- Email: [email protected]
Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute
Nicola Vistarini, MD, Christina Chen, BEng, Amine Mazine, MD, Denis Bouchard, MD, Yves Hebert, MD, Michel Carrier, MD, Raymond Cartier, MD, Philippe Demers, MD, Michel Pellerin, MD, and Louis P. Perrault, MD, PhD Department of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, Montreal, Quebec, Canada; and Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Pavia University School of Medicine, Pavia, Italy
Background. The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors. Methods. Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. Results. Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation
were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. Conclusions. The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.
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pericardiectomy at a single surgical center over a period of 20 years. The main objectives of our analysis were longterm survival, clinical outcome, and identification of risk factors for early and late mortality.
onstrictive pericarditis (CP) is a chronic inflammatory disease involving fibrotic lesions and serous effusions, leading to pericardial thickening, adhesions, and sometimes calcifications, thus causing ventricular compression [1]. The resulting heart failure is the consequence of impaired diastolic ventricular function and may be life-threatening for the patient [2, 3]. Despite the lack of prospective studies comparing the different therapeutic strategies, surgical pericardiectomy is a valuable treatment under most circumstances [4–10]. The main benefits of this operation are the increase in survival, the relief of symptoms, and the prevention of disease worsening [11–14]. Despite a general consensus supporting the procedure, this operation is still associated with significant morbidity. Previous studies have reported different early and long-term survival after pericardiectomy, with a great heterogeneity regarding preoperative and intraoperative risk factors [15–18]. The present study was designed to evaluate early and long-term results after Accepted for publication Feb 18, 2015. Address correspondence to Dr Perrault, Department of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, 5000 B elanger St, Montreal H1T 1C8, Quebec, Canada; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;100:107–13) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods Study Population and Study Design From January 1994 through February 2014, 99 consecutive patients underwent total or partial pericardiectomy at the Montreal Heart Institute, and they constitute the subjects of this report. Only the patients in whom the main surgical indication was CP were considered in the study. We also excluded the cases in which the pericardiectomy was an unplanned procedure, performed after an intraoperative finding of CP. The patients’ clinical charts were reviewed, and preoperative, intraoperative, and postoperative data were recorded on a computer-based surgical database. The CP was evaluated preoperatively by echocardiography, computed tomography (CT), angiography, magnetic resonance imaging (MRI), and chest roentgenography (Fig 1). We considered in our analysis relevant clinical information: demographics (age, sex, race), cause of CP (idiopathic, infectious, postsurgical, 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.054
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Fig 1. Preoperative evaluation of a patient with constrictive calcified pericarditis. (A) Chest roentgenogram. (B) Cardiac angiogram. (C) Chest computed tomographic scan.
postirradiation, miscellaneous), clinical signs and symptoms (New York Heart Association [NYHA] class, duration of symptoms, distended jugular veins, hepatomegaly, ascites, pulsus paradoxus, pleural effusion), comorbidities (systemic hypertension, diabetes, atrial fibrillation, renal insufficiency), echocardiographic data (left and right ventricular function, pulmonary hypertension, pericardial calcification), preoperative laboratory test results (creatinine, sodium, bilirubin, albumin), and intraoperative data (surgical approach, total or partial pericardiectomy, associated procedures, need for cardiopulmonary bypass [CPB]). Follow-up of patients was done with telephone calls to the patients or their relatives and through the reports of cardiologic clinical and echocardiographic controls.
Surgical Techniques Median sternotomy has been the preferred surgical approach in the great majority of cases, offering easy access for a complete pericardiectomy. Alternative approaches were left or right anterolateral thoracotomy, performed in the fourth or fifth intercostal space, and subxiphoid approach. In all cases of pericardiectomy, a circuit for extracorporeal circulation was ready to use, and the perfusionist was present in the operating room. External defibrillation pads were always installed before operation. Total pericardiectomy was defined as radical phrenic-to-phrenic excision of the pericardium, from the great arteries superiorly to the diaphragmatic surface inferiorly. Any other type of pericardial resection that did not meet these criteria was classified as a partial pericardiectomy. The key element of this surgical procedure, regardless of the extent of the resection, is the decompression of the right cavities, which are almost always at the center of the symptoms and therefore of the indication. In this sense it is important to remove any constriction from the orifices of the caval veins, and this can be obtained without touching the posterior surface of these vessels, simply breaking sufficiently the “banding effect” to achieve the result.
Definitions The causes of CP were deduced mainly by clinical history. Postsurgical pericarditis was defined when CP developed in patients with previous cardiac operations. Patients with a history of mediastinal irradiation were defined as having postirradiation pericarditis. Additional possible causes included infectious (bacterial or viral) or miscellaneous (posttraumatic, tumor-related, and post– myocardial infarction). Patients who did not fit in any of those groups were classified into the idiopathic group. The diagnosis of CP was mainly established on echocardiographic data: comprehensive evaluation of systolic and diastolic left and right ventricular function, search for abnormal motion of the interventricular septum, inferior venae cava dilatation, pericardial thickening, and variations in mitral and tricuspid inflow velocity and in pulmonary and hepatic vein flow. Other instrumental examinations that were used to complete or refine the diagnosis were invasive hemodynamic measurements, MRI, and high-resolution CT. Pericardial calcification was defined as the presence of calcifications detected preoperatively on chest roentgenogram, angiography, CT, or MRI (Fig 1). Hospital mortality was defined as death occurring in the first 30 days after operation or during the same hospitalization as for operation.
Statistical Analysis Statistical analyses were performed with the Statistical Package for Social Sciences (SPSS) version 20 (Chicago, IL). Continuous variables are presented as mean standard deviation, and categoric variables are reported as frequency (percentage). Predictors of hospital mortality were assessed by a multivariable logistic regression model. Variables screened as potential confounders were the preoperative baseline characteristics. All variables with p < 0.20 on univariate analysis were considered as having a potential confounding effect. Variables with p < 0.05 were retained in the final model. Long-term survival was assessed by Kaplan-Meier actuarial methods. Risk factors for late mortality were evaluated with a multivariable Cox proportional hazards model. The variables
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assessed as potential risk factors were the same as for hospital mortality, and variable selection was carried out in the same manner.
