Treating Constrictive Pericarditis in a Chinese Single-Center Study: A Five-Year Experience

doi:10.1016/j.athoracsur.2012.05.002

The Annals of Thoracic Surgery

Volume 94, Issue 4, October 2012, Pages 1235-1240

https://doi.org/10.1016/j.athoracsur.2012.05.002 Get rights and content

Background

Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening of the pericardium. Prompt treatment of constrictive pericarditis is necessary to limit morbidity and mortality.

Methods

We analyzed the clinical details of 51 constrictive pericarditis patients who underwent surgery from January 2005 to December 2010 at our center.

Results

Of the patients, 33 (65%) had tuberculous constrictive pericarditis, 13 (25%) had idiopathic pericarditis, 3 (6%) had previous cardiac surgery, and 1 (2%) had connective tissue disease. All patients underwent total pericardiectomy by midline sternotomy. The in-hospital mortality rate was 3.9% (2 of 51 patients). The cause of death was severe low cardiac output syndrome in 1 patient and acute renal failure in the other patient. There were 2 cases of recurrent constrictive pericarditis after discharge. The actuarial 1-year survival rate was 93.7%. One-year follow-up revealed that an initial higher erythrocyte sedimentation rate, abnormal creatinine value, postoperative low output syndrome, and pleural effusion were all associated with increased mortality.

Conclusions

Rapid diagnosis and treatment of constrictive pericarditis are crucial to reduce mortality and morbidity. Pericardiectomy should be performed early after diagnosis, in order to prevent chronic illness. After surgery, inotropes, diuretics, salt restriction, and nutrition supply are also critical to improve the prognosis. The inflammation marker erythrocyte sedimentation rate should be evaluated during follow-up.

Section snippets

Patients and Methods

We retrospectively analyzed the clinical reports of 51 consecutive patients (38 males, 13 females; age 40.1 ± 15.5 years; range 13 to 73 years) with constrictive pericarditis who underwent surgery from January 2005 to January 2011 in our single-center institution. Our institutional ethics committee approved the present study and all patients gave written informed consent.

The diagnosis of constrictive pericarditis was made according to the combination of Doppler echocardiography (thickened or

Results

Table 1 lists the causes of constriction in the series. Of the 51 patients, 33 patients (65%) had Tb constrictive pericarditis and 13 (25%) had idiopathic constrictive pericarditis. Underlying conditions were previous cardiac surgery for 3 patients (6%) and connective tissue disease for 1 patient (2%). The remaining patient had chest trauma 40years ago.

The average pulse pressure was 34 ± 8 mm Hg, and the mean heart rate was 100 ± 14 beats per minute. When classifying patients using the

Comment

Constrictive pericarditis is an uncommon condition involving impaired mid and late ventricular filling due to a thickened or noncompliant pericardium. The most important findings of our evaluation were that clinical manifestations could worsen, even with short durations of symptoms, and thus timely diagnosis and prompt treatment are important to improved prognosis.

Our results are consistent with previous studies, which showed that constriction was more common in males [7, 12, 20]. While there

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Cited by (44)

