Central Journal of Cardiology & Clinical Research

Cite this article: Kumar S, Tewarson V, Hakim MZ, Kumar S, Singh SK (2020) Constrictive Pericarditis - A Long Term Surgical Experience. J Cardiol Clin Res 8(2): 1153.

*Corresponding author

Prof. Sushil K Singh, Professor and Head, Department of Cardiovascular and Thoracic surgery, King George’s Medical University, Lucknow, 226003, India, Tel and Fax: 91-522-2258830; Email: doctorsushil@hotmail.com

Submitted: 30 July 2020

Accepted: 14 August 2020

Published: 18 August 2020

Copyright© 2020 Kumar S, et al.

OPEN ACCESS

Keywords•Constrictive Pericarditis; Tuberculosis;

Pericardiectomy; Surgical technique

Research Article

Constrictive Pericarditis - A Long Term Surgical ExperienceSarvesh Kumar, Vivek Tewarson, Mohammad Zeeshan Hakim,

Shobhit Kumar, and Sushil K Singh*

Department of Cardiovascular and Thoracic Surgery, King George’s Medical University,

India

Abstract

Introduction: Chronic constrictive pericarditis is a significant cause for diastolic dysfunction of the heart. Tuberculosis is considered a significant etiology in developing countries, whereas idiopathic cases are most common world-wide. Although pericardiectomy is an established procedure for chronic constrictive pericarditis, the extent of resection and utility of cardiopulmonary bypass is still debatable. The aim of this study was to study the feasibility and surgical outcomes of pericardiectomy for this disease in a large patient group in today’s scenario.

Materials & methods: We retrospectively analyzed data of all patients who underwent pericardiectomy at our center between 2005 to 2019. We collected data of precise etiopathology of constrictive pericarditis. Analysis of surgical approach and outcomes was done. Inclusion criteria involved all consecutive patients with a diagnosis of constrictive pericarditis.

Results: A total of 311 patients underwent pericardiectomy. Good surgical outcomes were demonstrated. There was a significant improvement in the functional status after surgery. Tuberculosis was the predominant etiology as seen in 48.23% cases, while idiopathic cases constituted 42.12%. Adequate removal of pericardium in all cases was possible without resorting to cardiopulmonary bypass and 23.15% patients could be operated through left antero-lateral thoracotomy. In-hospital mortality was 1.6%.

Conclusion: Tubercular pericarditis is still a common etiology of pericardial disease in our set-up and pericardiectomy carried out without use cardiopulmonary bypass can achieve excellent results for such cases.

ABBREVIATIONSCCP: Chronic Constrictive Pericarditis; ECG:

Electrocardiography; TTE: Trans-Thoracic Echocardiography; AF: Atrial Fibrillation; CT: Computed Tomography; CMR: Cardiac Magnetic Resonance; 2D Echo: Two-Dimensional Echocardiography; CPB: Cardiopulmonary Bypass; LV: Left Ventricle; RV: Right Ventricle; CVP: Central Venous Pressure; ICU: Intensive Care Unit; NYHA: New York Heart Association; SD: Standard Deviation; IVC: Inferior Vena Cava

INTRODUCTIONInflammation of the pericardium or pericarditis has been

associated with a variety of causes. Chronic Constrictive Pericarditis (CCP), is the end result of chronic scarring and inflammation of the pericardium, that leads to eventual thickening, fibrosis and calcification of the pericardial sac [1]. This inelastic pericardium prevents adequate diastolic filling, which leads to progressive diastolic dysfunction and eventually, heart failure [2,3]. Idiopathic or viral pericarditis has been cited as one of the most common aetiologies of constrictive pericarditis world-wide. Tuberculosis is considered to be a significant

etiology in the developing countries and in immunosuppressed individuals [2-7].

Clinical signs and symptoms arise as a result of fluid overload and diminished cardiac output, and include dyspnea, increased jugular venous pressure, hypotension, pulsus paradoxus, muffled heart sounds, Kussmaul’s sign, pericardial knock, edema, ascites, pleural effusion or cachexia. Diagnostic modalities for the initial diagnosis include Electrocardiography (ECG), chest radiograph and trans-thoracic echocardiography (TTE). While chest radiograph may show only effusion, pericardial calcification may also be present. Low voltage complexes are noted on ECG and atrial fibrillation (AF) is also seen in 30% cases. TTE is the first line investigation for diagnosis of constrictive pericarditis. Other modalities such as computed tomographic (CT), or cardiac magnetic resonance (CMR) imaging provide additional information when needed such as the extent of pericardial thickening, calcification and scarring [8-10]. Although pericardiectomy is an established procedure for CCP, the extent of resection and utility of cardiopulmonary bypass often becomes debatable. The aim of this study was to study the feasibility and surgical outcomes of pericardiectomy for this disease in a large patient group in today’s scenario.