Results Preoperative Characteristics Table 1 shows the preoperative characteristics of patients. In two thirds of cases, CP was idiopathic. The miscellaneous causes of CP were prior chest trauma in 2 patients, malignancy in 1 patient, and myocardial infarction in 6 patients. The duration of symptoms was less than 6 months only in 47% of patients, and the remaining patients had symptoms for longer than 6 months, in some cases years. Two thirds of patients were in NYHA functional class III or IV.
Intraoperative Findings The patients’ intraoperative characteristics are reported in Table 2. The operation was performed through a standard sternotomy in the great majority of cases (97 patients). Left thoracotomy was performed in 1 patient, right thoracotomy in 1 patient, and a subxiphoid Table 1. Preoperative Characteristics Characteristic Age (y) Male gender Cause Idiopathic Infectious Postsurgical Postirradiation Miscellaneous NYHA preoperative class I II III IV NA LVEF (%) Distended jugular veins Hepatomegaly Ascites Pleural effusion Pericardial calcification Atrial fibrillation Diabetes mellitus Systemic arterial hypertension Renal failure (serum creatinine 120 mmol/L) Pulmonary hypertension (PAPs 60 mm Hg)
Median (Range)
n
%
60 (24–79) . . . . . . . . . . . . . 55 (14–70) . . . . . . . . .
. 85
. 86
60 15 13 2 9
61 15 13 2 9
7 23 61 7 1 . 51 29 22 41 62 34 16 47 20
7 23 62 7 1 . 52 29 22 41 63 34 16 47 20
.
5
5
LVEF ¼ left ventricular ejection fraction; NA ¼ not available; NYHA ¼ New York Heart Association; PAPs ¼ systolic pulmonary arterial pressure.
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Table 2. Intraoperative Characteristics Characteristic
n
%
Sternotomy Thoracotomy þ sternotomy Subxiphoid Thoracotomy Need for CPB Associated procedures Coronary artery bypass Valvular operation Miscellaneous Complete pericardiectomy
93 3 1 2 37 36 20 13 8 60
94 3 1 2 37 36 20 13 8 61
CPB ¼ cardiopulmonary bypass.
approach in another patient. In 3 patients a thoracotomy was initially performed, but then it was extended into a median sternotomy. Complete pericardiectomy was performed in 61% of patients. Associated procedures were performed in 36% of patients. Miscellaneous procedures included thymectomy (n ¼ 2), resection of epicardial pacemaker electrode (n ¼ 1), Maze procedure (n ¼ 1), Maze procedure and septal myomectomy (n ¼ 2), resection of lung cancer (n ¼ 1), and decortication of the lung (n ¼ 1). CPB was used in 37% of patients, but only 8 of them underwent isolated pericardiectomy.
Postoperative Findings Regarding the postoperative course, complications included renal failure (n ¼ 16), atrial fibrillation (n ¼ 16), pleural effusion (n ¼ 11), postoperative bleeding (n ¼ 9), respiratory failure (n ¼ 3), paralytic ileus (n ¼ 2), and hepatic failure (n ¼ 1). Hospital mortality was 9%, and the causes of death were multiorgan failure (n ¼ 4), heart failure (n ¼ 3), and respiratory failure (n ¼ 2). Among these 9 patients, pericardiectomy was incomplete in only 2 patients, CPB was required in 4 patients for associated cardiac procedures and in 2 patients for hemodynamic instability. Several preoperative variables (age, sex, race, cause of CP, NYHA functional class, duration of symptoms, distended jugular veins, hepatomegaly, ascites, pulsus paradoxus, pleural effusion, systemic hypertension, diabetes, atrial fibrillation, renal insufficiency, creatinine, sodium, bilirubin, albumin, left and right ventricular function, pulmonary hypertension, pericardial calcification) and intraoperative variables (surgical approach, total or partial pericardiectomy, associated procedures, need for CPB) were tested in the statistical analysis of the risk factors affecting hospital mortality after operations for CP. Table 3 shows the variables that were statistically significant at univariate and multivariate analysis. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality (odds ratio [OR] 0.11) compared with those who were symptomatic for longer times. Preoperative hepatomegaly was associated with significantly higher mortality on both univariate and multivariate analysis. No significant difference was found in mortality according to the cause
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Table 3. Univariate and Multivariate Analysis for Predictors of Hospital Mortality (entire cohort, n ¼ 99) Univariate Analysis
p Value
OR
0.075 0.045 0.020 0.009
1.071 0.114 5.368 7.200
Age Symptoms <6 months Hepatomegaly Associated valvular operation
95%
CI
0.993 1.155 0.014 0.950 1.302 22.135 1.632 31.763
Multivariate Analysis Age Symptoms <6 months Hepatomegaly Associated valvular operation CI ¼ confidence interval;
0.404 0.054 0.029 0.014
1.035 0.111 13.419 21.710
0.955 0.012 1.297 1.883
1.120 1.036 138.878 250.255
OR ¼ odds ratio.
of the CP. The only intraoperative variable found to be significant at univariate and multivariate analysis was concomitant valvular operation, and all 4 patients with early deaths underwent associated procedures, specifically valvular procedures. For this reason we performed a statistical subanalysis, considering only isolated cases of pericardiectomy, with the aim to assess outcomes and risk factors for this subgroup of patients. Hospital mortality was 7.9% in cases of isolated pericardiectomy and 11.1% in cases of associated procedures (p ¼ 0.93). Hepatomegaly, diabetes, preoperative creatinine, preoperative sodium, and chronic renal failure were associated with significantly higher mortality on univariate analysis (Table 4), but none of these variables were significant on multivariate analysis.
