Pericardiectomy is the definitive treatment for constrictive pericarditis but the best surgical approach remains controversial. In this study we compared the results of pericardiectomy performed on 36 patients with constrictive pericarditis between 1995 and 2001. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. All patients were reviewed at 6 weeks post operatively. Both groups of patients were similar in age, sex distribution, NYHA shortness of breath status, aetiology, presenting symptoms and duration of symptoms. Mortality was similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. NYHA status improved in both thoracotomy (3.0+/-0.8 to 1.6+/-0.7; P=3.3x10(-6)) and median sternotomy (2.9+/-0.7 to 1.5+/-0.6; P=2.8x10(-5)) groups. The degree of improvement was not significant between the two groups (P=0.63). In addition ionotropic support and postoperative hospital stay were similar between the two groups. There was a higher incidence of wound infections (23.8 versus 6.6%; P=0.13) and pulmonary complications (23.8 versus 13.3%; P=0.33) associated with thoracotomy. In conclusion pericardiectomy improves NYHA status in all patients and mortality rates are similar in both the approaches.

/pdf/surgical-approach-for-pericardiectomy-a-comparative-study-41wp65urjs.pdf

Surgical approach for pericardiectomy: a comparative study between median sternotomy and left anterolateral thoracotomy.

Pericardiectomy is the definitive treatment for constrictive pericarditis but the best surgical approach remains controversial. In this study we compared the results of pericardiectomy performed on 36 patients with constrictive pericarditis between 1995 and 2001. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. All patients were reviewed at 6 weeks post operatively. Both groups of patients were similar in age, sex distribution, NYHA shortness of breath status, aetiology, presenting symptoms and duration of symptoms. Mortality was similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. NYHA status improved in both thoracotomy (3.0 ^ 0.8 to 1.6 ^ 0.7; P ¼ 3:3 £ 10 26 ) and median sternotomy (2.9 ^ 0.7 to 1.5 ^ 0.6; P ¼ 2:8 £ 10 25 ) groups. The degree of improvement was not significant between the two groups (P ¼ 0:63). In addition ionotropic support and postoperative hospital stay were similar between the two groups. There was a higher incidence of wound infections (23.8 versus 6.6%; P ¼ 0:13) and pulmonary complications (23.8 versus 13.3%; P ¼ 0:33) associated with thoracotomy. In conclusion pericardiectomy improves NYHA status in all patients and mortality rates are similar in both the approaches.

Institutional review - Cardiac general Surgical approach for pericardiectomy: a comparative study between median sternotomy and left anterolateral thoracotomy

Background: Constrictive pericarditis is a disease characterized by marked thickening and dense scarring of the pericardium with pericardial sac obliteration, or calcification of the pericardium. Without treatment this disease is characterized by high morbidity and mortality. Objective: To review the surgical management of constructive pericarditis and the post operative challenges. Methods: Eleven patients who had pericardiectomy for constructive pericarditis between 2000 and 2005 were studied. Data was obtained from the operating theatre register, histopathological reports and patient’s case notes. Results: The mean age was 33 years with a range of 14 to 53 years. There were seven males (63.6%) and four females (36.4%). Seven (63.6%) out of the eleven patients operated were treated for pulmonary tuberculosis. The cause of pericardial constriction in four patients (36.4%) was undetermined. Follow up period was between 4-59 months. The mean follow up was 17.5 months. Seven patients (63.6%) were off diuretics and had no exercise intolerance. Patients were classified using the New York Heart Association (NYHA) n (NYHA) functional and therapeutic classification in class I-V. Two patients preoperatively in class III are now in class I after surgery on low dose diuretics. One patient who had calcific constrictive pericarditis and came in class III was now in class II with diuretics after 3 years of follow up. There was no postoperative mortality. One patient was lost to follow up. Conclusion: Pericardiectomy is a useful procedure for constrictive pericarditis and was beneficial to all the patients in this study with an improvement in their functional capacity. Intensive peri-operative monitoring and management reduced morbidity and mortality.

/pdf/surgical-management-of-constrictive-pericarditis-23e0372519.pdf

Surgical management of constrictive pericarditis.

