Outcomes and Risk Factors Associated with Pericardiectomy in Patients with Constrictive Pericarditis: A Retrospective Study from China.

PURPOSE: Pericardiectomy is the definitive treatment option for constrictive pericarditis and is associated with a high prevalence of morbidity and mortality. However, information on the associated outcomes and risk factors is limited. We aimed to report the mid-term outcomes of pericardiectomy from a single center in China. METHODS: We retrospectively reviewed data collected from patients who underwent pericardiectomy at our institute from April 2018 to January 2023. RESULTS: Eighty-six consecutive patients (average age, 46.1 ± 14.7 years; 68.6 men) underwent pericardiectomy through midline sternotomy. The most common etiology was idiopathic (n = 60, 69.8%), and 82 patients (95.3%) were in the New York Heart Association function class III/IV. In all, 32 (37.2%) patients underwent redo sternotomies, 36 (41.9%) underwent a concomitant procedure, and 39 (45.3%) required cardiopulmonary bypass. The 30-day mortality rate was 5.8%, and the 1-year and 5-year survival rates were 88.3% and 83.5%, respectively. Multivariable analysis revealed that preoperative mitral insufficiency (MI) ≥moderate (hazard ratio [HR], 6.435; 95% confidence interval [CI] [1.655-25.009]; p = 0.007) and partial pericardiectomy (HR, 11.410; 95% CI [3.052-42.663]; p = 0.000) were associated with increased 5-year mortality. CONCLUSION: Pericardiectomy remains a safe operation for constrictive pericarditis with optimal mid-term outcomes.

Fluid Balance of the Second Day Following Operation is Associated with Early Mortality and Multiorgan Failure After Pericardiectomy for Constrictive Pericarditis.

BACKGROUND: The operative mortality of pericardiectomy still is high. This retrospective study was conducted to determine the risk factors of early mortality and multiorgan failure. METHODS: We retrospectively analyzed patients undergoing pericardiectomy from January 2009 to June 2020 at our hospital. Pericardiectomy was performed via sternotomy. Histopathologic studies of pericardium tissue from every patient were done. All survivors were monitored to the end date of the study. RESULTS: Ninety-two consecutive patients undergoing pericardiectomy for constrictive pericarditis were included in the study. Postoperatively, central venous pressure significantly decreased, and left ventricular end diastolic dimension and left ventricular ejection fractions significantly improved. The overall mortality rate was 5.4%. The common postoperative complications include acute renal injury (27.2%), and multiorgan failure (8.7%). Analyses of risk factors showed that fluid balance of the second day following operation is associated with early mortality and multiorgan failure. In this series from Guangxi, China, characteristic histopathologic features of tuberculosis (60/92, 65.2%) of pericardium were the most common histopathologic findings, and 32 patients (32/92, 34.8%) had the histopathologic findings of chronic nonspecific inflammatory changes. The functional status of the patients improved after pericardiectomy; 6 months later postoperatively 85 survivors were in class I (85/87, 97.7%) and two were in class II (2/87, 2.3%). CONCLUSIONS: Tuberculosis is the most common cause of constrictive pericarditis in Guangxi, China. Fluid balance of the second day following operation is associated with early mortality and multiorgan failure after pericardiectomy for constrictive pericarditis in our study.

Acute Kidney Injury: Lessons from Pericardiectomy.

BACKGROUND: Acute kidney (renal) injury (AKI) is a severe and common complication that occurs in ~40% of patients undergoing cardiac surgery. AKI has been associated with increased mortality and worse prognosis. This prospective study was conducted to determine the risk factors for AKI after pericardiectomy and decrease the operative risk of mortality and morbidity. METHODS: This was a prospective, observational cohort study of patients with constrictive pericarditis undergoing pericardiectomy. All patients underwent pericardiectomy via median sternotomy. Serum creatinine was used as the diagnostic standard of AKI according to Kidney Disease Improving Global Outcomes classification. All survivors were monitored to the end date of the study. RESULTS: Consecutive patients (N = 92) undergoing pericardiectomy were divided into 2 groups: with AKI (n = 25) and without AKI (n = 67). The incidence of postoperative AKI was 27.2% (25/92). Hemodialysis was required for 10 patients (40%), and there were 5 operative deaths. Mortality, intubation time, time in intensive care unit, fresh-frozen plasma, and packed red cells of the group with AKI were significantly higher than those of the group without AKI. Both univariate and multivariate analyses showed that statistically significant independent predictors of AKI include intubation time, chest drainage, fresh-frozen plasma, and packed red cells. The latest follow-up data showed that 85 survivors were New York Heart Association class I (97.7%) and 2 were class II (2.3%). CONCLUSIONS: AKI after pericardiectomy is a serious complication and contributes to significantly increased morbidity and mortality. Prevention of AKI development after cardiac surgery and optimization of pre-, peri-, and postoperative factors that can reduce AKI, therefore, contribute to a better postoperative outcome and leads to lower rates of AKI, morbidity, and mortality.