Long-Term Outcome Survival after pericardiectomy in the entire cohort of patients is shown in Figure 2, and 11 patients died over a median follow-up time of 54 months. The cause of death was cardiac related in 4 patients (1 case of bioprosthesis stenosis and 3 cases of cardiac failure), noncardiac related in 2 patients (1 for cancer and 1 for complications after lung operation), and unknown in the remaining 5 patients. Survival at 1, 3, and 5 years was 92.1%, 87.7%, and 79.4% for isolated pericardiectomy and 85.7%, 81.6%, and 81.6% in cases of pericardiectomy with associated procedures (Fig 3). The same variables tested for the analysis of the risk factors of hospital mortality were also Table 4. Univariate Analysis for Predictors of Hospital Mortality in Cases of Isolated Pericardiectomy (n ¼ 63) Univariate Analysis Age Hepatomegaly Diabetes Preoperative creatinine Preoperative sodium Chronic renal failure CI ¼ confidence interval;
p Value
OR
95%
CI
0.194 0.024 0.004 0.009 0.032 0.012
1.061 13.846 20.250 1.026 0.805 22.500
0.970 1.421 2.588 1.006 0.659 2.004
1.159 134.903 158.462 1.046 0.982 252.569
OR ¼ odds ratio.
evaluated for long-term mortality. The univariate analysis showed no significant risk factor for long-term mortality. The functional status at follow-up was greatly improved after pericardiectomy, as shown in Figure 4 by the increased number of patients in NYHA functional class I or II after the operation.
Comment The clinical outcome of pericardiectomy for CP remains constrained by high operative mortality. Our study has highlighted that some pre-and intra-operative factors, mainly related to the clinical condition of the patients, can adversely affect the short term outcome. However, if patients make it through the operation, the long-term survival and the clinical improvement are excellent in most cases. Hospital mortality was 9% in our series (7.9% in cases of isolated pericardiectomy and 11.1% in cases of associated procedures), which compares favorably with the 4.9% to 12% rate in other series published in the past 10 years [4, 6–9, 15–19]. The first aspect to consider in the analysis of this hospital mortality is represented by the fact that in our cohort, there were only two cases of postirradiation pericarditis. Previous studies have reported considerably different survival depending on the cause, with postirradiation pericarditis significantly associated with increased mortality [3, 4, 8–10, 20]. In fact, in these cases, there is not only diastolic heart failure caused by the constrictive process but also an element of systolic failure resulting from myocardial fibrosis and injury from the radiation therapy. This could explain why the outcomes are worse in series that have a higher number of postirradiation patients. Such a correlation was not possible in our study because of the small number of cases. This can be mainly related to the fact that these patients are operated on less frequently than they once were because there is evidence that even a complete pericardiectomy does not always relieve cardiac failure [3, 21]. Another possible explanation can be represented by the decrease in the absolute numbers of postirradiation pericarditis requiring pericardiectomy, certainly related to improved radiation strategies in oncology, leading to a lower incidence of this complication. Statistical analysis has shown that surgical treatment within 6 months of the onset of symptoms is associated with reduced hospital mortality (OR ¼ 0.11). This suggests that an early operation may prevent clinical deterioration and may provide a better outcome for patients with CP. The other preoperative factor significantly associated with increased mortality was hepatomegaly (OR ¼ 13.42). Also this aspect is directly linked to the evolution of clinical disease because it reflects an advanced stage of heart failure resulting from severe persistent pericarditis. In this context it seems therefore strongly recommended that patients with CP are referred for operation as quickly as possible once the symptoms have appeared. Previous studies have highlighted that even some markers of liver dysfunction (bilirubin),
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Fig 2. Kaplan-Meier curve for survival after pericardiectomy for constrictive pericarditis in the entire cohort of patients (n ¼ 99).
malnutrition, and overall poor health (hypoalbuminemia) are associated with an increased risk of short-term and long-term mortality [8]. In a recent study, Komoda and colleagues [17] showed that the Child-Pugh score is a useful tool for stratifying the risk of mortality after radical pericardiectomy, thus emphasizing that congestive hepatopathy and impairment of liver function are useful predictors of mortality. Other preoperative variables, such as age, NYHA functional class III or IV, and pericardial calcification, identified as risk factors in previous clinical studies, showed only a trend toward a worse outcome but did not reach statistical significance in our analysis. Concerning intraoperative variables, the only predictor of increased hospital mortality was the associated valvular operation (OR ¼ 21.71). This factor, although related to the type of operation performed, reflects the characteristics of patients who are usually sicker and require associated procedures. In this regard, which therapeutic strategy should be adopted for these patients remains a matter of debate. Possibly the higher surgical risk of a complete but complex operation could be reduced if only CP is treated in the first instance, which can be done almost always without extracorporeal circulation. In fact, this strategy could provide a clinical recovery that would allow the patient to undergo a valve operation hemodynamically compensated. However, it remains to assess the risk of repeated sternotomy, the optimal timing of reoperation, and the appropriate surgical strategy in cases of redo valve operations (conventional vs minimally invasive approach, transcatheter valve implantation, percutaneous mitral valve repair).
Concerning our statistical subanalysis of isolated cases of pericardiectomy, hepatic failure was confirmed to be a risk factor (OR ¼ 13.8), as were renal failure (OR ¼ 22.5) and diabetes (OR ¼ 20.2), which were also associated with increased mortality. Therefore, in summary, when the most complex cases with associated procedures were
Fig 3. Kaplan-Meier curves for survival, comparing isolated pericardiectomy cases (n ¼ 63) and pericardiectomy with associated procedures (n ¼ 36).
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Fig 4. Changes over time in the proportion of NYHA (New York Heart Association) functional classes.
