnetic resonance imaging (MRI) showed moderate localized pericardial effusion along anterolateral, inferolateral left ventricular wall, left atrial and right atrial free wall, but no pericardial thickening or evidence of constrictive physiology. There was trivial delayed enhancement of lateral parietal pericardium (Figure 1). Due to her recurrent symptoms and side effects of the anti-inflammatory therapy, she then underwent a radical pericardiectomy. The pericardium was incised systematically from the left, right, and posterior leaving behind a thin strip along the phrenic nerves bilaterally. Post-pericardiectomy, her symptoms improved and cardiac MRI at 3 months showed interval improvement with only mild residual enhancement of remaining fibrinous material/visceral pericardium on T2STIR as well as post gadolinium delayed enhancement imaging suggestive of mild inflammation. She was continued on aspirin and colchicine, and steroids were slowly tapered off.

Over the next 2 years she had only two episodes of pericarditis flare, while being off steroids. Follow up cardiac MRI at 2 years showed complete interval resolution of the mild residual enhancement that was noted on previous study. There was no abnormal peri/epicardial signal intensity on STIR imaging to suggest pericardial edema (Figure 2). She remained symptom free and was taking only aspirin 650 mg twice daily.

Figure 1: Pre-pericardiectomy. Delayed enhancement image demonstrating a loculated lateral pericardial effusion (blue arrow) with mild pericardial delayed enhancement (yellow arrow).

Figure 1

Figure 2: Post-pericardiectomy. Delayed enhancement image demonstrating pericardial stripping and resolution of the pericardial effusion and inflammation.

Figure 2

Which of the following is not true for pericardiectomy in patients with recurrent or relapsing pericarditis?

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