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Background: Atrial fibrillation (AF) and pericardial effusion are notable complications following coronary artery bypass grafting (CABG), contributing to increased morbidity and healthcare costs. Posterior pericardiotomy has been proposed to mitigate these complications. This systematic review and meta-analysis aim to evaluate the efficacy of posterior pericardiotomy in reducing postoperative AF and pericardial effusion in isolated CABG patients., Materials and Methods: A comprehensive literature search, adhering to PRISMA guidelines, was conducted across PubMed, MEDLINE via Ovid, Embase, Scopus, the Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov up to December 2023. Only randomised controlled trials (RCTs) comparing prophylactic posterior pericardiotomy to control treatments in adult CABG patients were included. The primary outcomes assessed were the incidences of postoperative AF and pericardial effusion., Results: The meta-analysis incorporated 16 RCTs with a total of 2414 patients. The findings demonstrated a significant reduction in the incidence of postoperative AF (Odds Ratio = 0.34, 95 % CI: 0.25-0.48, P < 0.00001) and pericardial effusion (Odd Ratio = 0.24, 95 % CI: 0.15-0.38, P < 0.0001) in the group undergoing posterior pericardiotomy. However, the analysis revealed substantial heterogeneity and publication bias in the included studies., Conclusion: The posterior pericardiotomy is effective in reducing the incidences of AF and pericardial effusion in patients undergoing isolated CABG. Despite the positive outcomes, the presence of heterogeneity and publication bias warrants a cautious interpretation of the results and underscores the need for further multicentre RCTs in this area., Competing Interests: Declaration of competing interest All authors declare that there is no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

A 64-year-old woman with a history of subarachnoid hemorrhage, breast cancer, cervical spine tumor, and syringomyelia developed recurrent pericardial effusion and cardiac tamponade after receiving the third dose of coronavirus disease 2019 mRNA vaccine, mRNA-1273 (Spikevax, Moderna). The cardiac tamponade of unknown etiology was intractable with nonsteroidal anti-inflammatory drugs, colchicine, and prednisolone. She underwent thoracoscopic pericardiectomy, and microthrombi were detected in the pericardial tissue. Although the exact causal relationship between vaccination and recurrent cardiac tamponade was unclear, the vaccine possibly caused or triggered the microthrombi formation, resulting in recurrent cardiac tamponade. Because of the potential for cardiovascular side effects such as thrombosis and myocarditis following vaccination, it was deemed necessary to accumulate and analyze such cases., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: Previous cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment., Methods: We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation., Results: Median patient age was 64 (56-72) years, and the median interval between previous operation and pericardiectomy was 2.7 years (range, 0-54 years). Previous operations included coronary artery bypass grafting in 114 (43%), valve surgery in 85 (32%), combined coronary artery bypass grafting and valve surgery in 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate-to-severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P = .013), diabetes (P = .019), and nonelective pericardiectomy within 2 years of cardiac surgery (P < .001) were associated with decreased long-term survival., Conclusions: Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Owing to the lack of understanding of the clinical significance of pericardial calcification during pericardiectomy, whether pericardial calcification should be considered when determining the optimal timing for pericardiectomy is debatable. We aimed to investigate the effect of pericardial calcification on early postoperative outcomes in patients who underwent pericardiectomy for constrictive pericarditis., Methods: Altogether, 44 patients who underwent pericardiectomy for constrictive pericarditis were enrolled. After excluding three patients who underwent concurrent surgeries, a total of 41 patients were categorized into two groups based on the presence of pericardial calcification as determined by preoperative computed tomography and pathological examination. Preoperative clinical and imaging characteristics, intraoperative data, and early postoperative outcomes were compared between the two groups. A multivariable analysis was performed to identify the factors associated with postoperative complications., Results: The group with and without PC comprised 21 and 20 patients, respectively. No significant differences were observed in 30-day mortality (n = 1 [5%]) in the group with pericardial calcification and no mortality in the group without pericardial calcification (p > 0.999). Other early postoperative outcome variables did not demonstrate any significant differences between the two groups. However, the use of cardiopulmonary bypass was associated with postoperative complications (p < 0.009, odds ratio: 63.5, 95% confidence interval: 5.13-3400)., Conclusions: Pericardial calcification did not significantly affect the postoperative outcomes after pericardiectomy. Further comprehensive studies, including those with larger sample sizes and longitudinal designs, are necessary to determine whether pericardial calcification can significantly influence the timing of surgical intervention., (© 2024. The Author(s).)