excluded, the risks appeared to be mainly related to the preoperative comorbidities, as with any other type of heart operation. The impact of the surgical approach on outcome remains controversial, with an open debate that compares sternotomy with thoracotomy and total versus partial pericardiectomy [4, 6–8, 13]. Our experience and our data cannot support any comment about the benefits of a surgical approach over another because median sternotomy was the preferred approach in nearly all cases. The reasons for this choice are mainly related to better surgical exposure, easier complete pericardiectomy, greater versatility in case of associated procedures, and easier installation of extracorporeal circulation in case of complications. The need for CPB was not a predictor of hospital mortality in our series, and in most cases it was secondary to associated surgical procedures. Survival and clinical improvement for patients discharged after pericardiectomy were satisfactory. Our 5-year survival of 87.5% compares favorably with those in other published series (Cleveland Clinic, 7-year survival of 76% for idiopathic CP; Mayo Clinic, 5-year survival of 78%; Baltimore, 5-year survival of 79.8% for idiopathic CP; New York, 5-year survival of 94.6%) [3, 5, 8, 9], and it confirms the favorable evolution of the patients who survive the operation. On univariate analysis, no factor was significantly associated with an increased risk of long-term mortality; therefore, it was not possible to perform a multivariate analysis. The clinical outcome in late survivors was excellent, moving from 70% of patients in NYHA class III or IV preoperatively to 80% in NYHA class I or II postoperatively. Incomplete pericardiectomy was performed
in 55% of patients who experienced either new or recurrent NYHA class III or IV at follow-up. The study limitations are represented by the retrospective and observational design, with its inherent bias, and by the relative small sample size, given that it was a single-center study. In conclusion, although pericardiectomy for CP remains associated with high operative mortality, the longterm outcome is favorable, and surgical treatment is able to improve the functional class in the majority of late survivors. Some preoperative and intraoperative factors, mainly related to the patients’ clinical conditions, can adversely affect the short-term outcome. Associated valvular procedures significantly increase the risk of hospital mortality, and the most suitable surgical strategy in these cases remains to be determined. Patient selection and therapeutic strategy must therefore take account of these factors, and early operation appears to be the most appropriate choice to avoid clinical deterioration caused by heart failure.
References 1. Bergman M, Vitrai J, Salman H. Constrictive pericarditis: a reminder of a not so rare disease. Eur J Int Med 2006;17: 457–64. 2. DeValeria PA, Baumgartner WA, Casale AS, et al. Current indications, risks, and outcome after pericardiectomy. Ann Thorac Surg 1991;52:219–24. 3. 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. 4. Szab o G, Schmack B, Bulut C, et al. Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy:
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24 years of experience. Eur J Cardiothorac Surg 2013;44: 1023–8. 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;29: 434–8. Chowdhury UK, Subramaniam GK, Kumar AS, et al. Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques. Ann Thorac Surg 2006;81:522–30. Tokuda Y, Miyata H, Motomura N, et al, Japan Adult Cardiovascular Database Organization. Outcome of pericardiectomy for constrictive pericarditis in Japan: a nationwide outcome study. Ann Thorac Surg 2013;96:571–6. George TJ, Arnaoutakis GJ, Beaty CA, Kilic A, Baumgartner WA, Conte JV. Contemporary etiologies, risk factors, and outcomes after pericardiectomy. Ann Thorac Surg 2012;94:445–51. Bertog SC, Thambidorai SK, Parakh K, et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol 2004;43:1445–52. Ni Y, von Segesser LK, Turina M. Futility of pericardiectomy for postirradiation constrictive pericarditis? Ann Thorac Surg 1990;49:445–8. Somerville W. Constrictive pericarditis. With special reference to the change in natural history brought about by surgical intervention. Circulation 1968;38:102–11. Seifert FC, Miller DC, Oesterle SN, Oyer PE, Stinson EB, Shumway NE. Surgical treatment of constrictive pericarditis: analysis of outcome and diagnostic error. Circulation 1985;72: II264–73.
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13. Nataf P, Cacoub P, Dorent R, et al. Results of subtotal pericardiectomy for constrictive pericarditis. Eur J Cardiothorac Surg 1993;7:252–5; discussion 255–6. 14. Astudillo R, Ivert T. Late results after pericardectomy for constrictive pericarditis via left thoracotomy. Scand J Thorac Cardiovasc Surg 1989;23:115–9. 15. Kang SH, Song JM, Kim M, et al. Prognostic predictors in pericardiectomy for chronic constrictive pericarditis. J Thorac Cardiovasc Surg 2014;147:598–605. 16. Ha JW, Oh JK, Schaff HV, et al. Impact of left ventricular function on immediate and long-term outcomes after pericardiectomy in constrictive pericarditis. J Thorac Cardiovasc Surg 2008;136:1136–41. 17. Komoda T, Frumkin A, Knosalla C, Hetzer R. Child-Pugh score predicts survival after radical pericardiectomy for constrictive pericarditis. Ann Thorac Surg 2013;96: 1679–85. 18. 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;93:1236–40. 19. Gopaldas RR, Dao TK, Caron NR, Markley JG. Predictors of in-hospital complications after pericardiectomy: a nationwide outcomes study. J Thorac Cardiovasc Surg 2013;145:1227–33. 20. Karram T, Rinkevitch D, Markiewicz W. Poor outcome in radiation-induced constrictive pericarditis. Int J Radiat Oncol Biol Phys 1993;25:329–31. 21. Culliford AT, Lipton M, Spencer FC. Operation for chronic constrictive pericarditis: do the surgical approach and degree of pericardial resection influence the outcome significantly? Ann Thorac Surg 1980;29:146–52.
INVITED COMMENTARY The authors [1] are to be congratulated on a significant series of patients having pericardiectomy for constrictive pericarditis in a single center, and for providing a thorough review of other series on the subject. In preparing this comment, my own search for manuscripts on the subject found little not referenced here. Constrictive pericarditis is an uncommon disease with few reports of large series and poor understanding of the factors contributing to morbidity and mortality. Even high-volume centers have provided few reports of series in this range, and this manuscript contributes significantly to our understanding of the problem. Constriction of the pericardium is a highly morbid disease leading to heart failure and death. While other forms of pericarditis may be best treated with antiinflammatory strategies, surgical pericardiectomy is most effective for constriction and best when complete pericardiectomy is accomplished. The mortality of this procedure is high, with in-hospital rates of 5% to 12%. Those patients who survive the perioperative period have marked improvement in symptoms and good longterm survival. Understandably, the daunting risk of pericardiectomy deters many surgeons from accepting care of these patients, but the natural history is dismal in terms of both quality of life and survival. An understanding of factors impacting outcome is important to deciding when to operate, when to refer to a higher volume center, and how to counsel patients with this disease. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Clearly patients with constriction requiring concomitant procedures, those with radiation-induce pericarditis, and those with long-standing symptoms fare worst. This series confirms that preoperative hepatomegaly or hepatic dysfunction, diabetes, and renal failure are predictors of early mortality. These are factors common to poor outcome for any heart surgery. For surgical survivors, quality of life is much improved. Late survival appears to be related to overall comorbidities rather than a history of constrictive pericarditis per se. Patients with constrictive pericarditis should be considered for pericardiectomy early in the process. The risk factors defined here, and in the few other series reported, should be considered and carefully explained to patients that they may best participate in the difficult decision regarding operation for this disease. Andrea J. Carpenter, MD, PhD Division of Thoracic Surgery University of Texas Health Science Center - San Antonio 7703 Floyd Curl Dr, MC 7841 San Antonio, TX 78229 e-mail: [email protected]
Reference 1. Vistarini N, Chen C, Mazine A, et al. Pericardiectomy for constrictive pericarditis: 20 years of experience at the Montreal Heart Institute. Ann Thorac Surg 2015;100:107–13.
