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Preface
No single laboratory test or diagnostic nding should be considered pathognomonic of chronic constrictive pericarditis. A combination of clinical and investigative results should be thoughtfully analysed to diagnose this disease entity.
Surgical treatment of chronic constrictive pericarditis commences with the pericardial anatomy, terminology, and history of pericardiectomy. This is followed by
multiple sections dealing with the essentials for the surgeon-scholar who wishes for
a basic understanding of this fascinating and multifaceted problem. It includes
chapters on the incidence and varied country-specic aetiologic spectrum, as well
as the morphologic and pathogenetic aspects of the disease. The series of chapters
devoted to surgery are introduced by a discussion on decision-making on the timing
of pericardiectomy, extent of surgical resection with or without extracorporeal support, and valid justications of different surgical approaches.
The techniques of pericardiectomy are described in detail, with operative photographs and surgical videos, framed by recommendations for perioperative management. State-of-the-art technology and the latest in surgical techniques are also
discussed. In the nal chapters, we present the results of pericardiectomy emanating
from major surgical centres across the globe, and what we consider adequate longterm patient follow-up.
A note of caution: diagrams do not bleed. There exist a substantial difference
between conceptualization of an operation and its expeditious accomplishment. On
reading this monograph, he astute reader will appreciate that a direct and unswerving attack on the surgical pathology and judicious surgical dissection are paramount
for a successful surgical outcome.
The extent of contribution by researchers dealing with this disease is reected in
the large bibliography of this monograph. Through the usual scientic channels, all
of us have pooled our knowledge in such a way that we have stood upon each other’s
shoulders in preparing this manuscript.
We have taken utmost precautions to conrm the accuracy of the information
presented and to describe generally accepted practices. The authors, editors, and
publisher are not, however, responsible for errors or omissions in, or for any consequences from application of, the information in this book, and make no warranty,
expressed or implied, with respect to the currency, completeness, or accuracy of the
contents of the publication. Application of this information in a particular situation
remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug
selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. In view of ongoing research, changes
in government regulations, and the constant ow of information relating to drug
therapy and drug reactions, the reader is urged to check the package insert for each
drug for any change in indications and dosage, and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this manuscript have Food and
Drug Administration (FDA) clearance for limited use in restricted research settings.
It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in their clinical practice.
Preface
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We have sought to maintain a standard style throughout the text avoiding abbreviations, introducing colour illustrations throughout the text, and closing each of the
chapters with a complete list of references. We hope that you, the reader, share our
own enthusiasm as you make your way through its pages.
This book is humbly submitted to all members of the medical profession as a
summary of conclusions which we have drawn from the greatest of teachers—the
personal experience.
New Delhi, India UjjwalK.Chowdhury
New Delhi, India LakshmiKumariSankhyan
Acknowledgements
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Ujjwal Kumar Chowdhury thanks his wife Sanjukta, his two daughters Priyanka
and Sreenita, and his son Abhishek, for their constant unwavering support and
their gift of many hours labour spent in preparing the book for publication. After
they achieve advanced professional education, I encourage them to pursue a lifetime
scholarship.
Lakshmi Kumari Sankhyan acknowledges her parents (Shri Rakesh Kishore and
Smt. Chinta Devi) and her daughter Anayesha, whose support served as a constant
reminder of life’s most important attributes.
Ujjwal Kumar Chowdhury is greatly indebted to Associate Editor, Lakshmi
Kumari Sankhyan, for putting in the time, energy, and effort that were required for
the preparation of this textbook.
Most grateful thanks go to Prof. Robert H.Anderson, a long-time colleague
and long-term friend who piloted, provided unwavering support, and stirred this
project to its worthy end.
Special appreciation is given to Mr. Shubroto Bhattacharjee, BTech (Hons),
IIT Bombay (an Audio Engineer), for his attention to detail, editing skills, and the
extra effort to bring it to completion.
We wish to express our sincere thanks and gratitude to Dr. Niraj Nirmal Pandey
DM (Cardiac Radiology) for providing us detailed information with computed
tomography and magnetic resonance images.