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MATERIALS AND METHODSThis was a retrospective study of patients and their surgical

outcome for pericardiectomy from 2004 to 2019 (15 years), at our institution.

Inclusion criteria involved all consecutive patients with a diagnosis of constrictive pericarditis.

Preoperative Evaluation-All patients underwent preoperative evaluation with two-dimensional echocardiography (2D Echo), and chest X-ray. Routine pre-operative blood work-up, evaluation for tuberculosis and electrocardiography (ECG), was done.

Surgical technique -A full informed consent was taken from each patient prior to surgery. Part preparation and draping was done in the standard manner for cardiac surgery, with the groins available if emergency cardiopulmonary bypass (CPB), should become necessary, which wasn’t required in any of our case. Pericardiectomy was performed through either a median sternotomy or a left anterolateral thoracotomy. Median sternotomy provided good access to the right ventricle, right atrium, and great vessels, including the caval–right atrial junctions and thus enabled a good clearance of the diseased pericardium from phrenic nerve to phrenic nerve. The left anterolateral thoracotomy was employed for infected-purulent cases as in effusive constrictive pericarditis, in order to avoid sternal infections postoperatively.

The conventional approach was to decorticate the Left Ventricle (LV), before the Right Ventricle (RV), to avoid pulmonary edema but this was not always easy to perform on a beating heart. After freeing the mid-anterior part using sharp and blunt dissection techniques, dissection proceeded laterally on both right and left sides. During this stage, the aim was to cautiously find a dissection plane between the epicardium and the fibrotic-constricted parietal pericardium by paying attention to the coronary arteries whose visibility during the procedure was ensured throughout by ensuring correct depth of the dissection plane. When access to the correct dissection plane was attained, better diastolic relaxation of the heart was observed after removal of the fibrotic parietal pericardium & there was hemodynamic relief. The lateral extent of dissection was about 1 cm anterior to the right and left phrenic nerves and dissection lateral to the main pulmonary artery was avoided. This was done to prevent injury to the phrenic nerves at this level. During continuous intraoperative monitoring, evaluation of the hemodynamic impact of the pericardiectomy intraoperatively was achieved by measuring fall in central venous pressure (CVP).

Thick or fibrotic tissue that was hard to peel off was left alone to prevent inadvertent injury to the underlying cardiac chambers. Small bleeding spots were dealt with as required. The waffle procedure [11], in which multiple transverse and longitudinal incisions are made in the epicardial layer was also employed at times in areas where the pericardium was fibrotic and not able to be removed. After completion of pericardiectomy, hemostasis was confirmed, and drains were inserted. After checking for improvement of the echocardiographic and hemodynamic values the surgery was concluded and the sternum closed in standard fashion.

Post-operative management- The patients were shifted un-reversed from general anesthesia to the cardiac surgical Intensive Care Unit (ICU), where invasive monitoring was continued, and ionotropic and ventilator support was carried on. Weaning off ventilatory support and subsequent extubation was done according to protocol. Routine histopathology and tissue / fluid cultures were sent.

In known cases of tubercular pericarditis, if the patient had already completed a course of anti-tubercular therapy, new course was not started. In others, anti-tubercular therapy was started only when the pericardial biopsy was positive or there was strong clinical evidence of active tuberculosis. These patients received 6 months of antitubercular therapy as per Revised National Tuberculosis Programme guidelines. Follow up was scheduled for 10 days and 1, 6 and 12-months and then yearly for 5 years respectively to assess the outcomes of patients.

Statistical Analysis- The statistical analysis was done using statistical software -Statistical Product and Service Solutions (IBM SPSS®) for Windows® Version 19.0. Paired t-test and Chi square Test were used to assess data (p value of less than 0.05 has been considered significant) for our sample size of 311 patients. There was no control group in this study as this was a retrospective observational study.

RESULTSAs depicted in Table 1, a total of 311 patients underwent

pericardiectomy at our center over 15 years. The mean age of patients undergoing the procedure was 26.53 ± 18.23 years and the majority were male. Progressive dyspnea was the commonest presentation. Almost all patients had raised CVP, while pulsus paradoxus was present in 32.15% cases. Chest X-ray findings included congestion in 21.86% cases, while presence of calcification (Figure 1), and effusion were seen in 4.5% and 3.54% of cases respectively. 2D-Echo revealed pericardial thickening in 95% cases while 23.15% cases had pericardial effusion. Septal bounce was noted in 95.18% cases and 88.10% had ventricular septal shift. A large number of patients (96.46%), had diastolic reversal in hepatic vein flow.

