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2 History
and plateau pressure-pulse to diagnose constrictive pericarditis [3, 22–24]. Hancock popularized effusive-constrictive pericarditis as another variant of constrictive peri­carditis [25, 26]. Occult constrictive pericarditis was rst reported by Bush and associates in 1977 [4]. Constrictive pericarditis following cardiac surgery was rst described in 1972 by Kendall [36]. Isner and associates in 1982 described the diag­nostic usefulness of computed tomography in constrictive pericarditis, and Soulen and associates described the role of magnetic resonance imaging in evaluation of patients with constrictive pericarditis [33, 44]. Sengupta and associates in 2008, for the rst time, measured the extent of myocardial deformation (contraction or stretching) using speckle tracking echocardiography by strain-rate and strain imag­ing [45–52].
The rst successful pericardiotomy was performed by Rowero in 1819, and the rst pericardiocentesis was performed by Franz Schub in 1843. The idea of resect­ing the pericardium for constrictive pericarditis dates back to 1895 and 1898 when Wells and DeLorme respectively suggested pericardial excision [20, 55]. Brauer reported resection of ribs and costal cartilages for surgical treatment of constrictive pericarditis [5, 20, 55].
Subsequently, Rehn in 1913 and Sauerbruch in 1925, successfully performed the rst pericardiectomy for chronic constrictive pericarditis via left anterolateral thora­cotomy [43]. In 1929, Churchill performed the rst successful pericardiectomy [10]. Among the 15 patients of chronic constrictive pericarditis described by White in his St. Cyre’s Lecture, 7 patients underwent successful pericardiectomy [53, 54].
After this landmark history of thoracic surgery, this incision remains the standard approach. It was used by Beck and Griswald; Blalock and Burwell; Harrington and Barnes; and Heuer and Stewart [5–8, 27–29]. By 1945 a total of 256 patients treated by this approach had been reported in the literature, collectively reviewed by Heuer and Stewart [27–29].
In 1944, Harrington employed a U- shaped incision, with left sternal border forming the base of incision, and bilateral anterolateral thoracotomy for performing pericardiectomy constrictive pericarditis [27]. In 1955, Holman and Willett per­formed the rst successful pericardiectomy via median sternotomy, and presented their experience in the Hunterian lecture [30–32]. In 1965, Kloster demonstrated that normalization of pressure volume loop can be used as an indicator of successful pericardiectomy [37].
Chronic constrictive pericarditis following open heart surgery was reported rst in 1972 by Kendall [36]. In 1975, Copeland and Culliford from the Stanford group advocated radical pericardiectomy utilizing cardiopulmonary bypass as a routine [12–14]. In 1944, Harrington described the signicance of constricting epicardial peel. For pericardiectomy to be successful, all the constricting layers including the ventricular epicardium are to be removed [27, 28]. Chronic constrictive pericarditis following cardiac transplantation was reported rst in 1986 by Copeland from Stanford University [13]. In 2008, the author developed techniques to perform radi­cal pericardiectomy using left anterolateral thoracotomy without employing cardio­pulmonary bypass [15–19, 52].
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25
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2. Brockington GM, Zebede J, Pandian NG. Constrictive pericarditis. Cardiol Clin. 1990;8:645–66.
3. Bloomeld RA, Lauson HD, Coumand A, Breed ES, Richards DW.Recording of right heart. Pressures in normal subjects and in patients with chronic pulmonary disease and various types of cardio circulatory diseases. J Clin Invest. 1946;25:639–64.
4. Bush CA, Stang JM, Wooley CF, Kilman JW.Occult constrictive pericardial disease: diagnosis by rapid volume expansion as a correction by pericardiectomy. Circulation. 1977;56:924–30.
5. Beck CS, Griswald RA.Pericardiectomy in the treatment of the Pick syndrome: experimental and clinical observations. Arch Surg. 1930;21:1064.
6. Beck CS.Acute and chronic compression of the heart. Am Heart J. 1937;14:515–25.
7. Beck W, Schrire V, Vogelpoel L.Splitting of the second heart sound in constrictive pericarditis, with observations on the mechanism of pulsus paradoxus. Am Heart J. 1962;64:765–78.