Background: We aimed to determine the rate and impact of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery and the perioperative factors associated with its occurrence., Methods: All consecutive patients who underwent native valve-sparing aortic valve surgery (i.e., repair ± ascending aorta replacement, valve-sparing root replacement, Ross procedure ± ascending aorta replacement) at our institution between January 2021 and August 2023 served as our study population. Post-pericardiotomy syndrome was diagnosed if patients showed at least two of the following diagnostic criteria: evidence of (I) new/worsening pericardial effusion, or (II) new/worsening pleural effusions, (III) pleuritic chest pain, (IV) fever or (V) elevated inflammatory markers without alternative causes. A logistic regression model was calculated., Results: During the study period, 91 patients underwent native valve-sparing aortic valve surgery. A total of 21 patients (23%) developed post-pericardiotomy syndrome early after surgery (PPS group). The remaining 70 patients (77%) showed no signs of post-pericardiotomy syndrome (non-PPS group). Multivariate logistic regression revealed blood type O (OR: 3.15, 95% CI: 1.06-9.41, p = 0.040), valve-sparing root replacement (OR: 3.12, 95% CI: 1.01-9.59, p = 0.048) and peak C-reactive protein >15 mg/dl within 48 hours postoperatively (OR: 4.27, 95% CI: 1.05-17.29, p = 0.042) as independent risk factors. 73% (8/11) of patients displaying all three risk factors, 60% (9/15) of patients with blood type O and valve-sparing root replacement, 52% (11/21) of patients with blood type O and early postoperative peak C-reactive protein >15 mg/dl and 45% (13/29) of patients with early postoperative peak C-reactive protein >15 mg/dl and valve-sparing root replacement developed post-pericardiotomy syndrome., Conclusion: In summary, blood type O, valve-sparing root replacement and peak C-reactive protein >15 mg/dl within 48 hours postoperatively are significantly associated with post-pericardiotomy syndrome after native valve-sparing aortic valve surgery. Particularly, the presence of all three risk factors is linked to a particularly high risk of post-pericardiotomy syndrome., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Holst et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aim: We aim to access the effect of pericardiectomy for constrictive pericarditis with or without cardiopulmonary bypass., Methods: This was a review of pericardiectomy for constrictive pericarditis., Results: Cardiopulmonary bypass is actually an important maneuver to attain complete relief of the constriction. The short additional time of cardiopulmonary bypass during the procedure has very little effect on the risk of morbidity of the main operation., Conclusion: Incomplete pericardiectomy perhaps was the cause of postoperative remnant constriction and high diastolic filling pressure leading to multiorgan failure. Complete pericardiectomy (removal of phrenic-to-phrenic and the postero-lateral and inferior wall pericardial thickening) using cardiopulmonary bypass should be the routine for total relief of the constriction of the heart., Competing Interests: The authors declare no competing interests in this work., (© 2024 Huang and Tang.)

Objectives: The aim of this study was to analyze the efficacy and safety of percutaneous balloon pericardiotomy (PBP) in oncological patients who present with a malignant pericardial effusion (MPE)., Background: The use of PBP as a treatment for MPE is not standardized due to the limited evidence. Furthermore, the performance of a second PBP for a recurrence after a first procedure is controversial., Methods: The BALTO Registry (BALloon pericardioTomy in Oncological patients) is a prospective, single-center, observational registry that includes consecutive PBP performed for MPE from October 2007 to February 2022. Clinical and procedural, characteristics, as well as clinical outcome were analyzed., Results: Seventy-six PBP were performed in 61 patients (65% female). Mean age was of 66.4 ± 11.2 years. In 15 cases, a second PBP procedure was performed due to recurrence despite the first PBP. The procedure could be performed effectively in all cases with only two serious complications. Ninety-five percent of cases were discharged alive from the hospital. During a median follow-up of 6.3 months (interquartile range [IQR], 0.9-10.8), MPE recurred in 24.5% cases although no recurrences were reported after the second procedure. No evidence of malignant pleural effusion developed on follow-up. The median overall survival time was 5.8 months (IQR, 0.8-10.2) and the time to recurrence after the first PBP was 2.4 months (IQR, 0.7-4.5)., Conclusions: PBP is a safe and effective treatment for MPE. It could be considered an acceptable therapy in most MPE, even in those who recur after a first procedure., (© 2024 Wiley Periodicals LLC.)

