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.

Fifteen-year experience with pericardiectomy at a tertiary referral center.

PURPOSE: Pericardiectomy has traditionally carried relatively high perioperative mortality and morbidity, with few published reports of intermediate- and long- term outcomes. We investigated our 15-year experience performing pericardiectomy at our institution. METHODS: Retrospective study of all patients who underwent pericardiectomy at our institution between 2005 and 2019. Baseline demographics, intraoperative details, and postoperative outcomes including long-term survival were analyzed. RESULTS: Sixty-three patients were included in the study. 66.7% of subjects underwent isolated pericardiectomy while 33.3% underwent pericardiectomy concomitantly with another cardiac surgical procedure. The most common indications for pericardiectomy were constrictive (79.4%) and hemorrhagic (9.5%) pericarditis. Preoperatively, 76.2% of patients were New York Heart Association class II and III, while postoperatively, 71.4% were class I and II. One-, three-, five-, and ten- year overall mortality was 9.5, 14.3, 20.6, and 25.4%, respectively. Overall pericarditis recurrence rate was 4.8%. CONCLUSION: Pericardiectomy carries relatively high overall mortality rates, which likely reflects underlying disease etiology and comorbidities. Patients with prior cardiac intervention, history of dialysis, and immunocompromised state are associated with worse outcomes.

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.

Effectiveness and outcomes of 2 therapeutic interventions for cardiac tamponade: A retrospective observational study.

Pericardial effusions can either be drained by percutaneous pericardiocentesis (PCC) or by surgical pericardiotomy (SP), with limited evidence of superiority for the management of cardiac tamponade (CTa).This study uses the US Nationwide Emergency Department Sample database to investigate the effectiveness of SP and PCC in patients with CTa in terms of clinical outcomes and healthcare costs.Retrospective observational study conducted on the US Nationwide Emergency Department Sample 2014 dataset CTa patients. Descriptive and multivariate logistic regression analyses were done to assess the impact of different procedures (none, SP, PCC, SP, and PCC) on mortality.A total of 10,410 CTa patients were included, of which 28.9% underwent no procedure, 32.9% underwent SP, 30.2% underwent PCC and 8.0% underwent SP and PCC. Mortality rates were highest in patients undergoing no procedure (22.3%) followed by PCC (15.0%), SP and PCC (11.5%), and then SP (9.6%) (P < .001). SP patients had longer length of stay (11.65 vs 8.16 days, P < .001) and higher total charges ($162,889.1 vs $100,802, P < .001) compared to PCC patients. Undergoing any procedure for CTa reduced the rate of mortality compared to no procedure with SP being the most effective (OR = 0.323, 95%CI 0.244-0.429), followed by SP & PCC (OR = 0.387, 95% CI 0.239-0.626), and then PCC (OR = 0.582, 95% CI 0.446-0.760).Adult CTa patients treated with SP had lower mortality rates but longer length of stay and higher healthcare expenses. This SP associated benefit remained consistent across different subpopulations after stratifying by age and potential disease etiology.

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.

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.

Radical pericardiectomy for chronic constrictive pericarditis.

BACKGROUND: We studied the impact of radical pericardiectomy on early and long-term patient survival, postoperative New York Heart Association (NYHA) functional class, and left ventricular ejection fraction in patients with chronic constrictive pericarditis compared to a sub-total pericardiectomy. METHODS: From 1991 to 2016, 41 patients underwent pericardiectomy for chronic constrictive pericarditis. Sub-total pericardiectomy was performed in 17 (41%) and radical pericardiectomy in 24 (59%) patients. Patients in the two study groups had statistically similar NYHA functional class, left ventricular ejection fraction, and cardiac catheterization data. Follow-up was 100% complete with a median time of 4 years. RESULTS: Radical pericardiectomy resulted in increased survival rates at 10 years (94%) compared to sub-total pericardiectomy (55%) (P = 0.014). In the idiopathic chronic constrictive pericarditis sub-group, long-term survival rates were also increased after a radical pericardiectomy (P = 0.001). Eighty-five percent of patients after a radical pericardiectomy were in NYHA functional class I or II after 5 years and 94% up to 25 years versus 53% and 63%, respectively, for the sub-total pericardiectomy group. CONCLUSIONS: Radical pericardiectomy provided superior 10-year survival and clinical functional improvement in patients with chronic constrictive pericarditis compared to sub-total pericaridectomy.

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.

Long-Term Outcomes after Video-Assisted Thoracoscopic Pericardiectomy for Pericardial Effusion.