Constrictive pericarditis: 21 years' experience and review of literature.

To the best of our knowledge there are no publications about Tunisian experience in constrictive pericarditis (CP); the aim of this study was therefore to review our twenty-one years' experience in terms of clinical and surgical outcomes and risk factors of death after pericardiectomy. An analytic bicentric and retrospective study carried out on 25 patients (20 male) with CP underwent pericardiectomy, collected over a 21-years period. The mean age was 40.46±16.74 years [7.5-72]. The commonest comorbid factor was tabagism (52%). The most common etiology was tuberculosis (n = 11, 44%). Dyspnea was the most common functional symptom (n = 21, 84%). Pericardiectomy was performed in all our patients within 2.9±3.19 months after confirmation of diagnosis. It was subtotal in 96% of cases. The commonest postoperative complications are pleural effusion (20%). Dyspnea was regressed within 1.8 months in 80% of cases and clinical signs of right heart failure within a mean duration of 1.62 months in 53% of cases. Perioperative mortality was 12% (3 deaths), late mortality was 4% (1 patient). Cardiopulmonary bypass, New York Heart Association (NYHA) over class II and right ventricular dysfunction are the prognostic factors of mortality (p = 0.001, 0.046, 0.019). Tuberculosis as etiology of CP had no impact on mortality. CP is a rare disease, with non-specific clinical signs. Pericardiectomy is effective with a significant improvement of the functional status of patients and favorable outcome at short and long term nevertheless hospital mortality is not negligible and depends on many factors.

MELD and MELD XI Scores as Predictors of Mortality After Pericardiectomy for Constrictive Pericarditis.

OBJECTIVE: To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis. PATIENTS AND METHODS: Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity. RESULTS: A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays. CONCLUSION: Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.

Tricuspid Valve Regurgitation in Patients Undergoing Pericardiectomy for Constrictive Pericarditis.

We hypothesized that tricuspid valve regurgitation was associated with increased risk of mortality after pericardiectomy for constrictive pericarditis. We reviewed the records of 518 patients who received pericardiectomy for constrictive pericarditis between January 2000 and December 2016. We excluded cases of radiation induced constrictive pericarditis, tuberculous-related constrictive pericarditis, and concomitant tricuspid valve intervention. Patients were classified according to preoperative transthoracic echocardiography tricuspid regurgitation grade: none/trivial in 276 (53%) patients, mild in 191 (37%), and moderate/severe in 51 (10%). A multivariable Cox proportional hazards regression model was used to determine an association between tricuspid valve regurgitation grade and mortality. Primary endpoint of this study was mortality. Median patient age was 62 years (interquartile range 51-69), sex was male in 409 (79%) patients, and left ventricular ejection fraction was 60% (54-65). Clinical follow-up was obtained in all patients at a median of 7.6 years (3.6-11.3). Kaplan-Meier estimates of mortality were 10.6% at 1 year, 23.5% at 5 years, and 39.0% at 10 years. Multivariable analysis demonstrated increased mortality risk with mild tricuspid valve regurgitation vs none/trivial (hazard ratio 1.64; 95% confidence interval 1.11-2.43; P = 0.012) and moderate/severe tricuspid valve regurgitation vs none/trivial (hazard ratio 2.27; 95% confidence interval 1.39-3.69; P = 0.001). These findings were independent of right ventricular function. Tricuspid valve regurgitation is a common and clinically important comorbidity in patients operated with pericardiectomy for constrictive pericarditis. Mild or greater tricuspid valve regurgitation is associated with an increased risk of mortality following operation.