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Background. The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors. Methods. Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. Results. Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation
were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. Conclusions. The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.
C
pericardiectomy at a single surgical center over a period of 20 years. The main objectives of our analysis were longterm survival, clinical outcome, and identification of risk factors for early and late mortality.
onstrictive pericarditis (CP) is a chronic inflammatory disease involving fibrotic lesions and serous effusions, leading to pericardial thickening, adhesions, and sometimes calcifications, thus causing ventricular compression [1]. The resulting heart failure is the consequence of impaired diastolic ventricular function and may be life-threatening for the patient [2, 3]. Despite the lack of prospective studies comparing the different therapeutic strategies, surgical pericardiectomy is a valuable treatment under most circumstances [4–10]. The main benefits of this operation are the increase in survival, the relief of symptoms, and the prevention of disease worsening [11–14]. Despite a general consensus supporting the procedure, this operation is still associated with significant morbidity. Previous studies have reported different early and long-term survival after pericardiectomy, with a great heterogeneity regarding preoperative and intraoperative risk factors [15–18]. The present study was designed to evaluate early and long-term results after Accepted for publication Feb 18, 2015. Address correspondence to Dr Perrault, Department of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, 5000 B elanger St, Montreal H1T 1C8, Quebec, Canada; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;100:107–13) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods Study Population and Study Design From January 1994 through February 2014, 99 consecutive patients underwent total or partial pericardiectomy at the Montreal Heart Institute, and they constitute the subjects of this report. Only the patients in whom the main surgical indication was CP were considered in the study. We also excluded the cases in which the pericardiectomy was an unplanned procedure, performed after an intraoperative finding of CP. The patients’ clinical charts were reviewed, and preoperative, intraoperative, and postoperative data were recorded on a computer-based surgical database. The CP was evaluated preoperatively by echocardiography, computed tomography (CT), angiography, magnetic resonance imaging (MRI), and chest roentgenography (Fig 1). We considered in our analysis relevant clinical information: demographics (age, sex, race), cause of CP (idiopathic, infectious, postsurgical, 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.054
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Fig 1. Preoperative evaluation of a patient with constrictive calcified pericarditis. (A) Chest roentgenogram. (B) Cardiac angiogram. (C) Chest computed tomographic scan.
postirradiation, miscellaneous), clinical signs and symptoms (New York Heart Association [NYHA] class, duration of symptoms, distended jugular veins, hepatomegaly, ascites, pulsus paradoxus, pleural effusion), comorbidities (systemic hypertension, diabetes, atrial fibrillation, renal insufficiency), echocardiographic data (left and right ventricular function, pulmonary hypertension, pericardial calcification), preoperative laboratory test results (creatinine, sodium, bilirubin, albumin), and intraoperative data (surgical approach, total or partial pericardiectomy, associated procedures, need for cardiopulmonary bypass [CPB]). Follow-up of patients was done with telephone calls to the patients or their relatives and through the reports of cardiologic clinical and echocardiographic controls.
Surgical Techniques Median sternotomy has been the preferred surgical approach in the great majority of cases, offering easy access for a complete pericardiectomy. Alternative approaches were left or right anterolateral thoracotomy, performed in the fourth or fifth intercostal space, and subxiphoid approach. In all cases of pericardiectomy, a circuit for extracorporeal circulation was ready to use, and the perfusionist was present in the operating room. External defibrillation pads were always installed before operation. Total pericardiectomy was defined as radical phrenic-to-phrenic excision of the pericardium, from the great arteries superiorly to the diaphragmatic surface inferiorly. Any other type of pericardial resection that did not meet these criteria was classified as a partial pericardiectomy. The key element of this surgical procedure, regardless of the extent of the resection, is the decompression of the right cavities, which are almost always at the center of the symptoms and therefore of the indication. In this sense it is important to remove any constriction from the orifices of the caval veins, and this can be obtained without touching the posterior surface of these vessels, simply breaking sufficiently the “banding effect” to achieve the result.
Definitions The causes of CP were deduced mainly by clinical history. Postsurgical pericarditis was defined when CP developed in patients with previous cardiac operations. Patients with a history of mediastinal irradiation were defined as having postirradiation pericarditis. Additional possible causes included infectious (bacterial or viral) or miscellaneous (posttraumatic, tumor-related, and post– myocardial infarction). Patients who did not fit in any of those groups were classified into the idiopathic group. The diagnosis of CP was mainly established on echocardiographic data: comprehensive evaluation of systolic and diastolic left and right ventricular function, search for abnormal motion of the interventricular septum, inferior venae cava dilatation, pericardial thickening, and variations in mitral and tricuspid inflow velocity and in pulmonary and hepatic vein flow. Other instrumental examinations that were used to complete or refine the diagnosis were invasive hemodynamic measurements, MRI, and high-resolution CT. Pericardial calcification was defined as the presence of calcifications detected preoperatively on chest roentgenogram, angiography, CT, or MRI (Fig 1). Hospital mortality was defined as death occurring in the first 30 days after operation or during the same hospitalization as for operation.