Purpose: Pericardiectomy is the definitive treatment option for constrictive pericarditis and is associated with a high prevalence of morbidity and mortality. However, information on the associated outcomes and risk factors is limited. We aimed to report the mid-term outcomes of pericardiectomy from a single center in China., Methods: We retrospectively reviewed data collected from patients who underwent pericardiectomy at our institute from April 2018 to January 2023., Results: Eighty-six consecutive patients (average age, 46.1 ± 14.7 years; 68.6 men) underwent pericardiectomy through midline sternotomy. The most common etiology was idiopathic (n = 60, 69.8%), and 82 patients (95.3%) were in the New York Heart Association function class III/IV. In all, 32 (37.2%) patients underwent redo sternotomies, 36 (41.9%) underwent a concomitant procedure, and 39 (45.3%) required cardiopulmonary bypass. The 30-day mortality rate was 5.8%, and the 1-year and 5-year survival rates were 88.3% and 83.5%, respectively. Multivariable analysis revealed that preoperative mitral insufficiency (MI) ≥moderate (hazard ratio [HR], 6.435; 95% confidence interval [CI] [1.655-25.009]; p = 0.007) and partial pericardiectomy (HR, 11.410; 95% CI [3.052-42.663]; p = 0.000) were associated with increased 5-year mortality., Conclusion: Pericardiectomy remains a safe operation for constrictive pericarditis with optimal mid-term outcomes.

Constrictive pericarditis is a rare, potentially treatable, cause of heart failure with preserved ejection fraction that is characterized by insidious onset, challenging diagnosis and dismal prognosis, even following complete surgical pericardiectomy, particularly in advanced disease stages. In recent years it has been proposed that transient pericardial constriction may occur, with an even rarer frequency, during early phases of acute pericarditis and may resolve following specific treatment without progressing to the chronic, irreversible form. We recently observed two cases of well-documented transient pericardial constriction. In the present work we describe these two cases and provide a review on this rare condition, that, if unrecognized and left untreated, may lead to irreversible constrictive pericarditis., Competing Interests: Declaration of Competing Interest The authors report no relationships that could be construed as a conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

Objectives: Although pericardiectomy is an effective treatment for constrictive pericarditis (CP), clinical outcomes are not always successful. Pericardial calcification is a unique finding in CP, although the amount and localization of calcification can vary. We investigated how the pattern and amount of pericardial calcification affect mid-term postoperative outcomes after pericardiectomy to treat CP., Methods: All patients of total pericardiectomy in our hospital from 2010 to 2020 were enrolled. Preoperative Computed tomography (CT) scans of 98 consecutive patients were available and analyzed. Medical records were reviewed retrospectively. Cardiovascular events were defined as cardiovascular death or hospitalization associated with a heart failure symptom, and all-cause events were defined as any event that required admission. CT scans were analyzed, and the volume and localization pattern of peri-calcification were determined. Pericardium calcium scores are presented using Agatston scores., Results: Of the 98 patients, 25 (25.5%) were hospitalized with heart failure symptoms after pericardiectomy. The median follow-up duration for all patients was 172 weeks. The group with a cardiovascular event had a lower calcium score than patients without an event. Multivariate Cox proportional analysis showed that high ln(calcium score+1) before pericardiectomy was a dependent predictor of cardiovascular event (hazard ratio, 0.90; p = 0.04) after pericardiectomy. When we set the cut-off value (ln(calcium score+1) = 7.22), there was a significant difference in cardiovascular events in the multivariate Cox proportional analysis (p = 0.04)., Conclusion: A low burden of pericardial calcification was associated with a high rate of mid-term clinical events after pericardiectomy to treat CP., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Calcific constrictive pericarditis is a very rare complication of systemic sclerosis. This is the first report of surgically treated calcific constrictive pericarditis in systemic sclerosis. A 53 years-old woman, affected by limited systemic sclerosis, had a diagnosis of calcific constrictive pericarditis. She had a medical history of congestive heart failure since 2022. The patient was treated with pericardiectomy. Via a median sternotomy, the pericardium was dissected and removed from the midline to the left phrenic nerve, thus freeing the heart. Three months after the pericardiectomy, there was a significant clinical improvement. The calcific evolution of chronic pericarditis is a rare complication of systemic sclerosis. This case represents, at best of our knowledge, the first report of calcific constrictive pericarditis, in systemic sclerosis, treated with pericardiectomy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The data on constrictive pericarditis following heart transplantation are scarce. Herein, the authors present 2 patients who developed a constrictive pericarditis 19, and 55 months after heart transplantation. They underwent several diagnostic procedures and successfully recovered after a radical pericardiectomy. In addition, the authors review the literature and report the incidence, aetiology, diagnostic features, and management of this rare and challenging condition.

