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12 Decision-Making on the Timings of Pericardiectomy, Selection of the Optimal…
little hemodynamic sequence in the great majority of patients undergoing pericardial resection.
Additionally, it is literally an impossible task to excise the portion of pericardium
posterior to the phrenic nerves through median sternotomy without utilizing cardiopulmonary bypass [5, 14–23, 30, 35, 60–62, 77, 79–81, 100].
In a South African study as 113 patients undergoing pericardiectomy for tubercular chronic constrictive pericarditis, 97% were discharged from hospital. Although
hepatomegaly and pedal oedema quickly resolved in the great majority of patients,
regression of ascites and venous congestion occurred over 2–3months [33].
At author’s institute, in a study on 395 patients undergoing pericardiectomy
being followed-up for 17.9±0.3years, 96.3% of pericardiectomy survivors of the
sternotomy group and 79.1% of survivors of the thoracotomy group were in functional class I/II (p<0.001). The time taken for normalization of hemodynamics and
improved functional classes I and II in the sternotomy and thoracotomy groups was
34±12 and 70±22days respectively (p<0.001).
Diastolic lling characteristics remained abnormal in 15.9% (n= 54) patients
undergoing total pericardiectomy and 61.4% (n=35) patients undergoing partial
pericardiectomy (p<0.001) in the immediate postoperative period. At the time of
reporting, 3.7% (n= 11) of sternotomy survivors and 20.9% (n=9) of the thoracotomy survivors exhibited persistent abnormal diastolic lling pattern on Doppler
echocardiogram (p=0.004) [19].
Despite total pericardiectomy, the perioperative mortality was 7.6% in our series
and 6–19% in several large series published after 1985; the reported incidence of
low cardiac output syndrome ranges from 50% to 69% [4, 5, 12–27, 50–53, 60, 62,
80, 100].
In order to further decrease the perioperative mortality rates of 7.6% and postoperative low cardiac output syndrome, the author proceeded to perform several technical modications of the conventional left anterolateral thoracotomy to achieve
radical excision of the pericardium posterior to the phrenic nerve and diaphragmatic
pericardium and published the preliminary experience with step-by-step surgical
illustrations on 25 patients in Operative Techniques in Thoracic and Cardiovascular
Surgery [26].
The surgical approach for pericardiectomy, although mostly based on surgeon’s
preference, median sternotomy was the preferred approach in the following subset
of patients:
(i) atrioventricular annular constrictive pericarditis,
(ii) “cocoon” pericardial calcication encompassing all cardiac chambers,
(iii) calcic pericardial patch compressing the right atrium and right ventricular
outow tract,
(iv) extracardiac intrapericardial mass mostly comprising of caseous material,
(v) presence of a 2 mm or greater gradient in the superior or inferior cavoatrial
junctions,
(vi) constrictive pericarditis following open heart surgery,
(vii) postradiation constrictive pericarditis, and
12.2 Criteria for Decision-Making on the Indications and Timings for Pericardiectomy…
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(viii) recurrent constrictive pericarditis following partial pericardiectomy.
Median sternotomy was preferred for the above clinical circumstances for improved
surgical exposure without compromising the hemodynamics, and easy institution of
cardiopulmonary bypass in the event of inadvertent surgical injury and bleeding
[19–27].
Till 2020, a series of 127 consecutive patients underwent total pericardiectomy
via modied left anterolateral thoracotomy without utilizing cardiopulmonary
bypass (UKC’s modication) at the author’s institution [27]. By employing these
modications, the author succeeded to reduce the perioperative mortality from
7.6% (previous series) to 3.1% (present series), and postoperative low cardiac output syndrome from 69% (previous series) to 24.4% (present series) [27]. Our overall perioperative mortality is 3.1%, which is in accordance with the 6% to 19%
perioperative mortality rate of large series published after 1985 [1, 2, 4, 5, 15–27,
50, 52, 58–60, 62–64, 67, 69, 79, 82–84, 109]. At a mean follow-up of
97.3±50.8months, 93.4% (n=113) were in functional class I/II and 6.6% (n=8)
were in functional class III.The time taken to achieve normal hemodynamics and
improved functional class was 39± 10days. Although hepatomegaly and ascites
resolved promptly in the majority of patients, overall venous body congestion
improved over a period of 30–40days in some patients [27].