We are especially indebted to all the cardiologists in the Department of
Cardiology, All India Institute of Medical Sciences, New Delhi, in particular Prof.
Sundeep Mishra, Prof. Rajeev Narang, Prof. Sandeep Seth, Prof.
S.Ramakrishnan, Prof. Nitish Naik, and Prof. Gautam Sharma, for providing
unstinting support in the diagnostic evaluation of the patients in this study. We
would like to thank Dr. Niwin George, Dr. Suruchi Hasija, and Dr. Shikha Goja
for their skilful contributions to this beautifully crafted book.
We also express a huge debt of gratitude to Mr. Sanjay Kumar and the Centre
for Medical Education and Technology, All India Institute of Medical Sciences,
New Delhi, for preparing the video and photographic illustrations.
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Acknowledgements
We are grateful to the Editorial Staff at Springer, in particular Mr. Grant Weston,
who were instrumental in the editing process, providing excellent, valuable
recommendations.
The unique talent of Mr. Shankar Sharma is gratefully acknowledged. He
worked endless hours over a 4-year period to prepare the manuscript.
Contents
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1 Anatomy, Histology, Applied Anatomy,
and Physiology of the Human Pericardium . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Fibrous Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 Serous Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4 Pericardial Recesses and Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 The Pericardial Lines of Reection Localized Around
the Aorta and Pulmonary Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.6 The Pericardial Reection Line Around the Venous
Pole of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.7 The Superior Aortic Recess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.8 Transverse Pericardial Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.9 The Oblique Pericardial Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.10 Number of Pulmonary Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.11 Postcaval Recess (PCR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.12 Pulmonary Venous Recesses (Left and Right Pulmonary
Venous Recesses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.13 Vascular Supply, Lymphatic Drainage, and Innervation . . . . . . . . . . 7
1.14 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.15 Histology and Ultrastructural Features of Normal Pericardium . . . . 8
1.16 Physiology of Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.17 Mechanical Effects of Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.18 Reex Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.19 Membranous Effects of Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.20 Metabolic Effects of Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.21 Epicardial Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.22 Ligamentous Effects of Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.23 Imaging Techniques of the Pericardium, Pericardial
Sinuses and Recesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.24 Applied Anatomy of Autologous Pericardium . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
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2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.1 Chronic Constrictive Pericarditis with Normal Thickness
of the Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4 Aetiological Search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5 Clinical Challenges and Diagnostic Dilemma of Chronic
Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.1 Salient Hemodynamic Features of Chronic
Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6 Pathophysiology of Chronic Constrictive Pericarditis . . . . . . . . . . . . . 69
6.1 Dissociation of Intrapericardial and Intrathoracic Pressures . . . . . . . 70
6.2 Exaggerated Ventricular Interdependence . . . . . . . . . . . . . . . . . . . . . 70
6.3 Fluid Retention in Chronic Constrictive Pericarditis . . . . . . . . . . . . . 76
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
7 Clinical Presentation, Lab Investigations,
and Endomyocardial Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
7.1 Clinical Challenges and Diagnostic Dilemma . . . . . . . . . . . . . . . . . . 81
7.2 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
7.3 Laboratory Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7.4 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7.5 Chest Radiography, Echocardiography, Multimodality
Imaging, Cardiac Catheterization Studies . . . . . . . . . . . . . . . . . . . . . 84
7.6 Endomyocardial Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
8 Imaging Studies and Haemodynamics in Chronic
Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.1 Chest Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.1.1 Overview of Specic Imaging Modalities . . . . . . . . . . . . . . . 92
8.2 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
8.3 Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
8.3.1 Pericardial Structural Evaluation . . . . . . . . . . . . . . . . . . . . . . 109
8.3.2 Cardiac Magnetic Resonance Imaging in Chronic
Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
8.3.3 Scout Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
8.3.4 Real Time Cine Steady-State Free Precision Imaging . . . . . . 117
8.3.5 Myocardial Tagging with Spatial Modulation of
Magnetization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