8. Blalock A, Burwell CD.Chronic constrictive pericarditis. J Am Med Assoc. 1938;110:265.
9. Chevers N.Observations on diseases of the orice and valves of the aorta. Guy’s Hosp Rep. 1842;7:387–92.
10. Churchill ED. Decortication of the heart (Delorme) for adhesive pericarditis. Arch Surg. 1929;19:1457–69.
11. Corrigan. Cited in Connolly DC, Mann RJ, Cominic J.Corrigan (1802–1880) and his descrip­tion of the pericardial knock. Mayo Clin Proc. 1980;55:771–3.
12. Copeland JG, Stinson EB, Griepp RB, Shumway NE.Surgical treatment of chronic constric­tive pericarditis using cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1975;69:236–8.
13. Copeland JG, Riley JE, Fuller J. Pericardiectomy for effusive constrictive pericarditis after heart transplantation. J Heart Transplant. 1986;5:171–2.
14. Culliford AT, Lipton M, Spencer FC. Operation for chronic constrictive pericarditis: do the surgical approach and degree of pericardial resection inuence the outcome signicantly? Ann Thorac Surg. 1980;29:146–52.
15. Chowdhury UK, Seth S, Reddy SM.Pericardiectomy for chronic constrictive pericarditis. J Op Tech Thorac Cardiovasc Surg. 2008;13:14–25.
16. Chowdhury UK, Narang R, Malhotra P, Choudhury M, Choudhury A, Singh SP.Indications, timing and techniques of radical pericardiectomy via modied left anterolateral thoracotomy (UKC’s modication) and total pericardiectomy via median sternotomy (Holman and Willett) without cardiopulmonary bypass. J Prac Cardiovasc Sci. 2016;2:17–27.
17. Chowdhury UK, George N, Kumari LS, Singh S, Chauhan AS.Radical pericardiectomy via left anterolateral thoracotomy (UKC’s modication): a video presentation. Intern Med. 2019;1(4)
18. Chowdhury UK, George N, Singh S, Sankhyan LK, Sengupta S, Ray R, Vaswani P, etal. Total pericardiectomy via modied left anterolateral thoracotomy without cardiopulmonary bypass: a video presentation. Ann Thorac Surg. 2021; https://doi.org/10.1016/j.athoracsur.2020.10.045.
19. Chowdhury UK, George N, Singh S, Sankhyan LK, Sengupta S, Ray R, Vaswani P, Kalaivani M.Total pericardiectomy via modied left anterolateral thoracotomy without cardiopulmo­nary bypass. Ann Thorac Surg. 2021; https://doi.org/10.1016/j.athoracsur.2020.10.045.
20. Delorme E.Sur un traitement chirurgical: De la symphyse cardo-pericardique. Gaz des hop. 1898;71:1150–1.
21. Fowler NO. Constrictive pericarditis: its history and current status. Clin Cardiol. 1995;18:341–50.
22. Hansen AT, Eskildsen P, Göotzsche H.Pressure curves from the right auricle and the right ventricle in chronic constrictive pericarditis. Circulation. 1961;3:881–8.
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23. Hetzel PS, Wood EH, Burchell HB. Pressure pulses in the right side of the heart in a case of amyloid disease and in a case of idiopathic heart failure. Proc Staff Meet Mayo Clin. 1953;28:107–12.
24. Hancock EW. On elastic and rigid forms of constrictive pericarditis. Am Heart J. 1980;100:917–23.
25. Hancock EW.Subacute effusive constrictive pericarditis. Circulation. 1971;43:183–92.
26. Hancock EW. A clearer view of effusive-constrictive pericarditis. N Engl J Med. 2004;350:435–7.
27. Harrington SW.Chronic constrictive pericarditis: partial pericardiectomy and epicardiolysis in twenty-four cases. Ann Surg. 1944;120:468–85.
28. Harrington SW, Barnes AR.Diagnoses and surgical treatment of chronic constrictive pericar­ditis. South Surg. 1940;9:459.
29. Heuer GT, Stewart HJ.The surgical treatment of chronic constrictive pericarditis. NY State J Med. 1945;45:993.
30. Holman E, Willett F.The surgical correction of constrictive pericarditis. Surg Gynecol Obstet. 1949;89:129.
31. Holman E, Willet F.Treatment of active tuberculous pericardial pericardiectomy. J Am Med Assoc. 1951;146:1–7.
32. Holman E, Willet F.Results of radical pericardiectomy for constrictive pericarditis. J Am Med Assoc. 1955;157:789–94.