Statistical Analysis Statistical analyses were performed with the Statistical Package for Social Sciences (SPSS) version 20 (Chicago, IL). Continuous variables are presented as mean standard deviation, and categoric variables are reported as frequency (percentage). Predictors of hospital mortality were assessed by a multivariable logistic regression model. Variables screened as potential confounders were the preoperative baseline characteristics. All variables with p < 0.20 on univariate analysis were considered as having a potential confounding effect. Variables with p < 0.05 were retained in the final model. Long-term survival was assessed by Kaplan-Meier actuarial methods. Risk factors for late mortality were evaluated with a multivariable Cox proportional hazards model. The variables
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assessed as potential risk factors were the same as for hospital mortality, and variable selection was carried out in the same manner.
Results Preoperative Characteristics Table 1 shows the preoperative characteristics of patients. In two thirds of cases, CP was idiopathic. The miscellaneous causes of CP were prior chest trauma in 2 patients, malignancy in 1 patient, and myocardial infarction in 6 patients. The duration of symptoms was less than 6 months only in 47% of patients, and the remaining patients had symptoms for longer than 6 months, in some cases years. Two thirds of patients were in NYHA functional class III or IV.
Intraoperative Findings The patients’ intraoperative characteristics are reported in Table 2. The operation was performed through a standard sternotomy in the great majority of cases (97 patients). Left thoracotomy was performed in 1 patient, right thoracotomy in 1 patient, and a subxiphoid Table 1. Preoperative Characteristics Characteristic Age (y) Male gender Cause Idiopathic Infectious Postsurgical Postirradiation Miscellaneous NYHA preoperative class I II III IV NA LVEF (%) Distended jugular veins Hepatomegaly Ascites Pleural effusion Pericardial calcification Atrial fibrillation Diabetes mellitus Systemic arterial hypertension Renal failure (serum creatinine 120 mmol/L) Pulmonary hypertension (PAPs 60 mm Hg)
Median (Range)
n
%
60 (24–79) . . . . . . . . . . . . . 55 (14–70) . . . . . . . . .
. 85
. 86
60 15 13 2 9
61 15 13 2 9
7 23 61 7 1 . 51 29 22 41 62 34 16 47 20
7 23 62 7 1 . 52 29 22 41 63 34 16 47 20
.
5
5
LVEF ¼ left ventricular ejection fraction; NA ¼ not available; NYHA ¼ New York Heart Association; PAPs ¼ systolic pulmonary arterial pressure.
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Table 2. Intraoperative Characteristics Characteristic
n
%
Sternotomy Thoracotomy þ sternotomy Subxiphoid Thoracotomy Need for CPB Associated procedures Coronary artery bypass Valvular operation Miscellaneous Complete pericardiectomy
93 3 1 2 37 36 20 13 8 60
94 3 1 2 37 36 20 13 8 61
CPB ¼ cardiopulmonary bypass.
approach in another patient. In 3 patients a thoracotomy was initially performed, but then it was extended into a median sternotomy. Complete pericardiectomy was performed in 61% of patients. Associated procedures were performed in 36% of patients. Miscellaneous procedures included thymectomy (n ¼ 2), resection of epicardial pacemaker electrode (n ¼ 1), Maze procedure (n ¼ 1), Maze procedure and septal myomectomy (n ¼ 2), resection of lung cancer (n ¼ 1), and decortication of the lung (n ¼ 1). CPB was used in 37% of patients, but only 8 of them underwent isolated pericardiectomy.
Postoperative Findings Regarding the postoperative course, complications included renal failure (n ¼ 16), atrial fibrillation (n ¼ 16), pleural effusion (n ¼ 11), postoperative bleeding (n ¼ 9), respiratory failure (n ¼ 3), paralytic ileus (n ¼ 2), and hepatic failure (n ¼ 1). Hospital mortality was 9%, and the causes of death were multiorgan failure (n ¼ 4), heart failure (n ¼ 3), and respiratory failure (n ¼ 2). Among these 9 patients, pericardiectomy was incomplete in only 2 patients, CPB was required in 4 patients for associated cardiac procedures and in 2 patients for hemodynamic instability. Several preoperative variables (age, sex, race, cause of CP, NYHA functional class, duration of symptoms, distended jugular veins, hepatomegaly, ascites, pulsus paradoxus, pleural effusion, systemic hypertension, diabetes, atrial fibrillation, renal insufficiency, creatinine, sodium, bilirubin, albumin, left and right ventricular function, pulmonary hypertension, pericardial calcification) and intraoperative variables (surgical approach, total or partial pericardiectomy, associated procedures, need for CPB) were tested in the statistical analysis of the risk factors affecting hospital mortality after operations for CP. Table 3 shows the variables that were statistically significant at univariate and multivariate analysis. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality (odds ratio [OR] 0.11) compared with those who were symptomatic for longer times. Preoperative hepatomegaly was associated with significantly higher mortality on both univariate and multivariate analysis. No significant difference was found in mortality according to the cause
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Table 3. Univariate and Multivariate Analysis for Predictors of Hospital Mortality (entire cohort, n ¼ 99) Univariate Analysis
p Value
OR
0.075 0.045 0.020 0.009
1.071 0.114 5.368 7.200
Age Symptoms <6 months Hepatomegaly Associated valvular operation
95%
CI
0.993 1.155 0.014 0.950 1.302 22.135 1.632 31.763
Multivariate Analysis Age Symptoms <6 months Hepatomegaly Associated valvular operation CI ¼ confidence interval;
0.404 0.054 0.029 0.014
1.035 0.111 13.419 21.710
0.955 0.012 1.297 1.883
1.120 1.036 138.878 250.255
OR ¼ odds ratio.
of the CP. The only intraoperative variable found to be significant at univariate and multivariate analysis was concomitant valvular operation, and all 4 patients with early deaths underwent associated procedures, specifically valvular procedures. For this reason we performed a statistical subanalysis, considering only isolated cases of pericardiectomy, with the aim to assess outcomes and risk factors for this subgroup of patients. Hospital mortality was 7.9% in cases of isolated pericardiectomy and 11.1% in cases of associated procedures (p ¼ 0.93). Hepatomegaly, diabetes, preoperative creatinine, preoperative sodium, and chronic renal failure were associated with significantly higher mortality on univariate analysis (Table 4), but none of these variables were significant on multivariate analysis.