Impact of concomitant coronary artery bypass grafting on postoperative outcomes in patients undergoing pericardiectomy: A 33-year experience
2023, JTCVS Open
Concomitant coronary artery bypass grafting (CABG) and pericardiectomy (PC) can be a technically challenging operation. We sought to study the outcomes of patients undergoing concomitant PC and CABG.
Between July 1983 and August 2016, 70 patients (median age, 67 years; 88% males) underwent concomitant PC and CABG (PC + CABG group). Multivariable analysis was used to identify predictors of mortality. Matched patients who underwent isolated PC (PC group) were identified, and postoperative outcomes and long-term survival in the 2 groups were compared.
Compared with the PC group, cardiopulmonary bypass time was significantly longer in the PC + CABG group (82 minutes vs 61 minutes; P < .001). In-hospital mortality was 4% in the PC group and 7% in the PC + CABG group (P = .380). Multivariable analysis identified peripheral vascular disease (hazard ratio [HR], 2.67; 95% CI, 1.06-6.76; P = .04) as a predictor of increased morbidity or mortality and a borderline association with New York Heart Association functional classes III and IV (HR, 2.41; 95% CI, 0.99-5.86; P = .05) with increased morbidity and mortality in the PC + CABG group. Kaplan–Meier estimates demonstrated similar late mortality rates in the 2 groups at a 15-year follow-up (P = .700).
Concomitant PC and CABG is not associated with increased morbidity or mortality compared with isolated PC. Thus, CABG should not be denied at the time of PC.
Cardiac surgery for constrictive pericarditis
2022, Debulking in Cardiovascular Interventions and Revascularization Strategies: Between a Rock and the Heart
The pericardium is a protective cardiac biologic tissue. The pericardial structure consists of an avascular, double-walled sac containing two layers: the visceral pericardium, which is a thin layer comprising an inner serous monolayer and pericardial physiologic fluid, and the parietal pericardium, which consists of an outer fibroelastic layer. There are two pericardial sinuses: transverse and oblique. The pericardium serves important ligamentous, membranous, metabolic, reflexive, and mechanical functions that are described within the text of this chapter. Constrictive pericarditis is a serious cardiac pathologic process with profound clinical and hemodynamic implications. In constrictive pericarditis, chronic fibrous tight thickening of the pericardial tissue develops secondary to inflammation. As a result, the pericardial elasticity and compliance are adversely effected, in a process that severely impairs cardiac physiology. Clinically, constrictive pericarditis commonly presents with a picture of right-sided heart failure including symptoms of fatigue, exertional dyspnea, and peripheral edema. Associated left cardiac chambers dysfunction also presents as pulmonary congestive symptoms, chest pain, palpitations, abdominal symptoms, and frank anasarca. The unique physical examination findings when this pathology is encountered are delineated in this chapter. The diagnosis of constrictive pericarditis involves physical examination, electrocardiography, chest radiography, and echocardiography. Further evaluation and confirmation include cardiac imaging with computed tomography, magnetic resonance, and, when indicated, right and left heart catheterization.
Definitive surgical management is commonly performed through pericardiectomy. This operation remains technically challenging and its various approaches, challenges, and complications are described. Long-term survival after pericardiectomy is largely dependent on etiology and on patient comorbidities such as older age, New York Heart Association (NYHA) class, renal dysfunction, pulmonary hypertension, increased Child-Pugh liver disease, previous chest irradiation, and hyponatremia. Postoperatively, most patients exhibit improved hemodynamic condition, improved cardiac function, and become symptom free providing that accurate pre-op assessment, adequate patient selection, and timely surgical intervention are performed.
Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
This supported the current recommendation that pericardial resection should be as complete as possible in the first surgery, which does not increase (and may reduce) surgical mortality.10,29,34,43,52 Perioperative mortality rates after pericardiectomy have decreased over time and in recent studies have ranged from 0%-to-18.6%.2,12,29,32,33,42,44,47-51,53-55,57-63 This reduction in surgical mortality over time was demonstrated by Murashita et al., who reported a historical 30-day mortality rate of 13.5% compared with 5.2% after 1990 in a single center.29
Constrictive pericarditis is caused by pericardial inflammation and fibrosis, leading to diastolic heart failure. The diagnosis requires a high index of suspicion because it often can mimic restrictive myocardial disease and cardiac tamponade and can be associated with severe tricuspid regurgitation and chronic liver disease. Patients who remain undiagnosed can experience a 90% mortality rate, and for those who undergo pericardiectomy, the survival rate varies significantly, depending on the underlying etiology and preoperative functional class of the patient. In this article, the authors review the pathophysiology, echocardiographic findings, management, and surgical outcomes of constrictive pericarditis to aid the cardiothoracic anesthesiologist in the perioperative management of this disorder.
Surgical treatment of tuberculous chronic constrictive pericarditis: A retrospective observational study from tertiary hospital of eastern Nepal
2021, Indian Journal of Tuberculosis
Tuberculosis remains an important cause of chronic constrictive pericarditis (CCP) in developing countries. It is a surgically treatable cause of diastolic heart failure. Without surgery, it is associated with high morbidity and mortality.
We conducted a retrospective observational study of clinical presentations and perioperative outcomes of pericardiectomy in all patients operated from July 2015 to December 2018 for tuberculous CCP.