33. Isner JM, Carter BL, Bankoff MS, Kostam MA, Salem DN.Computed tomography in the diagnosis of pericardial heart disease. Ann Intern Med. 1982;97:473–9.
34. Kussmaul A, Stern M.Pericarditis and the paradox pulse, vol. 38. Berl Klin Wochenschr; 1873.
35. Kussmaul A.Ueber schwielige Mediastino-Pericarditis und den Parodoxen Puls. Bed Klin Wochenschr. 1873;10:433–5.
36. Kendall ME, Rhodes GR, Wolfe W.Cardiac constriction following aorta-to-coronary bypass surgery. J Thorac Cardiovasc Surg. 1972;64:142–53.
37. Kloster FR, Crislip RL, Bristow JD, Herr RH, Ritzmann LW, etal. Haemodynamic studies following pericardiectomy for constrictive pericarditis. Circulation. 1962;25:484.
38. Lower R: cited by Straehley CJ.Discussion. J Thorac Cardiovasc Surg. 1985;89:348–9.
39. Lancisi. Cited in Chevers N.Observations on diseases of the orice and valves of the aorta. Guy’s Hosp Rep. 1842;7:387–92.
40. McCaughan BC, Schaff HV, Piehler JM, Danielson GK, Orszulak TA, Puga FJ, Pluth JR, Connolly DC, McGoon DC.Early and late results of pericardiectomy for constrictive pericar­ditis. J Thorac Cardiovasc Surg. 1985;89(3):340–50.
41. Morgagni JB.De Sedibus et Causis Morborum per Anatomen Indigatis, especially Epistles 16, 22, 53 (3), 63 (4, 5). Louvain, Typographica Academica; 1756.
42. Pick F.Ueber chronische, unter dem Bilde der Lebercirrhose verlaufende Pericarditis (pericar­ditische Pseudolebercirrhose) nebst Bemerkungen über die Zuckergussleber (Curschmann). Ztschr f klin Med. 1896;29:385.
43. Rehn, Sauerbruch. Chronic constrictive pericarditis (Pick’s disease) treated by pericardial resection. Lancet. 1935;2:539–97.
44. Soulen RL, Stark DD, Higgins CB.Magnetic resonance imaging of constrictive pericardial disease. Am J Cardiol. 1985;55:480–4.
45. Sengupta PP, Eleid MF, Sundt TM.Regional variability of pericardial thickness inuences left ventricular diastolic recoil mechanics in constrictive pericarditis. J Am Soc Echocardiogr. 2008;21:518.
46. Sengupta PP, Eleid MF, Khandheria BK.Constrictive pericarditis. Circ J. 2008;72:1555–62.
47. Sengupta PP, Korinek J, Belohlavek M, Narula J, Vannan MA, Jahangir A, et al. Left ven­tricular structure and function: basic science for cardiac imaging. J Am Coll Cardiol. 2006;48:1988–2001.
2 History
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48. Sengupta PP, Khandheria BK, Korinek J, Wang J, Jahangir A, Seward JB, etal. Apex-to-base dispersion in regional timing of left ventricular shortening and lengthening. J Am Coll Cardiol. 2006;47:163–72.
49. Sengupta PP, Tajik AJ, Chandrasekaran K, Khandheria BK.Twist mechanics of the left ven­tricle: principles and application. JACC Cardiovasc Imaging. 2008;1:366–76.
50. Sengupta PP, Krishnamoorthy VK, Abhayaratna WP, etal. Disparate patterns of left ventricu­lar mechanics differentiate constrictive pericarditis from restrictive cardiomyopathy. JACC Cardiovasc Imaging. 2008;1(1):29–38.
51. Sengupta PP, Huang YM, Bansal M, Ashra A, Fisher M, Shameer K, etal. Cognitive machine­learning algorithm for cardiac imaging: a pilot study for differentiating constrictive pericarditis from restrictive cardiomyopathy. Circ Cardiovasc Imaging. 2016;9:e004330.
52. Sankhyan LK, Yadav V, Sharma S, Choubey M, George N, Sushamagayatri B, Malik V, Chowdhury UK.Assessment of myocardial mechanics in patients undergoing pericardiectomy for chronic constrictive pericarditis by tissue doppler imaging and 2D speckled tracking echo­cardiography: a prospective observational (Cohort) study. J Clin Cardiol Cardiovasc Interv. 4(3) https://doi.org/10.31579/2641- 0419/115.