Long-Term Outcome Survival after pericardiectomy in the entire cohort of patients is shown in Figure 2, and 11 patients died over a median follow-up time of 54 months. The cause of death was cardiac related in 4 patients (1 case of bioprosthesis stenosis and 3 cases of cardiac failure), noncardiac related in 2 patients (1 for cancer and 1 for complications after lung operation), and unknown in the remaining 5 patients. Survival at 1, 3, and 5 years was 92.1%, 87.7%, and 79.4% for isolated pericardiectomy and 85.7%, 81.6%, and 81.6% in cases of pericardiectomy with associated procedures (Fig 3). The same variables tested for the analysis of the risk factors of hospital mortality were also Table 4. Univariate Analysis for Predictors of Hospital Mortality in Cases of Isolated Pericardiectomy (n ¼ 63) Univariate Analysis Age Hepatomegaly Diabetes Preoperative creatinine Preoperative sodium Chronic renal failure CI ¼ confidence interval;
p Value
OR
95%
CI
0.194 0.024 0.004 0.009 0.032 0.012
1.061 13.846 20.250 1.026 0.805 22.500
0.970 1.421 2.588 1.006 0.659 2.004
1.159 134.903 158.462 1.046 0.982 252.569
OR ¼ odds ratio.
evaluated for long-term mortality. The univariate analysis showed no significant risk factor for long-term mortality. The functional status at follow-up was greatly improved after pericardiectomy, as shown in Figure 4 by the increased number of patients in NYHA functional class I or II after the operation.
Comment The clinical outcome of pericardiectomy for CP remains constrained by high operative mortality. Our study has highlighted that some pre-and intra-operative factors, mainly related to the clinical condition of the patients, can adversely affect the short term outcome. However, if patients make it through the operation, the long-term survival and the clinical improvement are excellent in most cases. Hospital mortality was 9% in our series (7.9% in cases of isolated pericardiectomy and 11.1% in cases of associated procedures), which compares favorably with the 4.9% to 12% rate in other series published in the past 10 years [4, 6–9, 15–19]. The first aspect to consider in the analysis of this hospital mortality is represented by the fact that in our cohort, there were only two cases of postirradiation pericarditis. Previous studies have reported considerably different survival depending on the cause, with postirradiation pericarditis significantly associated with increased mortality [3, 4, 8–10, 20]. In fact, in these cases, there is not only diastolic heart failure caused by the constrictive process but also an element of systolic failure resulting from myocardial fibrosis and injury from the radiation therapy. This could explain why the outcomes are worse in series that have a higher number of postirradiation patients. Such a correlation was not possible in our study because of the small number of cases. This can be mainly related to the fact that these patients are operated on less frequently than they once were because there is evidence that even a complete pericardiectomy does not always relieve cardiac failure [3, 21]. Another possible explanation can be represented by the decrease in the absolute numbers of postirradiation pericarditis requiring pericardiectomy, certainly related to improved radiation strategies in oncology, leading to a lower incidence of this complication. Statistical analysis has shown that surgical treatment within 6 months of the onset of symptoms is associated with reduced hospital mortality (OR ¼ 0.11). This suggests that an early operation may prevent clinical deterioration and may provide a better outcome for patients with CP. The other preoperative factor significantly associated with increased mortality was hepatomegaly (OR ¼ 13.42). Also this aspect is directly linked to the evolution of clinical disease because it reflects an advanced stage of heart failure resulting from severe persistent pericarditis. In this context it seems therefore strongly recommended that patients with CP are referred for operation as quickly as possible once the symptoms have appeared. Previous studies have highlighted that even some markers of liver dysfunction (bilirubin),
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Fig 2. Kaplan-Meier curve for survival after pericardiectomy for constrictive pericarditis in the entire cohort of patients (n ¼ 99).
malnutrition, and overall poor health (hypoalbuminemia) are associated with an increased risk of short-term and long-term mortality [8]. In a recent study, Komoda and colleagues [17] showed that the Child-Pugh score is a useful tool for stratifying the risk of mortality after radical pericardiectomy, thus emphasizing that congestive hepatopathy and impairment of liver function are useful predictors of mortality. Other preoperative variables, such as age, NYHA functional class III or IV, and pericardial calcification, identified as risk factors in previous clinical studies, showed only a trend toward a worse outcome but did not reach statistical significance in our analysis. Concerning intraoperative variables, the only predictor of increased hospital mortality was the associated valvular operation (OR ¼ 21.71). This factor, although related to the type of operation performed, reflects the characteristics of patients who are usually sicker and require associated procedures. In this regard, which therapeutic strategy should be adopted for these patients remains a matter of debate. Possibly the higher surgical risk of a complete but complex operation could be reduced if only CP is treated in the first instance, which can be done almost always without extracorporeal circulation. In fact, this strategy could provide a clinical recovery that would allow the patient to undergo a valve operation hemodynamically compensated. However, it remains to assess the risk of repeated sternotomy, the optimal timing of reoperation, and the appropriate surgical strategy in cases of redo valve operations (conventional vs minimally invasive approach, transcatheter valve implantation, percutaneous mitral valve repair).
Concerning our statistical subanalysis of isolated cases of pericardiectomy, hepatic failure was confirmed to be a risk factor (OR ¼ 13.8), as were renal failure (OR ¼ 22.5) and diabetes (OR ¼ 20.2), which were also associated with increased mortality. Therefore, in summary, when the most complex cases with associated procedures were
Fig 3. Kaplan-Meier curves for survival, comparing isolated pericardiectomy cases (n ¼ 63) and pericardiectomy with associated procedures (n ¼ 36).