Perioperative data is depicted in Table 2 where it is seen that 23.15% patients were operated through a left antero-lateral thoracotomy approach, while the rest were operated through conventional median sternotomy for pericardiectomy. While conventional pericardiectomy could be performed in 90.03% cases, 9.97% underwent pericardial window procedure. There was a significant (p<0.001) drop in CVP seen on table after stripping of the diseased pericardium (26.36 ± 5.69 mm Hg vs 8.33 ± 2.13 mm Hg mean at the beginning vs after procedure respectively). Iatrogenic injuries were mostly encountered on the RV. Mean blood loss encountered during surgeries was 271.22 ± 241.80 ml and 180 patients required blood transfusions. While the mean ICU stay was 1.57 ± 0.692 days, the post-operative recovery was smooth for a majority of patients and only 13 patients stayed longer than 5 days after surgery. Surgical site infection was noted in 3.22% cases. In-hospital mortality was 1.6% (5 patients).

In our series tuberculosis was the most common etiology (48.23%), followed closely by idiopathic (42.12 %), cases. Non tuberculosis infections accounted for 8.68 % of the cases as

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Figure 1 (a) – Chest X-ray in a case of constrictive pericarditis showing extensive pericardial calcification (b) - Intra-operative photograph of the same case.

Table 1: Pre-operative Patient Profile (n=311).

Patient variables Mean ± SD Number (%)

Age (years)Age Distribution<2021-50>50

26.53 ± 18.23

142 (45.66)128 (41.16) 41(13.18)

SexMaleFemale

228 (73.31)83 (26.69)

Clinical FeaturesNYHA Class IIIIIIIVRaised CVPAscitesHepatomegalyPulsus Paradoxus

0 (0)104 (33.44)38 (12.22)169 (54.34)288 (92.60)87 (27.97)246 (79.09)100 (32.15)

Chest X-Ray FindingsIncreased cardio-thoracic ratioPulmonary CongestionPleural EffusionPericardial Calcification

32 (10.29)11 (3.54)68 (21.86)14 (4.50)

2D- Echocardiographic FindingsEjection Fraction (%)Pericardial thickeningVentricular Septal ShiftSeptal BouncePericardial EffusionIVC Maximum diameter (cm) IVC Minimum diameter (cm) Hepatic vein diastolic flow reversal

58.3±8.5

2.7 ± 0.62.3 ± 0.5

295 (94.85)299 (96.17)296 (95.18)72 (23.15)

300 (96.46)Abbreviations: n- number of patients, %- percentage, SD- standard deviation, NYHA-New York Health Association, CVP- central venous pressure, IVC- inferior vena cava, cm- centimetre.

evident histologically and on cultures. Out of the total number of neoplastic cases accounting for 0.96%, there were 2 cases of mesothelioma and one case of breast carcinoma respectively (Table 3).

Follow-up data is illustrated in Table 4. There was a significant improvement trend among all patients that presented in follow-up. The patients de-escalated from NYHA class III and

IV (87.58%), to NYHA class I and II (99.53%), over a 5-year follow-up. Even those patients who hadn’t completed their 5- year follow-up showed signs of functional improvement beginning 6 months after the procedure, this change was found to be statistically significant based on Chi square analysis. The radiological signs of pleural effusion and pulmonary congestion improved significantly after 1 and 2 years of follow-up period respectively.

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Table 2: Peri-Operative details (n=311).

Operative variables Mean ± SD Number (%)

Approaches (n)Median SternotomyAntero-Lateral Thoracotomy

239 (76.85)72 (23.15)

Procedures (n)PericardiectomyPericardial Window

280 (90.03)31 (9.97)

Blood loss (ml)0-200 201- 400 >400

271.22 ± 241.80167 (53.70)106 (34.08)38 (12.22)

Packed red cell transfusion requirement (n) 180 (57.88)

Post-Operative Ventilatory requirement (hours)<6 6 – 12>12

5.21 ± 3.64218 (70.09)91 (29.26)2 (0.64)

Post-Operative Inotropic support duration (hours) <66-12>12

6.13 ± 3.31144 (46.3)165 (53.05)2 (0.60)

ICU Stay (days)11-2>3

1.57 ± 0.692170 (54.66)105 (33.76)36 (11.58)

Hospital Stay (days)≤ 5>5

298 (95.82)13 (4.18)

Complications (n)Wound InfectionIatrogenic Injuries

3 (0.96)17 (5.46)

Mortality 5 (1.61)

Abbreviations: n- number of patients, %- percentage, SD- standard deviation, ml= millilitres, ICU- Intensive Care Unit

Table 3: Post-operative Histopathological Diagnosis (n=311).