Pericardiectomy for constrictive pericarditis: a risk factor analysis for early and late failure.

Predictors of early and late failure of pericardiectomy for constrictive pericarditis (CP) have not been established. Early and late outcomes of a cumulative series of 81 (mean age 60 years; mean EuroSCORE II, 3.3%) consecutive patients from three European cardiac surgery centers were reviewed. Predictors of a combined endpoint comprising in-hospital death or major complications (including multiple transfusion) were identified with binary logistic regression. Non-parametric estimates of survival were obtained with the Kaplan-Meier method. Predictors of poor late outcomes were established using Cox proportional hazard regression. There were 4 (4.9%) in-hospital deaths. Preoperative central venous pressure > 15 mmHg (p = 0.005) and the use of cardiopulmonary bypass (p = 0.016) were independent predictors of complicated in-hospital course, which occurred in 29 (35.8%) patients. During follow-up (median, 5.4 years), preoperative renal impairment was a predictor of all-cause death (p = 0.0041), cardiac death (p = 0.0008), as well as hospital readmission due to congestive heart failure (p = 0.0037); while partial pericardiectomy predicted all-cause death (p = 0.028) and concomitant cardiac operation predicted cardiac death (p = 0.026), postoperative central venous pressure < 10 mmHg was associated with a low risk both of all-cause and cardiac death (p < 0.0001 for both). Ten-year adjusted survival free of all-cause death, cardiac death, and hospital readmission were 76.9%, 94.7%, and 90.6%, respectively. In high-risk patients with CP, performing pericardiectomy before severe constriction develops and avoiding cardiopulmonary bypass (when possible) could contribute to improving immediate outcomes post-surgery. Complete removal of cardiac constriction could enhance long-term outcomes.

Surgical Pericardiectomy for Constrictive Pericarditis: A Single Tertiary Center Experience.

BACKGROUND: Although surgery is the sole therapeutic option for patients with constrictive pericarditis (CP), reports on high postoperative mortality rates have led to hesitant surgery referral. The aim of this study was to report the short- and long-term outcomes of surgical pericardiectomy (SP) from a large tertiary center. METHODS: Between January 2005 and January 2017, 55 consecutive patients underwent SP after comprehensive echocardiography, computed tomography, and hemodynamic studies. Detailed clinical, imaging, surgical techniques and follow-up outcomes were recorded. RESULTS: The most common etiology was idiopathic (n = 27, 49%) and 33 patients (60%) were in functional class 3/4. Sixteen patients (29%) underwent concomitant interventions during SP, and cardiopulmonary bypass (CPB) was used in these, as well as in four additional cases. Complete resection, independent of CPB, was achieved in 96%. One patient died during the index hospitalization, and four (7%) needed re-explorations due to bleeding. While 12 patients (22%) died during a mean follow-up of 52 ± 39 months, only 1 death was due to right heart failure. Functional class significantly improved (with a p-value < 0.001), diuretics were discontinued in all, and significant reductions of right atrial pressures were recorded. None of these outcomes differed as a result of concomitant interventions at the time of SP. CONCLUSION: Short- and long-term outcomes of SP, performed either alone or concomitantly with other procedures, indicate high safety and favorable clinical and hemodynamic efficacy for the treatment of CP.

The effects of HIV/AIDS on the clinical profile and outcomes post pericardiectomy of patients with constrictive pericarditis: a retrospective review.

OBJECTIVE: The clinical profile and surgical outcomes of patients with constrictive pericarditis were compared in HIV-positive and -negative individuals. METHODS: This study was a retrospective analysis of patients diagnosed with constrictive pericarditis at Inkosi Albert Luthuli Central Hospital, Durban, over a 10-year period (2004-2014). RESULTS: Of 83 patients with constrictive pericarditis, 32 (38.1%) were HIV positive. Except for pericardial calcification, which was more common in HIV-negative subjects (n = 15, 29.4% vs n = 2, 6.3%; p = 0.011), the clinical profile was similar in the two groups. Fourteen patients died preoperatively (16.9%) and three died peri-operatively (5.8%). On multivariable analysis, age (OR 1.17; 95% CI: 1.03-1.34; p = 0.02), serum albumin level (OR 0.63; 95% CI: 0.43-0.92; p = 0.016), gamma glutamyl transferase level (OR 0.97; 95% CI: 0.94-0.1.0; p = 0.034) and pulmonary artery pressure (OR 1.49; 95% CI: 1.07-2.08; p = 0.018) emerged as independent predictors of pre-operative mortality rate. Peri-operative complications occurred more frequently in HIV-positive patients [9 (45%) vs 6 (17.6%); p = 0.030]. CONCLUSIONS: Without surgery, tuberculous constrictive pericarditis was associated with a high mortality rate. Although peri-operative complications occurred more frequently, surgery was not associated with increased mortality rates in HIV-positive subjects.