A total 14 patients (mean age - 38 ± 13.3 years, 10 male), underwent pericardiectomy via median sternotomy without cardiopulmonary bypass. Eleven patients (79%) had completed treatment for pulmonary tuberculosis, and three (21%) were on anti-tubercular treatment at the time of referral for surgery. Ten patients (71%) had prior hospitalisation for cardiac failure. At the time of surgery, eight patients (57%) were in New York Heart Association (NYHA) class III-IV. The median duration of symptoms before surgical intervention was 15 months (range 11–24 months). Three patients (21%) had associated cardiac cirrhosis. Twelve patients (86%) underwent total pericardiectomy. Two patients (14%) underwent partial pericardiectomy. The mean operative time was 160 ± 33.8 minutes. The mean central venous press pressure before and after surgery were 28 ± 3.9 and 10 ± 2 mmHg respectively. The mean intensive care unit (ICU) and hospital stays were 4 ± 1.5 and 10 ± 2 days respectively. There was one (7%) 30-day mortality. There were two deaths (14%) due to non-cardiac causes at 10 and 16 months respectively. The remaining 11 patients (79%) are doing well (mean follow-up- 23 months), and are in NYHA class I.
Tuberculosis is the most common cause of CCP in our region. Pericardiectomy provides definitive treatment to alleviate symptoms resolution and improve survival.
Pericardial Diseases: Constrictive Pericarditis and Pericardial Effusion
2020, Diastology: Clinical Approach to Heart Failure with Preserved Ejection Fraction
Constrictive pericarditis is a unique and uncommon cause of diastolic heart failure, secondary to reduced pericardial compliance in the setting of pericardial inflammation and/or fibrosis. Its diagnosis is of extreme importance since it is a potentially curable disorder. In this chapter we review the pathophysiology, clinical manifestations, diagnostic approach, and management of constrictive pericarditis and related disorders.
US National Trends in the Management and Outcomes of Constrictive Pericarditis: 2005-2014
2019, Canadian Journal of Cardiology
Patient characteristics, trends in the management strategy, and outcomes of patients with constrictive pericarditis have not been characterized at the national scale.
Annual trends of patients admitted to hospitals in the United States with constrictive pericarditis were evaluated using the National Inpatient Sample dataset between 2005 and 2014. Poisson regression models adjusting for the US census population estimate were fitted to evaluate trends in the incidence of constrictive pericarditis, isolated pericardiectomy, and cardiopulmonary bypass (CPB) use. Descriptive analyses were performed to compare patient characteristics and in-hospital mortality rates between surgically and medically managed cohorts.
During 2005-2014, 29,487 patients were admitted with constrictive pericarditis. Sixteen percent underwent isolated pericardiectomy. The prevalence of constrictive pericarditis remained stable between 2005 and 2014 at 9-10 cases per million, but proportion of patients undergoing isolated pericardiectomy decreased from 18% in 2005 to 15% in 2014 (P = 0.001 for trend). CPB use increased from 15% to 29% (P < 0.001). Compared with medically managed patients, the pericardiectomy cohort was younger (age 57 vs 61 years, P < 0.001), less likely to be female (25% vs 41%, P < 0.001), and harboured fewer comorbidities. In-hospital mortality was 7.3% for those undergoing pericardiectomy and 6.8% for a medically managed cohort (P = 0.58) and operative mortality was stable across years (P = 0.99 for trend).
The prevalence of constrictive pericarditis remained stable between 2005 and 2014 at 9-10 cases per million. Surgical management was infrequent, with younger and less comorbid patients being more likely to be managed operatively. Increasing use of CPB without a change in operative mortality highlights the persisting challenge of this complex disease.
Les caractéristiques des patients, les tendances en matière de stratégies de prise en charge et le devenir des patients atteints de péricardite constrictive n’ont pas été caractérisés à l’échelle nationale.
Les tendances annuelles chez les patients atteints de péricardite constrictive hospitalisés aux États-Unis ont été évaluées à partir des ensembles de données du National Inpatient Sample couvrant la période allant de 2005 à 2014. Des modèles de régression de Poisson corrigés pour tenir compte de l’estimation de la population américaine effectuée lors du recensement ont été ajustés de façon à permettre l’évaluation tendancielle de la fréquence de la péricardite constrictive, de la péricardectomie isolée et du recours au pontage cardiopulmonaire (PCP). Des analyses descriptives ont été réalisées afin de comparer les caractéristiques des patients et les taux de mortalité intrahospitalière dans deux cohortes, l’une ayant été l’objet d’une prise en charge chirurgicale et l’autre, d’une prise en charge médicale.
De 2005 à 2014, 29 487 patients atteints de péricardite constrictive ont été hospitalisés. Une péricardectomie isolée a été pratiquée chez 16 % d’entre eux. La prévalence de la péricardite constrictive est demeurée stable entre 2005 et 2014, s’établissant à 9 à 10 cas par million, mais la proportion de patients ayant subi une péricardectomie isolée a diminué, passant de 18 % en 2005 à 15 % en 2014 (p = 0,001 pour la tendance). Le recours au PCP a augmenté, passant de 15 à 29 % (p < 0,001). Comparativement aux patients ayant été l’objet d’une prise en charge médicale, les patients formant la cohorte des péricardectomisés étaient plus jeunes (57 ans vs 61 ans, p < 0,001) et moins susceptibles d’être des femmes (25 % vs 41 %, p < 0,001) et ils présentaient moins de maladies concomitantes. Le taux de mortalité intrahospitalière a atteint 7,3 % chez les patients péricardectomisés et 6,8 % chez les patients de la cohorte ayant été l’objet d’une prise en charge médicale (p = 0,58), et la mortalité opératoire s’est avérée stable au fil des ans (p = 0,99 pour la tendance).
La prévalence de la péricardite constrictive est demeurée stable entre 2005 et 2014, s’établissant à 9 à 10 cas par million. La prise en charge chirurgicale a été peu fréquente; les patients plus jeunes et présentant moins de maladies concomitantes étaient plus susceptibles d’en être l’objet. Le recours croissant au PCP en l’absence de variation du taux de mortalité opératoire met en lumière le défi persistant que représente cette maladie complexe.