Purpose: Post-pericardiotomy syndrome (PPS) is a common complication of cardiac surgery. This systematic review aimed to investigate the efficacy of colchicine, indomethacin, and dexamethasone in the treatment and prophylaxis of PPS., Methods: Literature research was carried out using PubMed. Studies investigating ≥ 10 patients with clinically PPS treated with colchicine, dexamethasone, and indomethacin and compared with placebo were included. Animal or in vitro experiments, studies on < 10 patients, case reports, congress reports, and review articles were excluded. Cochrane risk-of-bias tool for randomized trials (RoB2) was used for the quality assessment of studies., Results: Seven studies were included. Among studies with postoperative colchicine treatment, two of them demonstrated a significant reduction of PPS. In the single pre-surgery colchicine administration study, a decrease of PPS cases was registered. Indomethacin pre-surgery administration was linked to a reduction of PPS. No significant result emerged with preoperative dexamethasone intake., Conclusion: Better outcomes have been registered when colchicine and indomethacin were administered as primary prophylactic agents in preventing PPS and PE. Further RCT studies are needed to confirm these results., (© 2021. The Author(s).)

Background: Atrial fibrillation (AF) associated with postoperative pericardial effusion is the most commonly reported adverse event after cardiac surgery., Aims: We aimed to determine the role of posterior pericardiotomy in preventing postoperative AF (POAF)., Methods: We searched PubMed, Scopus, Web of Science, Ovid, and EBSCO from inception until 30 June 2022. We included randomised clinical trials (RCTs) that compared posterior pericardiotomy (PP) versus control (no PP) in patients undergoing cardiac surgery. The primary endpoint was the incidence of POAF after cardiac surgery. The secondary endpoints were supraventricular arrhythmias, early/late pericardial effusion, pericardial tamponade, pleural effusion, length of hospital/intensive care unit stay, intra-aortic balloon pump use, revision surgery for bleeding, and mortality., Results: Twenty-five RCTs comprising 4,467 patients were included in this systematic review and meta-analysis. The overall incidence rate of POAF was 11.7% in the PP group compared with 23.67% in the no PP or control group, with a significant decrease in the risk of POAF following PP (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.38-0.61). Compared with the control group, the risk of supraventricular tachycardia (OR 0.66, 95% CI: 0.43-0.89), early pericardial effusion (OR 0.32, 95% CI: 0.22-0.46), late pericardial effusion (OR 0.15, 95% CI: 0.09-0.25), and pericardiac tamponade (OR 0.18, 95% CI: 0.10-0.33) were lower in the PP group., Conclusions: PP is an effective intervention for reducing the risk of POAF after cardiac surgery. Also, PP is economically efficient in terms of decreasing the length of hospital stay.

Background: In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect., Methods: We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used., Results: Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy., Conclusions: Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF., Competing Interests: Conflict of interest Dr Di Franco has consulted for Novo Nordisk, Servier and is an Advisory Board Member for Scharper. The other authors have no disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The mainstay of the treatment of constrictive pericarditis is pericardiectomy. However, surgery is associated with high early morbidity and mortality and low long-term survival. The aim of this study is to describe our series of pericardiectomies performed over 30 years., Methods: A descriptive, observational, and retrospective analysis of all pericardiectomies performed at the Institute of Cardiology and Cardiovascular Surgery of the Favaloro Foundation was performed., Results: A total of 45 patients underwent pericardiectomy between June 1992 and June 2022, mean age was 52 years (standard deviation ± 13.9 years), and 73.3% were men. Idiopathic constrictive pericarditis was the most prevalent (46.6%). The variables significantly associated with prolonged hospitalization were preoperative advanced functional class (incidence of 38.4%, P<0.04), persistent pleural effusion (incidence of 81.8%, P<0.01), and although there was no statistical significance with the use of cardiopulmonary bypass, a trend in this association is evident (P<0.07). We found that 100% of the patients with an onset of symptoms greater than six months had a prolonged hospital stay. In-hospital mortality was 6.6%, and 30-day mortality was 8.8%. The preserved functional class is 17 times more likely to improve their symptomatology after pericardiectomy (odds ratio 17, 95% confidence interval 2.66-71; P<0.05)., Conclusion: Advanced functional class at the time of pericardiectomy is the variable most strongly associated with mortality and prolonged hospitalization. Onset of the symptoms greater than six months is also a poor prognostic factor mainly associated with prolonged hospitalization; based on these data, we strongly support the recommendation of early intervention.