Re-pericardiectomy for recurrent chronic constrictive pericarditis: left anterolateral thoracotomy is a better approach.

BACKGROUND: Pericardiectomy is the final treatment for constrictive pericarditis. However, this greatest surgical approach is still very controversial. This study pursued to assess the outcomes in patients with recurrent chronic constrictive pericarditis undergoing reoperated pericardiectomy via median sternotomy versus left anterolateral thoracotomy and to explain which surgical approaches might be better for recurrent chronic constrictive pericarditis. METHODS: A total of 24 patients were identified with recurrent chronic constrictive pericarditis and underwent reoperation with pericardiectomy between July 2003 and July 2015. The decision for this surgical approach was mainly dependent on the operating surgeon's preference. Out of 20 patients, 16 patients underwent pericardiectomy via median sternotomy and 8 patients via left anterolateral thoracotomy pericardiectomy. Their data were obtained retrospectively from the case notes. RESULTS: Both groups of patients were similar in age, gender between two operations, and also in peripheral venous pressure, cardiac rhythm and New York Heart Association (NYHA) class distribution. The mortality rates were similar in both groups with one death (12.5%) due to low cardiac output syndrome in the left anterolateral thoracotomy group and two deaths (12.5%) in the median sternotomy group. All the deaths were associated with cardiac complications and happened in the perioperative period. NYHA functional class status enhanced in most of the patients. Patients in both groups had a similar and significant improvement in their NYHA status that improved from 3.4 ± 0.7 to 1.8 ± 0.1 (P = 0.001) in the left anterolateral thoracotomy group and reduced from 3.3 ± 0.6 to 1.9 ± 0.4 (P = 0.001) in the median sternotomy group. There was a significantly greater rate of pulmonary infection in the thoracotomy group than in the median sternotomy group (50% versus 25%, P = 0.02). Nevertheless, there was a significantly greater occurrence of wound infections in the median sternotomy group in 3 patients versus in one patient of the left anterolateral thoracotomy group (18.8% versus 12.5%, P = 0.02). CONCLUSIONS: Left thoracotomy incision was preferred to sternotomy in the current setting of this situation and was done safely without CPB. It avoided life-threatening sternal infection and it also has showed an equal as well las significant enhancement of NYHA status of the patients.

Right Atrial/Pulmonary Arterial Wedge Pressure Ratio in Primary and Mixed Constrictive Pericarditis.

BACKGROUND: Cardiac filling pressures may be elevated due to abnormalities in the myocardium, heightened pericardial restraint, or both. The authors hypothesized that the relative contributions due to myocardium and pericardium could be estimated by the ratio between right atrial pressure and pulmonary arterial wedge pressure (RAP/PAWP), which would enable better discrimination of the extent of myocardial disease in patients with constrictive pericarditis (CP). OBJECTIVES: This study investigated the relationships between RAP/PAWP and the pericardial thickness as well as echocardiographic parameters of myocardial function and assessed the prognostic implications of RAP/PAWP for long-term mortality in primary and mixed CP patients who underwent pericardiectomy. METHODS: A total of 113 surgically confirmed CP patients who underwent echocardiography and cardiac catheterization within 7 days of each other between 2005 and 2013 were included in the study. The patients were classified into a high RAP/PAWP group (≥0.77; n = 56) or a low RAP/PAWP group (<0.77; n = 57) according to the median RAP/PAWP value. The primary outcome was prognostic implication of RAP/PAWP on long-term mortality and assessment of the relationship between RAP/PAWP and Doppler echocardiographic parameters in primary and mixed CP. In addition, the relationship between RAP/PAWP and the pericardial thickness was assessed. RESULTS: RAP/PAWP was directly correlated with pericardial thickness (regression coefficient [ß] = 8.34; p < 0.001). RAP/PAWP had a significant direct correlation with early diastolic velocity of medial mitral annulus (e') (ß = 10.69; p < 0.001) and inverse relationship with early transmitral diastolic velocity (E) (ß = -105.15; p < 0.001), resulting in an inverse relationship with the ratio of E/e' (ß = -23.53; p < 0.001). Patients with high RAP/PAWP ratio had a better survival rate compared with those with low RAP/PAWP ratio (p = 0.01). Its prognostic value was significant in primary CP (p = 0.03) but not in mixed CP with concomitant myocardial disease (p = 0.89). CONCLUSIONS: The RAP/PAWP ratio can reflect the degree of pericardial restraint versus restrictive myocardium and was associated with the long-term survival after pericardiectomy.