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^⁎: Yiyun Lin and Mi Zhou contributed equally to this article.

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Original articleAdult cardiacTreating Constrictive Pericarditis in a Chinese Single-Center Study: A Five-Year Experience

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Tuberculous pericarditis

JAMA

Management of constrictive pericarditis in the 21st century

Curr Treat Options Cardiovasc Med

Constrictive pericarditis, still a diagnostic challenge: Comprehensive review of clinical management

Eur J Cardiothorac Surg

Pericardiectomy for constrictive pericarditis: A clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques

Ann Thorac Surg

Outcome of pericardiectomy for chronic constrictive pericarditis

[Article in Spanish] Rev Esp Cardiol

Tuberculous effusive-constrictive pericarditis

Cardiovasc J Afr

Surgical treatment of 128 cases of constrictive pericarditis

Nan Fang Yi Ke Da Xue Xue Bao

A century of tuberculosis

Am J Respir Crit Care Med

The management of tuberculous pericardial effusion: experience in 233 consecutive patients

Cardiovasc J S Afr

Pericardiectomy for chronic constrictive tuberculous pericarditis: risks and predictors of survival

Tex Heart Inst J

Pericardiectomy: a functional anatomical perspective for the choice of left anterolateral thoracotomy

J Card Surg

Risk of constrictive pericarditis after acute pericarditis

Circulation

Clinical characteristics and treatment of constrictive pericarditis in taiwan

Circ J

Diagnostic issues in the clinical management of pericarditis

Int J Clin Pract

Original article
Adult cardiac
Treating Constrictive Pericarditis in a Chinese Single-Center Study: A Five-Year Experience