8.3.6 T1 and T2 Weighted Images . . . . . . . . . . . . . . . . . . . . . . . . . 120
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8.3.7 T2-Weighted Triple Inversion Fast Spin-Echo and
STIR Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
8.3.8 Early Post Contrast T1-Weighted Fast Spin-Echo
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
8.3.9 Delayed Enhancement Imaging . . . . . . . . . . . . . . . . . . . . . . . 120
8.3.10 Velocity-Encoded Phase-Contrast Imaging . . . . . . . . . . . . . . 121
8.4 Cardiac Catheterization Haemodynamics . . . . . . . . . . . . . . . . . . . . . 127
8.5 Radionuclide Ventriculography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
9 Diseases Mimicking Constrictive Pericarditis: Salient
Features and Novel Strategies of Management . . . . . . . . . . . . . . . . . . . 143
9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
9.1.1 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
9.1.2 Echo Doppler Signs of Constriction . . . . . . . . . . . . . . . . . . . 144
9.1.3 Cardiac Computed Tomography . . . . . . . . . . . . . . . . . . . . . . 145
9.1.4 Cardiac Magnetic Resonance . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.1.5 Cardiac Catheterization Data . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.2 Endomyocardial Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.2.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.2.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.2.3 Causation: Evolving Concepts . . . . . . . . . . . . . . . . . . . . . . . . 146
9.2.4 Cardiac Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
9.2.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
9.2.6 Right Ventricular Endomyocardial Fibrosis . . . . . . . . . . . . . . 149
9.2.7 Left Ventricular Endomyocardial Fibrosis . . . . . . . . . . . . . . . 149
9.3 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9.3.1 Chest Radiography and Fluoroscopy . . . . . . . . . . . . . . . . . . . 150
9.3.2 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9.3.3 Echocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9.3.4 Cardiac Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . 150
9.3.5 Haemodynamics and Angiographic Studies . . . . . . . . . . . . . 151
9.3.6 Endomyocardial Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
9.3.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
9.3.8 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
9.4 Cardiac Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
9.4.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
9.4.2 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
9.4.3 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
9.4.4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
9.4.5 Primary AL Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
9.4.6 Familial Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
9.4.7 Senile Systemic Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . 153
9.4.8 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
9.4.9 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
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9.4.10 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
9.4.11 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
9.5 Restrictive Cardiomyopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.2 Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.5.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
9.6 Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
9.6.1 Clinical Features and Diagnosis. . . . . . . . . . . . . . . . . . . . . . . 162
9.6.2 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
9.6.3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
9.7 Cardiac Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
9.8 Budd-Chiari Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
9.8.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
9.8.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
9.8.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
9.8.4 Secondary Budd-Chiari Syndrome . . . . . . . . . . . . . . . . . . . . 165
9.8.5 Primary Budd-Chiari Syndrome . . . . . . . . . . . . . . . . . . . . . . 166
9.8.6 Clinical Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
9.8.7 Natural History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
9.9 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
9.9.1 Sonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
9.9.2 Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
9.9.3 Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . 167
9.9.4 Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
9.9.5 Percutaneous Liver Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . 168
9.10 Therapeutic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
9.10.1 Underlying Risk Factors for Thrombosis. . . . . . . . . . . . . . . . 168
9.10.2 Anticoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
9.10.3 Thrombolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
9.10.4 Percutaneous Transluminal Angioplasty . . . . . . . . . . . . . . . . 169
9.10.5 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
9.10.6 Surgical Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
9.10.7 Current Treatment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . 170
9.10.8 Current Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Contents
10 Definitions of The Extent of Pericardiectomy, Echocardiographic
Variables, Outcome Variables, Haemodynamic Studies,
and Normal Acceptable Values
10.1 Echocardiographic and Tissue Doppler Imaging Studies . . . . . . . . 188