Model for end-stage liver disease predicts mortality after pericardiectomy for constrictive pericarditis.

OBJECTIVES: Prognosis after pericardiectomy for constrictive pericarditis (CP) is affected by the aetiology of the constriction as well as by concomitant cardiac and non-cardiac disease, including liver dysfunction. However, few data exist on the risk stratification that accounts for liver function in patients with CP. We evaluated the effectiveness of the model for end-stage liver disease (MELD) score, an established measure of liver dysfunction, in predicting long-term survival and identifying other risk factors for death. METHODS: A total of 79 patients who underwent pericardiectomy for CP at a single centre between 2009 and 2016 were analysed. The prognostic utility of the MELD score was evaluated in our cohort. Logistic regression and Cox proportional hazard regression analyses were performed to assess the association of various clinical variables with 1-year and overall mortality rates. RESULTS: With multivariable analysis, only the MELD score was an independent predictor of 1-year mortality (P < 0.001); apart from the MELD (P = 0.003) score, post-surgical CP (P = 0.016), total bilirubin level (P = 0.042) and the European System for Cardiac Operative Risk Evaluation score II (P = 0.002) were independent predictors of overall mortality after pericardiectomy. Overall survival decreased as the MELD score increased. Scores ≤ 7.5, 7.51-15.50 and >15.5 were associated with overall survival rates of 92.9%, 69.8% and 8.3%, respectively. CONCLUSIONS: In addition to the underlying aetiology, we demonstrated that assessment of liver dysfunction using the MELD score provides additional information about risk because it is associated with postoperative death in patients undergoing pericardiectomy for CP.

Anterior Pericardiectomy for Postinfective Constrictive Pericarditis: Intermediate-Term Outcomes.

BACKGROUND: Posttubercular constrictive pericarditis is prevalent pericardial disease in developing countries. Pericardiectomy is the treatment of choice but considered a procedure of high morbidity and mortality. METHODS: From January 2003 to December 2013 we performed 130 pericardiectomies. The patients' mean age was 22.95 ± 12.55 years, and there were 92 (71%) male patients. All patients were symptomatic; 118 (91%) were in New York Heart Association functional class III or IV. Almost all patients were diagnosed to be of tubercular origin: 14 (11%) were histopathologically proven, 77 (59%) had definitive history, 39 (30%) were suspected to be of tubercular origin, and 91 (70%) received prior antitubercular treatment. RESULTS: Anterior pericardiectomy was done without the use but with provision for cardiopulmonary bypass, which was required in 5 (3.8%) patients for repair of tear in right atrium. Following pericardiectomy central venous pressure dropped from 20.9 to 10.8 mm Hg. Early mortality was 10 (7.69%). Prolonged ventilation was required in 22 (16.92%) patients, 31 (23.84%) developed renal dysfunction, and there were 3 (3.12%) cases of new-onset atrial fibrillation. On analysis of univariate predictors for early mortality, low ejection fraction (p < 0.001) and preoperative atrial fibrillation (p < 0.001) were found to be significant. In a follow-up of 12 months, 85% patients were in New York Heart Association functional class I or II with mean ejection fraction of 52%. There was no recurrence of constriction from residual pericardium on 1-year follow-up. CONCLUSIONS: Anterior pericardiectomy is sufficient in patients with constrictive pericarditis of infective etiology. Preoperative low ejection fraction, atrial fibrillation, poor functional class, and constrictive effusive pericarditis results in poor surgical outcome.