The timing of pericardiectomy in patients diagnosed with chronic constrictive
pericarditis remains ill dened. Based on the evidence enunciated above and in the
published literature, we conclude that the natural course of constrictive pericarditis
is permanent and often progressive in the majority unless the constriction is surgically relieved. It is indeed difcult to ascertain the degree of myocardial involvement in a case of constrictive pericarditis. Analysis of the published literature
substantiate poor results of pericardiectomy in patients dominant myocardial
involvement and superior results with dominant constrictive element which is reliably assessed by cardiac magnetic resonance imaging and speckle tracking echocardiography [19–27, 109].
Following successful pericardiectomy in patients with mixed constrictive restrictive disease, there may not be improvement of symptoms due to impaired myocardial compliance [1, 2, 4, 5, 15–27, 50, 52, 58–60, 62–64, 67, 69, 71, 79, 82–84,
109]. Although limited evidence-based data are available, an useful guideline is: the
more signicant inspiratory ow variations noted on Doppler echocardiography and
cardiac catheterization, the more likelihood of the presence of a dominant constrictive element and the better is the surgical result.
Since the degree of enhanced ventricular interaction is proportional to the severity of pericardial restraint, it is indeed important to ascertain the relationship
between the right and left ventricular pressure curves to determine the degree of
predominant pericardial or myocardial involvement of the disease process. In general, patients with constrictive pericarditis with a greater degree of ventricular discordance during respiratory cycles, benet maximum from pericardiectomy
[19–27].
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12 Decision-Making on the Timings of Pericardiectomy, Selection of the Optimal…
Conversely, some patients have a mild degree of ventricular discordance; the rise
of the diastolic pressure is disproportionate to the discordance. In these patients, the
major pathophysiological process is an abnormal myocardial compliance. These
patients exhibit persistent signs and symptoms of right heart failure despite pericardiectomy [69, 70]. The presence of advanced disease with myocardial involvement,
signs of severe congestive cardiac failure and hepatorenal involvement have been
identied as an incremental risk factors for death [19–27].
Analysis of the published literature substantiates that early pericardiectomy
appears benecial in patients with right atrial pressure between 12 to 15mmHg,
early signs of hepatorenal dysfunction, and massive ascites [8, 19, 24, 27, 33, 72,
87–93]. Thus, patients with markers of prolonged chronic constriction e.g. cachexia,
higher right atrial pressure, hepatorenal dysfunction, signs of progressive systemic
congestion like massive pleural effusion and ascites, a lesser degree of ventricular
discordance during respiratory cycle, brocalcic involvement of the myocardium
on cardiac magnetic resonance are suitable candidates for urgent pericardial excision [6–8, 19–27, 50, 57, 85, 87–92].
It has been further demonstrated that patients with ‘end-stage’ constrictive pericarditis derive little or no benet from pericardiectomy. Literature documents higher
operative risk in patients undergoing pericardiectomy for advanced calcic constrictive pericarditis [31–33, 37, 54, 55, 73]. Despite high operative risk, the survival
rate of patients with chronic constrictive pericarditis following pericardiectomy is
higher in this group than without surgery [3–5, 8, 11, 12, 31, 32, 42, 50–53, 57, 66,
74, 87–92, 100]. The indicators of end-stage constrictive pericarditis include car-
diac cachexia, reduced cardiac output (CI <1.2 LPM/m2), hepatic dysfunction due
to congestive hepatomegaly or cardiogenic cirrhosis, hypoalbuminemia due to
protein- losing enteropathy and liver cirrhosis [19–27].
Patients with cardiac tamponade or a large pericardial effusion as echocardiogram, usually undergo initial echo guided percutaneous pericardiocentesis using a
pigtail catheter. Early pericardiectomy may be desirable if pericardiocentesis fails
to drain loculated effusions, in cases of recurrent effusions, or if echocardiographic/
integrated imaging studies are suggestive of effusive-constrictive disease or early
constrictive pericarditis after 4 to 6weeks of anti-tubercular drug therapy [42, 57,
74, 87, 93, 95, 96, 102–104].
The therapeutic strategy in patients with tuberculous non-calcic constrictive
pericarditis involves a trial of anti-tubercular medication for 6–8weeks and referral
for pericardiectomy for patients with no improvement or worsening clinical signs
and symptoms of pericardial constriction with supportive structural and haemodynamic criteria [8, 19, 24, 27, 33, 72, 87–93].