10.2 Strain by Speckle Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
10.3 Low Cardiac Output Syndrome: Denition and Recognition . . . . . 190
10.4 Monitoring and Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
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10.5 Haemodynamics Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
10.6 Serial Semi-Invasive Haemodynamic Monitoring . . . . . . . . . . . . . . 191
10.7 FloTrac™ Sensor, Vigileo™ Monitor: Edwards
Lifesciences, Irvine, CA, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
11 Management of Chronic Constrictive Pericarditis . . . . . . . . . . . . . . . . 199
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
12 Decision-Making on the Timings of Pericardiectomy,
Selection of the Optimal Surgical Approach, Adequacy
of Pericardiectomy and Requirement of Cardiopulmonary
Bypass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
12.1 Anatomical Basis of the Adequacy of Pericardiectomy. . . . . . . . . . 218
12.2 Criteria for Decision-Making on the Indications and Timings for
Pericardiectomy, Selection of the Optimal Surgical Approach,
Adequacy of Surgical Resection, and Their Relationship to
Mortality and Low Cardiac Output Syndrome . . . . . . . . . . . . . . . . 219
12.3 Should Cardiopulmonary Bypass Be Used Routinely
while Performing Pericardiectomy? . . . . . . . . . . . . . . . . . . . . . . . . 223
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
13 Radical Pericardiectomy via Modified Left Anterolateral
Thoracotomy Without Cardiopulmonary Bypass
(UKC’s Modification): Criteria for Decision- Making and
Selection of the Optimal Surgical Approach . . . . . . . . . . . . . . . . . . . . . 231
13.1 Theoretical Basis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
14 The Operation: Total Pericardiectomy via Median Sternotomy
Without Cardiopulmonary Bypass (Holman and
Willett’s Approach)
14.1 Total Pericardiectomy for Chronic Constrictive Pericarditis
Via Median Sternotomy: Surgical Steps [1–3] . . . . . . . . . . . . . . . . 247
14.1.1 The Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
15 The Operation: Radical Pericardiectomy via Modified Left
Anterolateral Thoracotomy Without Cardiopulmonary
Bypass (UKC’s Modification) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
15.1 Technical Details to Facilitate Radical Pericardiectomy
Via Anterolateral Thoracotomy [1–5] . . . . . . . . . . . . . . . . . . . . . . . 255
15.1.1 The Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
15.2 Useful Maneuvers to Facilitate Pericardiectomy Via
Left Anterolateral Thoracotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
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16 Calcific Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
16.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
16.2 Pathogenesis and Disease Progression . . . . . . . . . . . . . . . . . . . . . . . 266
16.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
17 The Operation: Total Pericardiectomy for Calcific Constrictive
Pericarditis via Median Sternotomy Without Cardiopulmonary
Bypass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
17.1 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
17.1.1 Total Pericardiectomy for Calcic Chronic
Constrictive Pericarditis Via Median Sternotomy [1–4] . . . 281
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
18 Incidence and Management of Postoperative Low Cardiac
Output Syndrome After Pericardiectomy . . . . . . . . . . . . . . . . . . . . . . . . 301
18.1 Unresolved Issues and Controversies. . . . . . . . . . . . . . . . . . . . . . . . 301
18.2 Low Cardiac Output Syndrome: Denition and Recognition . . . . . 304
18.2.1 Monitoring and Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . 304
18.2.2 Management of Low Cardiac Output Syndrome . . . . . . . . . 305
18.2.3 Optimizing Preload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
18.2.4 Manipulating Systolic Function . . . . . . . . . . . . . . . . . . . . . . 308
18.2.5 Manipulating Afterload . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
18.2.6 Vasopressor Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
18.2.7 Role of Positive Pressure Ventilation in Treatment
of Low Cardiac Output Syndrome . . . . . . . . . . . . . . . . . . . . 310
18.2.8 Mechanical Circulatory Support . . . . . . . . . . . . . . . . . . . . . 310
18.3 The Timing of Pericardiectomy, Surgical Approaches,
Adequacy of Pericardial Resection, and their Relationship
to Low Cardiac Output Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 310
18.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
19 Cardiopulmonary Bypass and Mechanical Circulatory
Assistance in the Management of Pericardiectomy . . . . . . . . . . . . . . . . 321
19.1 Role of Cardiopulmonary Bypass in the Management of
Pericardiectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
19.2 Mechanical Circulatory Support . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
20 Specific Disease Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
20.1 Purulent/Bacterial Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
20.1.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
20.1.2 Incidence, Aetiology and Pathophysiology . . . . . . . . . . . . . 329
20.1.3 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
20.1.4 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
20.1.5 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
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