Aetiology Number (%)

Idiopathic 131 (42.12)

Tubercular 150 (48.23)

Other Infectious causesStreptococcus pneumoniaeStaphylococcus aureusOthers

27 (8.68)18 (5.79)6 (1.93)3 (0.96)

NeoplasticBreast cancerMesothelioma

3 (0.96)1 (0.32)2 (0.64)

Abbreviations: n- number of patients, %- percentage

DISCUSSIONThe incidence of idiopathic constrictive pericarditis is

highest in the world; however, the trends are not similar among developing and developed countries and our series showed a high incidence of tuberculosis associated pericarditis, which is similar to those reported in Asian and African studies [6,12,13]. There has also been an increase in the incidence of pericarditis in post-operative and post-irradiation cases [14]. The prevalence of CCP is less than 1 in 10000 and only 9% of acute pericarditis progress to chronic constrictive pericarditis. Presentation as cardiac failure is common and diagnosis is chiefly by 2D Echo,

which demonstrate thickened pericardium and diastolic septal bounce with inspiration, rapid diastolic filling and paradoxical septal motion along with a constrained total cardiac volume. Inspiratory ventricular septal shift reduced mitral annular velocity and hepatic vein diastolic flow reversal ratio >0.79 are considered specific findings [15,16]. We noted that reversal in diastolic hepatic vein flow and pericardial thickening were frequently present among our patients. Septal bounce and ventricular septal shift were also noted in 95.18% and 88.10% respectively, demonstrating these to be important signs to look for in 2D-echocardiography.

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Table 4: Follow-up data.

Follow up period

Number of patients on follow up

NYHA Status of patients

(n, % per class) p-value

Chest X-ray FindingsPulmonary Congestion

(n, %) p-valuePleural Effusion

(n, %) p-value

10 days 306

I -0 (0.00)II -38 (12.42)

III -102 (33.33)IV -166 (54.25)

- 9 (2.94) - 43 (14.05) -

6 months 303

I -30 (9.90)II -27 (8.91)

III -100 (33.00)IV -146 (48.19)

0.001 6 (1.98) 0.61 31 (10.23) 0.18

1 year 280

I -75 (26.79)II -30 (10.71)III -75 (26.79)

IV -100 (35.71)

0.000 3 (1.07) 0.15 20 (7.14) 0.01

2 year 260

I - 80 (30.77)II -32 (12.31)III -55 (21.15)IV -93 (35.77)

0.000 1 (0.38) 0.047 12 (4.62) 0.000

3 year 234

I -102 (43.59)II -28 (11.96)III -38 (16.24)IV -66 (28.21)

0.000 0 (0) 0.021 3 (1.28) 0.000

4 year 222

I -140 (63.06)II -26 (11.71)III -28 (12.61)IV -28 (12.61)

0.000 0 (0) 0.025 0 (0) 0.000

5 year 215

I -211 (98.14)II -3 (1.39)III -1 (0.46)IV -0(0.00)

0.000 0 (0) 0.028 0 (0) 0.000

Abbreviations: NYHA- New York Heart Association (functional status), %- percentage, n- number of patients

Another important investigation that aids diagnosis is the chest radiograph. Various signs such as presence of pulmonary congestion, effusion, presence and extent of pericardial calcification and increased cardio-thoracic ratio can be noted. Presence of calcification in chest radiographs as was seen in cases during our study (Figure 1), have been frequently noted with tubercular pericarditis. However, even with idiopathic pericarditis, about 30 to 50% cases have been reported having pericardial calcification in various series and this is also considered a poor prognostic factor in outcome [17,18]. Our study demonstrated a significant number of patients with tubercular and idiopathic pericarditis with signs of right sided cardiac failure such as raised CVP, hepatomegaly, pedal edema and poor functional class. 2D-Echo in these patients demonstrated thickened pericardium and ventricular septal shift in a large number of cases. While 2D Echo is the backbone of diagnosis, investigations must be individualized and appropriate use of chest x-ray, computerized tomographic and magnetic resonance scans can provide a good anatomical outline before embarking on the surgical procedure [19,20].