Calcic constrictive pericarditis whenever detected is, however, an absolute indication of pericardiectomy. Calcic pericardium signies late presentation with
myocardial brosis. Calcied spicules may penetrate the myocardium, causing left
ventricular dysfunction that may preclude surgical options [40]. However, we have
been able to remove the calcic spurs in all patients undergoing pericardiectomy for
calcic constrictive pericarditis in our institution [19, 23, 24, 26, 27].
12.3 Should Cardiopulmonary Bypass Be Used Routinely while Performing…
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12.3 Should Cardiopulmonary Bypass BeUsed Routinely
while Performing Pericardiectomy?
Published literature including our observations does not provide any conclusive
answer. Although it is easy to perform pericardiectomy for effusive-constrictive and
pyogenic pericarditis, it may indeed be difcult in cases of calcic and postirradiation constrictive pericarditis. The latter group of patents may not tolerate cardiac manipulation, while excising the pericardium.
Studies in which cardiopulmonary bypass was associated with higher perioperative mortality including the Stanford series reects an advanced disease process in
whom cardiopulmonary bypass was required [11–13]. Thus, one should not be
reluctant to use cardiopulmonary bypass, if required, to facilitate complete pericardial excision, since it improves long-term patient outcomes. Additionally, cardiopulmonary bypass allows one to ultraltrate some ascitic uid and tissue uids from
the third space. Thus, employment of cardiopulmonary bypass may prevent autotransfusion following pericardial resection, a concept thus far not well appreciated
and well-explored [5, 19–27, 34–36, 50, 52, 57, 59, 74, 100].
Cardiopulmonary bypass empties the cardiac chambers, thereby denes exact
dissection plane and facilitates management of inadvertent injury to cardiac chambers and great vessels. Tokuda and associates in the Japan Adult Cardiovascular
Surgery Database observed cardiopulmonary bypass as an incremental risk factor of
a worse outcome [100]. Cox regression analysis of the database indicated that
employment of cardiopulmonary bypass was not a surrogate of the severity of disease process but that the use of cardiopulmonary bypass itself was an incremental
risk factor for adverse outcome. Database analysis further demonstrated that use of
cardiopulmonary bypass was associated with bleeding and other bypass related
complications [101]. The Japanese study further observed that an increased incidence of reoperation for perioperative bleeding and an ICU stay exceeding 8days
among patients undergoing pericardiectomy using cardiopulmonary bypass than
those without cardiopulmonary bypass [100].
While performing pericardiectomy via left anterolateral thoracotomy, it is essential to prepare the left groin for emergent institution of cardiopulmonary bypass, if
deemed necessary. It is equally important to assess the respiratory function, and
exclude the presence of signicant right-sided pleural effusion preoperatively due to
the positional negative effect of thoracotomy [9].
Based on the available evidence in the literature, we conclude that cardiopulmonary bypass is useful in performing pericardiectomy in the following circumstances:
(i) inadvertent intraoperative injury to the cardiac chambers and great vessels, (ii)
constriction after previous open heart surgery, (iii) post irradiation constrictive pericarditis, (iv) recurrent constrictive pericarditis following partial pericardiectomy,
(v) calcied pericardial “Cocoon” compressing the cardiac chambers and great vessels, and (vi) co-existing cardiac lesion requiring open heart surgery [19–27]. In
addition, cardiopulmonary bypass facilitates ultraltration of ascitic uids, thus preventing autotransfusion and postoperative cardiac distension.
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12 Decision-Making on the Timings of Pericardiectomy, Selection of the Optimal…
Cardiac transplantation with constrictive pericarditis generally presents with
symptoms and signs of right-sided cardiac failure, with peripheral oedema and ascites mimicking cardiac rejection and restrictive cardiomyopathy. An integration of
clinical picture and multimodality imaging studies including M and Doppler echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging,
invasive cardiac catheterization is essential to establish an early diagnosis of posttransplant constrictive pericarditis. For early diagnosis, nuclear magnetic resonance
is the best imaging technique to document pericardial thickening, mediastinal
hematoma, and right atrial/right ventricular compression. A subxiphoid pericardiostomy for pericardial effusion followed by total pericardiectomy is treatment of
choice for these patients [10, 11, 28, 44–46, 49, 56, 105, 106].
The European society of Cardiology, American Heart Association, and Japanese
Cardiovascular Society acknowledges the role of medical management in a subset
of patients with constrictive pericarditis [3, 42, 49, 57, 65, 71, 72, 106]. However,
analysis of the published literature suggests timely institution of total pericardiectomy with epicardial decortication is essential for superior short- and long-term
outcomes [18–27].
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