Constrictive pericarditis: retrospective study of 109 patients.

Background Chronic constrictive pericarditis is the most common diastolic disorder of the heart. Non-elasticity of the pericardium with impaired cardiac diastolic function is constriction. Chronic constrictive pericarditis is the result of scarring and fibrosis in mid and late diastole. The clinical presentation is similar to that of right heart failure. Historically, the etiology is helpful but not diagnostic. Echocardiography and a hemodynamic study are the main diagnostic tools. A thick pericardium of more than 4 mm is not necessarily constrictive, but thickness ≥7 mm is highly specific for constrictive features. Pericardiectomy is usually associated with early normalization of hemodynamics, which can be achieved via a mid-sternotomy or left anterolateral thoracotomy. Methods Data of 109 patients who underwent pericardiectomy from January 1987 to June 2016 were reviewed retrospectively. Results The outcome of our 109 cases consisted of mortality in 2 patients only. Conclusion Progressive, fibrotic, thickened, adherent inflammatory changes in response to various pathologies of the pericardium impairing diastolic filling can be treated by pericardiectomy. Pericardiectomy can be achieved by a mid-sternotomy or anterolateral thoracotomy without any difference in outcome. The initial hemodynamic and clinical result may not always be dramatic but continued improvement is definite because of progressive enlargement of left ventricular dimensions.

Pericardiectomy for Constrictive Pericarditis: An Institution's 21 Years Experience.

BACKGROUND: The aim of this retrospective study was to evaluate our experience with the surgical pericardiectomy procedure for patients suffering from isolated severe constrictive pericarditis. METHODS: From 1995 to 2016, 39 patients underwent isolated pericardiectomy for constrictive pericarditis. Fifteen patients were excluded because of concomitant surgery. There were 31 male (79.5%) patients and 8 female (20.5%) patients, 28 to 76 years old (mean, 56.6 ± 13.6 years). The underlying etiologies were idiopathic pericarditis (74.5%), infection (10%), rheumatic disorders (8%), status post cardiac surgery (2.5%), tuberculosis (2.5%), and status post mediastinal irradiation (2.5%). RESULTS: Pericardiectomy was performed through midline sternotomy in all cases. Sixteen patients (41%) underwent pericardiectomy electively employing cardiopulmonary bypass with the heart beating, and 23 patients (59%) had surgery without extracorporeal circulation (ECC). The overall 30-day mortality rate was 50% if cardiopulmonary bypass was used (13.8% since 2007). If surgery was performed without a heart-lung machine, mortality was 0%. On-pump patients had a significantly longer intensive care unit (ICU) stay (12 ± 9 vs. 4 ± 4 days, p = 0.013). Likewise, the duration of mechanical ventilation was much longer (171 ± 246 vs. 21 ± 40 hours, p = 0.04). The hospital stay was comparable with 28 ± 10 and 24 ± 18 days (p = 0.21). CONCLUSION: The present study demonstrates that pericardiectomy, without the use of cardiopulmonary bypass as treatment for constrictive pericarditis, is a safe procedure with an excellent outcome in critically ill patients.

Importance of Clinical and Laboratory Findings in the Diagnosis and Surgical Prognosis of Patients with Constrictive Pericarditis / Importância dos Achados Clínicos e Laboratoriais no Diagnóstico e Prognóstico Cirúrgico de Pacientes com Pericardite Constritiva