53. White PD.Chronic constrictive pericarditis (Pick’s disease) treated by pericardial resection. Lancet. 1935;2:539–48; 597–603.
54. White PD.Chronic constrictive pericarditis. Circulation. 1951;4(2):288–94.
55. Wells WJ, Lindesmith GG.Ventricular septal defect. In: Arciniegas E, editor. Pediatric cardiac surgery. Chicago: Year Book Medical Publishers; 1985.
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Chapter 3
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Denition
Chronic constrictive pericarditis is a unique clinical haemodynamic syndrome of multifactorial aetiology. It is the end stage of a chronic inammatory or non­inammatory disease process, causing scarring, thickening, shrinkage or calcica­tion of one or both layers of the periepicardium, that leads to constriction and frequently to compression of the underlying cardiac chambers [2, 10–20, 25–30, 32,
34, 35, 39, 40, 60, 61, 63–68, 77, 87–90]. As a consequence of these morphologic
changes, the normal physiologic compliance is lost; there is impaired diastolic ll­ing of the cardiac chambers leading to cardiac failure, that manifests usually as systemic venous congestion without pulmonary congestion [46].
It is an elusive disease entity. It mimics endomyocardial brosis, restrictive car­diomyopathy, chronic liver disease, Budd-Chiari syndrome, and unexplained heart failure [3, 22, 23, 33, 36, 37, 47, 48, 56–59, 67, 69–71, 78, 81–86, 91, 93]. Localised chronic constrictive pericarditis secondary to constricting pericardial bands; tran­sient constrictive pericarditis; large pericardial calcic patches; occult constrictive pericarditis and effusive- constrictive pericarditis are clinically documented variants of constrictive pericarditis [1, 10–18, 21, 24–30, 34, 35, 38–45, 49–53, 55, 56, 63–
76, 87–90].
3.1 Chronic Constrictive Pericarditis withNormal Thickness
ofthePericardium
According to the modalities of assessment, the thickness of the pericardium varies (~0.8–1.0 mm thick on anatomic specimens, 0.7–1.2 mm by cardiac computed tomography, and 1.5–2.0mm by cardiac magnetic resonance [4–9, 31, 54, 60–66,
92]. Pericardial thickness greater than 4mm suggests pericardial constriction, and
one greater than 6mm has a high specicity for constriction [63–66]. With respect
Ltd. 2023 U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_3
29© The Author(s), under exclusive license to Springer Nature Singapore Pte
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3 Denition
to the extent of periepicardial changes, several forms of pericardial constriction may be distinguished [42, 93].
In the global form, both chambers are equally affected. The focal form may be classied as (i) annular (narrowing of the atrioventricular grooves); (ii) right-sided (compression of the right ventricle), or left-sided (compression of the left ventricle); (iii) surrounding the root of the great vessels; (iv) epicardial (mainly the epicardial layer is affected); or (v) effusive (epicardial constriction with effusion) [44, 45, 50,
60, 61].
However, the Mayo Clinic group in their series of 143 patients identied a subset of patients (18%) with normal pericardial thickness on imaging, with clinical and haemodynamic features for chronic constrictive pericarditis, in whom pericardiec­tomy was effective in relieving the symptoms [76, 79, 80]. These patients were mostly post-surgical and post-irradiation, wherein microscopic examination revealed inammation, focal non-caseating granulomas, focal brosis, and focal calcication.
Microscopically, although the pericardium consists primarily of extracellular collagen (with little elastic tissue), it is still living tissue, with broblasts to replen­ish collagen that degenerates over time. Ling and associates from the Mayo Clinic pointed out that if the rate of collagen production is less than that of degradation, the pericardial volume decreases. Thus a thin pathologic pericardium may underlie a similar pathophysiological process in a subset of patients with haemodynamic fea­tures of constrictive pericarditis. Rather than being like a suit of armour encasing the heart, the constriction is analogous to a thin wet-suit worn by a diver [44, 79,
80]. Therefore, in patients with clinical and haemodynamic features of chronic con-
strictive pericarditis and normal pericardial thickness on imaging, total or radical pericardiectomy remains the treatment of choice.
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3 Denition
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