In the US nationwide study for pericardiectomies conducted over past 15years, it was noted that early surgical intervention is being increasingly reported in a younger population presenting with disease symptoms. There has also been a decline in the number of surgeries with a slight but significant increase in the

use of CPB in these cases [21]. The Mayo clinic 8-decade analysis on the other hand has displayed a trend towards surgeries being carried out in an older and functionally poor population over the years. Regardless of the pre-operative picture, the post-operative outcome in terms of mortality and functional status of patients has improved over time [14,22]. Our study also described a relatively young population undergoing pericardiectomy with a predominant male fraction. This demographic trend is also noted among recent long-term studies [14,21,22] suggesting that the disease is more prevalent among young men.

Pericardiectomy is considered therapeutic for both chronic constrictive and effusive constrictive pericarditis. Approach through median sternotomy has been advocated for ease in employing cardiopulmonary bypass when needed. Use of alternate approaches including the left antero-lateral thoracotomy have been frequent and have proven beneficial especially in re-do cases and those that carry a higher risk of sternotomy wound infection [23,24]. In our series, we used left antero-lateral thoracotomy in patients for pericardiectomy as well as pericardial window.

The extent of pericardial resection has been a topic of debate, with proponents of complete or a more radical pericardial excision have carried out complete stripping of pericardium posterior to the phrenic nerves to the coronary sinus and pulmonary veins, thereby completely removing the parietal pericardium.

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The impact of such has been seen in a few studies and has been found to provide good short- and long-term results in these patients in experienced centers [6]. It has also been shown that there is a constant need for cardiopulmonary bypass in radical pericardiectomy and as such it is not widely practiced [25-27]. The waffle technique can provide an alternative substitute to complete excision in some areas of the pericardium by providing extensive anterior release providing good functional recovery [11].

The procedural outcome for pericardiectomy has improved with time. The recent report by Mori et al demonstrated an in-hospital mortality of 7.3%, in their large series of about 4800 patients. Other series have also reported similar mortality from 2 to 10% range or even less at times, with greater mortality being associated with additional procedures carried out along with pericardiectomy among other factors [4,6,14,21,22,28]. The factors predicting poor outcome following pericardiectomy therefore, include old age, delay on surgical procedure from the onset of symptoms, poor functional status before surgery (NYHA class III/IV), prior radiation, high pulmonary artery pressure, worse renal function, abnormal left ventricular ejection fraction, concomitant cardiac surgeries, post-operative AF and the need for CPB. The etiology has been an important predictor for outcome with best outcome with idiopathic pericarditis and worsening prognosis with post-irradiation and post-cardiac surgery cases [14,15,17,18,22,29,30].

The consumption of blood and blood products is associated more frequently with cases of adhesive than constrictive pericarditis and with the use of bypass; conversely the utility of cardiopulmonary bypass is greater with constrictive pericarditis [30]. The use of routine CPB has often been criticized and given the adverse effect on outcome, proponents advocate carrying out pericardiectomy off-pump only [18,31]. Long term assessment of patients undergoing pericardiectomy in a recent study by Gatti et al demonstrated the use of CPB as an indicator of poor outcome. The study also found elevated central venous pressures and poor renal function as independent risk factors for long term mortality. The emphasis is on early intervention in high risk groups, especially since the delay in surgery from onset of symptoms is itself associated with a poor prognosis as it allows cardiac function to decline further with increasing constriction [32]. In our series, mortality was noted in 1.61% cases which is fairly less, however, no concomitant surgeries were performed in our patients and 5 patients developed low cardiac output state leading to cardiac failure and death. The requirements of transfusion were limited to 57.8% cases. The low mortality rate and avoidance of cardiopulmonary bypass in our series reflects the contemporary world-wide practice and portrays the institution’s surgical experience and quality of post-operative care.

CONCLUSIONOur study demonstrates that pericardiectomy can be

performed with good success rates in patients with diverse etiologies wherein tubercular and idiopathic CCP are common in our setting. It also shows satisfactory outcomes in terms of patient morbidity and mortality which can be achieved without the detrimental effects of using CPB. Left anterolateral thoracotomy

approach is valuable in selected patients. Good functional status should be the aim of the surgeon and with proper and meticulous technique, this can be achieved consistently.

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Kumar S, Tewarson V, Hakim MZ, Kumar S, Singh SK (2020) Constrictive Pericarditis - A Long Term Surgical Experience. J Cardiol Clin Res 8(2): 1153.

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