Abstract Background: International studies have reported the value of the clinical profile and laboratory findings in the diagnosis of constrictive pericarditis. However, Brazilian population data are scarce. Objective: To assess the clinical characteristics, sensitivity of imaging tests and factors related to the death of patients with constrictive pericarditis undergoing pericardiectomy. Methods: Patients with constrictive pericarditis surgically confirmed were retrospectively assessed regarding their clinical and laboratory variables. Two methods were used: transthoracic echocardiography and cardiac magnetic resonance imaging. Mortality predictors were determined by use of univariate analysis with Cox proportional hazards model and hazard ratio. All tests were two-tailed, and an alpha error ≤ 5% was considered statically significant. Results: We studied 84 patients (mean age, 44 ± 17.9 years; 67% male). Signs and symptoms of predominantly right heart failure were present with jugular venous distention, edema and ascites in 89%, 89% and 62% of the cases, respectively. Idiopathic etiology was present in 69.1%, followed by tuberculosis (21%). Despite the advanced heart failure degree, low BNP levels (median, 157 pg/mL) were found. The diagnostic sensitivities for constriction of echocardiography and magnetic resonance imaging were 53.6% and 95.9%, respectively. There were 9 deaths (10.7%), and the risk factors were: anemia, BNP and C reactive protein levels, pulmonary hypertension >55 mm Hg, and atrial fibrillation. Conclusions: Magnetic resonance imaging had better diagnostic sensitivity. Clinical, laboratory and imaging markers were associated with death.

Resumo Fundamento: Estudos internacionais têm relatado o valor de perfil clínico e exames de imagem no diagnóstico e prognóstico da pericardite constritiva. Entretanto, dados da população brasileira são escassos. Objetivo: Avaliar as características clínicas, sensibilidade de exames de imagem e fatores relacionados ao óbito em uma série de casos de pericardite constritiva submetidos à pericardiectomia. Métodos: Pacientes com pericardite constritiva confirmada por cirurgia foram avaliados retrospectivamente quanto a variáveis clínicas e laboratoriais. Dois métodos diagnósticos foram utilizados: ecocardiograma transtorácico e ressonância cardíaca. Preditores de mortalidade foram determinados por análise univariada usando metodologia das proporções de Cox e hazard ratio. Todos os testes foram considerados bicaudais e um erro alfa ≤ 5% foi considerado como significante. Resultados: Foram estudados 84 pacientes com idade média de 44 ± 17,9 anos, sendo 67% do sexo masculino. Sinais e sintomas de insuficiência cardíaca (IC) predominantemente direita estiveram presentes com estase jugular, edema e ascite em 89%, 89% e 62% dos casos, respectivamente. Etiologia idiopática foi observada em 69% dos casos, seguida por tuberculose em 21%. Apesar do grau de IC, encontramos baixos níveis de BNP (mediana de 157 pg/mL). As sensibilidades diagnósticas para constrição do ecocardiograma e da ressonância foram 53,6% e 95,9%, respectivamente. Durante a evolução clínica, houve 9 óbitos (10,7%) e os fatores de risco foram: anemia, elevações de BNP, PCR, hipertensão pulmonar > 55 mmHg e fibrilação atrial. Conclusões: Pericardite constritiva manifesta-se com sinais e sintomas de IC biventricular com predomínio à direita e baixos níveis de BNP. A ressonância magnética apresenta melhor sensibilidade para diagnóstico. Marcadores clínicos, laboratoriais e de imagem estiveram associados ao óbito.

Importance of Clinical and Laboratory Findings in the Diagnosis and Surgical Prognosis of Patients with Constrictive Pericarditis.

BACKGROUND: International studies have reported the value of the clinical profile and laboratory findings in the diagnosis of constrictive pericarditis. However, Brazilian population data are scarce. OBJECTIVE: To assess the clinical characteristics, sensitivity of imaging tests and factors related to the death of patients with constrictive pericarditis undergoing pericardiectomy. METHODS: Patients with constrictive pericarditis surgically confirmed were retrospectively assessed regarding their clinical and laboratory variables. Two methods were used: transthoracic echocardiography and cardiac magnetic resonance imaging. Mortality predictors were determined by use of univariate analysis with Cox proportional hazards model and hazard ratio. All tests were two-tailed, and an alpha error ≤ 5% was considered statically significant. RESULTS: We studied 84 patients (mean age, 44 ± 17.9 years; 67% male). Signs and symptoms of predominantly right heart failure were present with jugular venous distention, edema and ascites in 89%, 89% and 62% of the cases, respectively. Idiopathic etiology was present in 69.1%, followed by tuberculosis (21%). Despite the advanced heart failure degree, low BNP levels (median, 157 pg/mL) were found. The diagnostic sensitivities for constriction of echocardiography and magnetic resonance imaging were 53.6% and 95.9%, respectively. There were 9 deaths (10.7%), and the risk factors were: anemia, BNP and C reactive protein levels, pulmonary hypertension >55 mm Hg, and atrial fibrillation. CONCLUSIONS: Magnetic resonance imaging had better diagnostic sensitivity. Clinical, laboratory and imaging markers were associated with death.