Constrictive pericarditis (CP) is a chronic condition where pericardium gets thickened, fibrosed, and calcified, thereby restricting the filling of the ventricles. Surgical removal of the pericardium is the best effective treatment for CP. Because of the advent of newer and better antibiotics, the need for surgical pericardiectomy has declined at least in the developing countries [1]. Nevertheless, malignancy and radiation induced CP is not that uncommon. Pericardiectomy can be either radical or subtotal depending upon the extent of release of adhered pericardium. It can be done via midline sternotomy or anterolateral thoracotomy either on bypass or off bypass. Each technique has got its own merits and demerits. Two main factors determining the clinical and hemodynamic improvement after surgery are the extent of adequate resection and status of the underlying ventricles. Adequate resection is said to be achieved when both ventricles, atrioventricular grooves, and the bases of the great vessels are freed of the disease process [2]. The adequacy of resection intraoperatively is generally monitored by the fall in the baseline central venous pressures and rarely by the improvement in the voltages of electrocardiogram (ECG) complexes. However, these monitors are not without drawbacks. The central venous pressure monitored by the internal jugular vein (IJV) catheter is influenced by many factors like patient position, volume status, inotrope therapy, anesthetic drugs, and usage of chest retractors. ECG monitor also has got inherent drawbacks like being less sensitive, prone for cautery disturbances, and poor signals owing to loss of contact of electrodes because of the disinfectants used for cleaning, whereas trans esophageal echo (TEE) as a monitor has no drawbacks as mentioned above. Intraoperative TEE helps the surgeon in assessing the adequacy of resection and also monitors the dynamic change or improvement in the filling of the ventricles [3]. TEE also helps to guide the surgeon to dissect those left over thickened pericardium even in the least accessible areas. It helps to monitor the dynamic filling of both the ventricles especially the left because the left ventricle being posteriorly located it is difficult to examine the adequacy of expansion by direct visual assessment. Moreover, Doppler assessment of transmitral flow (TMF) and more normalized respiratory variation in TMF should suggest adequate resection [4]. It also serves to sort out the etiology of hemodynamic compromise like damage to the epicardial coronaries reflected by wall motion abnormalities (WMA) should it occur. To conclude, TEE should be routinely used as a monitor during pericardiectomy. Adequacy of resection should be assessed by TEE especially in right ventricle (RV) inflowoutflow and transgastric mid papillary views apart from hemodynamic assessment.

https://link.springer.com/content/pdf/10.1007%2Fs12055-014-0354-1.pdf

TEE as a monitor during pericardiectomy for constrictive pericarditis

Background: Pericardiectomy is the only accepted curative treatment for improving cardiac haemodynamics in chronic constrictive pericarditis (CCP). This study was aimed at reviewing the experience and functional outcome of patients undergoing Pericardiectomy in Tikur Anbessa Hospital between January 1996 and December 2005. Methods: This was a retrospective Analysis done at the Thoracic Surgical unit, Tikur Anbessa Hospital, Department of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa, Ethiopia. During the period under review, 26 patients underwent Pericardiectomy for CCP. Medical records and operation theatre registers of 19 patients were retrieved and analysed. Results: Thirteen of the patients were males and six were females (M: F=2.2:1) The ages ranged from 14 to 42 years (mean 24.3±7). The duration of illness ranged between 2 and 36 months with a mean of 15.2±10.8). Diagnosis of constrictive pericarditis was based on the clinical picture of right sided heart failure along with chest roentgenogram, electrocardiogram, echocardiography and histological examinations. The most common presenting symptoms were dyspnea in 19 (100%) patients, abdominal discomfort in 14 (73.7%) and abdominal distension in 11 (68.4%) patients. Onphysical examination raised JVP, peripheral edema, hepatomegaly and ascites w 63.2%) patients, enlarged cardiac silhouette in 9 (47.4%) and pericardial calcification in 7 (36.8%). ECG showed low QRS voltage and T wave abnormality in 10 (52.6%) and 9 (42.1%) cases respectively. Pericardial thickening/calcification (52.6%), left ventricular septa motion abnormality (42.1%) and pericardial effusion (36.8%) were seen by echocardiography. The surgical approach was mainly median sternotomy in 15 (79%) patients, and the mean operation time was 112 (range 90-135±18.9) minutes. Fifteen (79%) patients had uneventful postoperative course. Two patients developed pneumonia and one a hydropneumothorax. There was one death in the immediate postoperative period. Long–term mortality of 10.5% was noted. Mean hospital stay and follow-up time were 14.3±5.3 (range 7-24) days and 12.8±6.9 (range 3-24) months respectively. Conclusion: Pericardiectomy can be performed without the use of CPB and with low mortality, and can result in an improved functional capacity in the majority of the patients.

/pdf/experience-of-pericardiectomy-in-tikur-anbessa-university-2ik66w3z3o.pdf

Experience of Pericardiectomy in Tikur Anbessa University Hospital, Ethiopia

Records of 103 patients with constrictive pericarditis who underwent subtotal pericardiectomy from January 1990 to December 1997 were retrospectively analyzed. The etiology of pericardial constrict...

Subtotal Pericardiectomy via Sternotomy for Constrictive Pericarditis

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Subtotal Pericardiectomy via Sternotomy for Constrictive Pericarditis