PURPOSE: Chronic or recurrent pericardial effusion is often associated with malignant disease. However, there have been few reports of the long-term outcomes after video-assisted thoracoscopic (VATS) pericardiectomy. We have performed it since 1992, and report our procedure and outcomes. METHODS: Patients who underwent VATS pericardiectomy were investigated. RESULTS: In all, 29 patients (12 men; median age: 61 (23-88) years) were evaluated; 8 had no malignancies and 21 did. Preoperative performance status (PS) scores were as follows: 1, 11 patients; 2, 10 patients; 3, 5 patients; and 4, 2 patients. One patient with malignancy died intraoperatively. PS improved significantly after the procedure (p = 0.0163). Median survival times were 5360 days in the nonmalignant group, 160 days in the malignant group, 209 days in breast cancer patients, and 62 days in other malignancy patients. The nonmalignant group had significantly longer survival than the malignant group (p = 0.0015). Most cases had uneventful postoperative courses. No recurrent pericardial effusions have been observed. CONCLUSION: In cases of nonmalignant pericardial effusion, long-term survival is expected following VATS pericardiectomy. Malignant pericardial effusion has a poor prognosis, but most cases maintain good PS. However, early postoperative death may occur, and it is important to select patients carefully.

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.

Results of pericardiectomy for constrictive pericarditis : Single-center experience.

BACKGROUND: We evaluated our early and late outcomes after pericardiectomy in patients with constrictive pericarditis (CP). PATIENTS AND METHODS: We retrospectively reviewed 31 patients who underwent pericardiectomy for CP from 1997 to 2015. Their mean age was 49.2 ± 18.5 years and 74.2 % of them were male. The vast majority had severe functional impairment (NYHA class III-IV) with a mean duration of symptoms of 14.2 ± 10.1 months. RESULTS: Early mortality was 9.7 %: n = 3; multiorgan failure (MOF) in 1, respiratory failure in 1, and left heart failure in 1. Preoperative systolic pulmonary artery pressure over 60 mmHg (p = 0.038, odds ratio [OR] = 0.12) and postoperative low cardiac output syndrome (p = 0.005, OR = 13.5) were significant predictors of early mortality in univariate analysis. Mean follow-up time was 57.8 ± 61.9 months (4-216 months). Late mortality was 6.8 % (2/28 patients) and the cause was MOF secondary to end-stage right heart failure. In Kaplan-Meier analyses, actuarial (including early mortality) and event-free survival rates were 83.9 and 51.1 % at 216 months, respectively. At the end of follow-up, the majority of patients (23/26, 92.9 %) were in good functional status (NYHA class I-II). There were fewer patients under diuretic therapy in the postoperative than in the preoperative period; however, the difference was not statistically significant (12/31 vs. 4/26, p = 0.76). There was no significant difference between the preoperative and follow-up tricuspid annular plane systolic excursion values (15.5 ± 2.2 and 16.6 ± 2.2 mm, respectively, p = 0.088). Left ventricular systolic function was preserved in all patients postoperatively. CONCLUSION: Although early mortality after pericardiectomy remains high, the procedure provides significant improvement in functional status in the long term.

Right-Sided Heart Failure and Extracorporeal Life Support in Patients Undergoing Pericardiectomy for Constrictive Pericarditis: A Risk Factor Analysis for Adverse Outcome.

Background Right ventricular failure is a life-threatening postoperative complication after pericardiectomy. We conducted a retrospective study with a special emphasis on right ventricular failure. Methods Between June 1997 and September 2011, 69 patients underwent surgical pericardiectomy at our center. Mean age was 59 ( ± 15.5) years, and 49 (71%) patients were male. Causes of constrictive pericarditis included idiopathic (52%, n = 36), tuberculosis (9%, n = 6), postcardiotomy (12%, n = 8), radiation (4%, n = 3), renal insufficiency (12%, n = 8), and autoimmune disease (12%, n = 8). Concomitant cardiac surgery was performed in 33 (48%) patients. Results In-hospital mortality rate was 14% (10/69 patients). Extracorporeal membrane oxygenation (ECMO) was necessary in 8 (12%) cases because of right (n = 7) or biventricular (n = 1) failure. Statistical analysis showed a significant correlation between early mortality and the following preoperative variables: postcardiotomy (p = 0.049), radiation (p = 0.009), pleural effusion (p = 0.012), ascites (p = 0.039), hepatic congestion (p = 0.023), absence of calcification on X-ray (p = 0.041), tricuspid valve insufficiency (TI, p < 0.001), and low cardiac index (p = 0.003). Diuretic usage (p = 0.044), peripheral edema (p = 0.050), low voltage (p = 0.027), dip-plateau sign (p = 0.027), elevated GGT (p < 0.001), and decreased serum protein (p < 0.001) correlated with ECMO implantation. Binary logistic regression identified pleural effusion (OR = 16.2, 95% CI = 1.4-191.5), moderate/severe TI (OR = 28.8, 95% CI = 2.7-306.8) and low cardiac index (OR = 25.3, 95% CI = 2.0-315.6) as preoperative independent risk factors for early mortality, whereas elevated GGT (OR = 28.3, 95% CI = 2.4-329.2) and decreased protein (OR = 24.7, 95% CI = 1.8-343.7) could predict right ventricular failure with the need for ECMO. Conclusion We recommend nondelayed ECMO support in case of significant postoperative right-sided heart failure. High-risk patients might benefit from elective pre- or intraoperative ECMO implantation.