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Fig 4. Changes over time in the proportion of NYHA (New York Heart Association) functional classes.
excluded, the risks appeared to be mainly related to the preoperative comorbidities, as with any other type of heart operation. The impact of the surgical approach on outcome remains controversial, with an open debate that compares sternotomy with thoracotomy and total versus partial pericardiectomy [4, 6–8, 13]. Our experience and our data cannot support any comment about the benefits of a surgical approach over another because median sternotomy was the preferred approach in nearly all cases. The reasons for this choice are mainly related to better surgical exposure, easier complete pericardiectomy, greater versatility in case of associated procedures, and easier installation of extracorporeal circulation in case of complications. The need for CPB was not a predictor of hospital mortality in our series, and in most cases it was secondary to associated surgical procedures. Survival and clinical improvement for patients discharged after pericardiectomy were satisfactory. Our 5-year survival of 87.5% compares favorably with those in other published series (Cleveland Clinic, 7-year survival of 76% for idiopathic CP; Mayo Clinic, 5-year survival of 78%; Baltimore, 5-year survival of 79.8% for idiopathic CP; New York, 5-year survival of 94.6%) [3, 5, 8, 9], and it confirms the favorable evolution of the patients who survive the operation. On univariate analysis, no factor was significantly associated with an increased risk of long-term mortality; therefore, it was not possible to perform a multivariate analysis. The clinical outcome in late survivors was excellent, moving from 70% of patients in NYHA class III or IV preoperatively to 80% in NYHA class I or II postoperatively. Incomplete pericardiectomy was performed
in 55% of patients who experienced either new or recurrent NYHA class III or IV at follow-up. The study limitations are represented by the retrospective and observational design, with its inherent bias, and by the relative small sample size, given that it was a single-center study. In conclusion, although pericardiectomy for CP remains associated with high operative mortality, the longterm outcome is favorable, and surgical treatment is able to improve the functional class in the majority of late survivors. Some preoperative and intraoperative factors, mainly related to the patients’ clinical conditions, can adversely affect the short-term outcome. Associated valvular procedures significantly increase the risk of hospital mortality, and the most suitable surgical strategy in these cases remains to be determined. Patient selection and therapeutic strategy must therefore take account of these factors, and early operation appears to be the most appropriate choice to avoid clinical deterioration caused by heart failure.
References 1. Bergman M, Vitrai J, Salman H. Constrictive pericarditis: a reminder of a not so rare disease. Eur J Int Med 2006;17: 457–64. 2. DeValeria PA, Baumgartner WA, Casale AS, et al. Current indications, risks, and outcome after pericardiectomy. Ann Thorac Surg 1991;52:219–24. 3. 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. 4. Szab o G, Schmack B, Bulut C, et al. Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy:
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13. Nataf P, Cacoub P, Dorent R, et al. Results of subtotal pericardiectomy for constrictive pericarditis. Eur J Cardiothorac Surg 1993;7:252–5; discussion 255–6. 14. Astudillo R, Ivert T. Late results after pericardectomy for constrictive pericarditis via left thoracotomy. Scand J Thorac Cardiovasc Surg 1989;23:115–9. 15. Kang SH, Song JM, Kim M, et al. Prognostic predictors in pericardiectomy for chronic constrictive pericarditis. J Thorac Cardiovasc Surg 2014;147:598–605. 16. Ha JW, Oh JK, Schaff HV, et al. Impact of left ventricular function on immediate and long-term outcomes after pericardiectomy in constrictive pericarditis. J Thorac Cardiovasc Surg 2008;136:1136–41. 17. Komoda T, Frumkin A, Knosalla C, Hetzer R. Child-Pugh score predicts survival after radical pericardiectomy for constrictive pericarditis. Ann Thorac Surg 2013;96: 1679–85. 18. 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;93:1236–40. 19. Gopaldas RR, Dao TK, Caron NR, Markley JG. Predictors of in-hospital complications after pericardiectomy: a nationwide outcomes study. J Thorac Cardiovasc Surg 2013;145:1227–33. 20. Karram T, Rinkevitch D, Markiewicz W. Poor outcome in radiation-induced constrictive pericarditis. Int J Radiat Oncol Biol Phys 1993;25:329–31. 21. Culliford AT, Lipton M, Spencer FC. Operation for chronic constrictive pericarditis: do the surgical approach and degree of pericardial resection influence the outcome significantly? Ann Thorac Surg 1980;29:146–52.
INVITED COMMENTARY The authors [1] are to be congratulated on a significant series of patients having pericardiectomy for constrictive pericarditis in a single center, and for providing a thorough review of other series on the subject. In preparing this comment, my own search for manuscripts on the subject found little not referenced here. Constrictive pericarditis is an uncommon disease with few reports of large series and poor understanding of the factors contributing to morbidity and mortality. Even high-volume centers have provided few reports of series in this range, and this manuscript contributes significantly to our understanding of the problem. Constriction of the pericardium is a highly morbid disease leading to heart failure and death. While other forms of pericarditis may be best treated with antiinflammatory strategies, surgical pericardiectomy is most effective for constriction and best when complete pericardiectomy is accomplished. The mortality of this procedure is high, with in-hospital rates of 5% to 12%. Those patients who survive the perioperative period have marked improvement in symptoms and good longterm survival. Understandably, the daunting risk of pericardiectomy deters many surgeons from accepting care of these patients, but the natural history is dismal in terms of both quality of life and survival. An understanding of factors impacting outcome is important to deciding when to operate, when to refer to a higher volume center, and how to counsel patients with this disease. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Clearly patients with constriction requiring concomitant procedures, those with radiation-induce pericarditis, and those with long-standing symptoms fare worst. This series confirms that preoperative hepatomegaly or hepatic dysfunction, diabetes, and renal failure are predictors of early mortality. These are factors common to poor outcome for any heart surgery. For surgical survivors, quality of life is much improved. Late survival appears to be related to overall comorbidities rather than a history of constrictive pericarditis per se. Patients with constrictive pericarditis should be considered for pericardiectomy early in the process. The risk factors defined here, and in the few other series reported, should be considered and carefully explained to patients that they may best participate in the difficult decision regarding operation for this disease. Andrea J. Carpenter, MD, PhD Division of Thoracic Surgery University of Texas Health Science Center - San Antonio 7703 Floyd Curl Dr, MC 7841 San Antonio, TX 78229 e-mail: [email protected]
Reference 1. Vistarini N, Chen C, Mazine A, et al. Pericardiectomy for constrictive pericarditis: 20 years of experience at the Montreal Heart Institute. Ann Thorac Surg 2015;100:107–13.
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