Experience With Pericardiectomy for Constrictive Pericarditis Over Eight Decades.

BACKGROUND: The purpose of this study was to review the surgical outcomes of pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period. METHODS: We reviewed all patients who underwent pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990-2013) group (n = 807). RESULTS: Patients in the contemporary group were older (61 versus 49 years; p < 0.001), more symptomatic (NYHA class III or IV in 79.6% versus 71.2%; p < 0.001), and more frequently underwent concomitant procedures (21.4% versus 5.4%; p < 0.001) compared with those in the historical group. In contrast to the historical cases in which the etiologies of constriction were mostly idiopathic (81.1%), nearly half of contemporary cases had a nonidiopathic etiology (postoperative 32.3%, radiation 11.4%). Although 30-day mortality decreased from 13.5% in the historical era to 5.2% in the contemporary era (p < 0.001), overall survival was similar after adjusting for patient characteristics. Risk factors of overall mortality in the contemporary group included NYHA class III or IV (HR 2.17, p < 0.001), etiology of radiation (HR 3.93, p < 0.001) or postcardiac surgery (HR 1.47, p < 0.001), and need for cardiopulmonary bypass (HR 1.35, p = 0.014). CONCLUSIONS: There was a significant change in disease etiology over the study period. Long-term survival after pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

Surgical Treatment of Constrictive Pericarditis.

Constrictive pericarditis is the final stage of a chronic inflammatory process characterized by fibrous thickening and calcification of the pericardium that impairs diastolic filling, reduces cardiac output, and ultimately leads to heart failure. Transthoracic echocardiography, computed tomography, and cardiac magnetic resonance imaging each can reveal severe diastolic dysfunction and increased pericardial thickness. Cardiac catheterization can help to confirm a diagnosis of diastolic dysfunction secondary to pericardial constriction, and to exclude restrictive cardiomyopathy. Early pericardiectomy with complete decortication (if technically feasible) provides good symptomatic relief and is the treatment of choice for constrictive pericarditis, before severe constriction and myocardial atrophy occur. We describe our surgical approach to constrictive pericarditis, summarize our results in 93 patients, and provide a brief overview of the literature.

Long-Term Clinical Outcomes and Prognostic Factors After Pericardiectomy for Constrictive Pericarditis in a Japanese Population.

BACKGROUND: Constrictive pericarditis (CP) is characterized by impaired diastolic cardiac function leading to heart failure. Pericardiectomy is considered effective treatment for CP, but data on long-term clinical outcomes after pericardiectomy are limited.Methods and Results:We retrospectively investigated 45 consecutive patients (mean age, 59±14 years) who underwent pericardiectomy for CP. Preoperative clinical factors, parameters of cardiac catheterization, and cardiac events were examined. Cardiac events were defined as hospitalization owing to heart failure or cardiac death.Median follow-up was 5.7 years. CP etiology was idiopathic in 16 patients, post-cardiac surgery (CS) in 21, tuberculosis-related in 4, non-tuberculosis infection-related in 2, infarction-related in 1, and post-radiation in 1. The 5-year event-free survival was 65%. Patients with idiopathic CP and tuberculosis-related CP had favorable outcomes compared with post-CS CP (5-year event-free survival: idiopathic, 80%; tuberculosis, 100%; post-CS, 52%). Higher age (hazard ratio: 2.51), preoperative atrial fibrillation (3.25), advanced New York Heart Association class (3.92), and increased pulmonary artery pressure (1.06) were predictors of cardiac events. Patients with postoperative right-atrial pressure ≥9 mmHg had lower event-free survival than those with right-atrial pressure <9 mmHg (39% vs. 75% at 5 years, P=0.013). CONCLUSIONS: Long-term clinical outcomes after pericardiectomy among a Japanese population were related to the underlying etiology and the patient's preoperative clinical condition. Postoperative cardiac catheterization may be helpful in the prediction of prognosis after pericardiectomy.