Pericardiectomy After Previous Bypass Grafting: Analyzing Risk and Effectiveness in this Rare Clinical Entity.

BACKGROUND: Historically the most common causes of pericarditis necessitating pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. METHODS: From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. We identified 98 patients who underwent pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38-81 years), and 91 of the patients (93%) were men. The indication for pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%-71%) and median NYHA functional class was III (91% were class III/IV). RESULTS: The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03-3.7]; p = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. CONCLUSIONS: The rate of early mortality for pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.

A 20-year experience with isolated pericardiectomy: Analysis of indications and outcomes.

OBJECTIVES: Outcome after pericardiectomy depends on many factors, but no large study has provided clarity on the effects of patient variables or cause of pericarditis on patient survival. We report early and late results from a 20-year experience with isolated pericardiectomy. METHODS: From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. In order to establish a homogeneous population to analyze the impact of pericardiectomy, we excluded patients with prior chest radiation, malignancy, and concomitant valvular or coronary procedures. We identified a cohort of 521 who underwent isolated pericardiectomy; of these, 513 patients gave consent for research and comprise the cohort for this analysis; median age at operation was 57 years (range, 18-84 years) and 363 (71%) were men. Indications for pericardiectomy were effusive/chronic relapsing pericarditis in 158 (31%) and pericardial constriction in 355 (69%). Prior coronary artery bypass grafting had been performed in 84 patients (14%). Median preoperative left ventricular ejection fraction was 60% (range, 24%-80%), and 77% of patients were in New York Heart Association (NYHA) functional class III/IV. RESULTS: Surgical approach was median sternotomy in 412 (80%), left thoracotomy in 71 (14%), and clamshell in 30 (5%). Extent of pericardial resection was radical in 414 (81%), subtotal in 71 (14%), and completion in 28 (5%). Cardiopulmonary bypass was used in 205 (40%). Overall mortality was 12/513 (2.3%); 3/158 (1.9%) for the effusive/chronic relapsing group versus 9/355 (2.5%) for the constriction group (P = .65). In the absence of multivariate predictors, which could not be identified, univariate predictors associated with increased risk of early death included lower left ventricular ejection fraction (hazard ratio [HR], 1.09; P = .03) and preoperative renal insufficiency (HR, 9.9; P < .001). Median duration of follow-up was 29 months (maximum 20.5 years) and overall 5-, 10-, and 15-year survival was 80%, 60%, and 38%, respectively. Overall survival according to surgical indication was higher in the effusive/chronic relapsing group when compared with the constriction cohort (P < .001). Independent predictors associated with increased risk of overall mortality identified on multivariate analysis included older age (HR, 1.05; 95% confidence interval [CI], [1.03, 1.07]; P < .001), congestive heart failure (HR, 1.49; 95% CI, [1.03, 2.2]; P = .02), diabetes (HR, 1.83; 95% CI, [1.2, 2.7]; P = .004), completion pericardiectomy (HR, 2.4; 95% CI, [1.2, 4.7]; P = .01), and chronic obstructive pulmonary disease (HR, 2.45; 95% CI, [1.5, 3.9]; P = .004). During the follow-up period, 80% of patients were free from NYHA functional class III/IV symptoms at 5 years and 78% at 10 years. CONCLUSIONS: Whereas early mortality after isolated pericardiectomy is low irrespective of the indication for surgery, late follow-up demonstrates better outcomes after pericardiectomy for effusive/chronic relapsing pericarditis compared with pericardial constriction. Importantly, the majority of patients were free from significant heart failure symptoms during follow-up.

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

OBJECTIVES: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.