Primary malignant pericardial mesothelioma (PMPM) is an extremely rare and lethal cardiac tumor. This article presents a 62-year-old man with recurrent pericardial fluid. The patient's clinical symptoms and imaging features were nonspecific. Initial diagnosis was constrictive pericarditis. After admission, the patient's symptoms worsened, and echocardiography indicated increased pericardial effusion. To diagnose and improve the patient's symptoms, pericardiotomy was performed; however, the procedure was unsuccessful because the pericardium was densely adherent to the myocardium. Histopathological examination, including immunohistochemical staining of the pericardial specimen revealed malignant mesothelioma. We recommended adjuvant therapy for the patient with cis-platinum and pemetrexed; however, the patient and his family refused treatment. The patient was discharged 11 days after surgery. The patient survived for more than 15 months with surgical treatment. In this report, the patient's symptoms improved, and the patient survived beyond the median survival after surgical treatment.   Conclusion: The definitive diagnosis of PMPM mostly has been obtained from specimens obtained by surgery. Surgery is an effective treatment method because it prevents cardiac tamponade and can improve symptoms or prognosis, but complete resection is impossible.

Objective: In the case of malignant pericardial effusion and cardiac tamponade, balloon pericardiotomy is an established minimally invasive option to the surgical creation of a subxiphoid pericardial window. Percutaneous balloon pericardiotomy effectively drains recurrent pericardial fluid by creating a pleuro (-abdominal-) pericardial communication. Design. A series of 26 patients with underlying malignant ( n  = 12) and nonmalignant ( n  = 14) diseases underwent percutaneous balloon pericardiotomy between 2008 and 2021. All interventions were done through a subxiphoid access under local anesthesia. Results. The mean survival in the malignant and nonmalignant groups was 1.2 versus 48.0 months, respectively ( p  < .001). There were neither severe periinterventional complications nor in-hospital deaths. In two patients with nonmalignant disease the surgical creation of a pericardial window was necessary during follow-up. The originally described procedure was modified by the removal of all catheters at the end of the intervention. The procedure was safe. It prevented immobility and facilitated an early discharge from the hospital. Conclusion. Our experiences show that percutaneous balloon pericardiotomy is a minimally invasive approach to successfully provide palliation in the group of patients with underlying malignant disease. On the other hand, we have shown that this technique is safe and feasible in the treatment of pericardial effusion based on nonmalignant disease. We think thereby that pericardial balloon pericardiotomy can be considered as a less invasive alternative to surgery in both groups of patients.

Background: We aimed to investigate risk factors of LCOS following pericardiectomy., Methods: This was a retrospective study of patients undergoing pericardiectomy at three hospitals between January 1994 and May 2021., Results: A total of 826 patients were divided into two groups: group with LCOS (N = 126) and group without LCOS (N = 700). The incidence of postoperative LCOS was 15.3%. There were 66 operative deaths (8.0%). Univariable and multivariable analyses showed that factors are associated with LCOS, including postoperative LVEDD (P < 0.001), preoperative LVEDD (P < 0.001), time between symptoms and surgery (P < 0.001), thickness of pericardium (P < 0.001), intubation time (P = 0.002), hospitalized time postoperative (P < 0.001), preoperative central venous pressure (P = 0.016), postoperative central venous pressure (P = 0.034), D0 fluid balance (P = 0.019), D2 fluid balance (P = 0.017), postoperative chest drainage (P < 0.001), surgical duration (P < 0.001), bleeding during operation (P = 0.001), serum creatinine 24h after surgery (P < 0.001), serum creatinine 48h after surgery (P = 0.017), fresh-frozen plasma (P = 0.005), packed red cells (P = 0.006), and tuberculosis pericarditis (P = 0.026)., Conclusion: In our study, incomplete pericardial dissection, fluid overload, delayed diagnosis and treatment, and tuberculosis pericarditis are associated with LCOS following pericardiectomy.

A 14-year-old boy presented with dyspnea on exertion and easy fatiguability for 1 year. He also had an episode of pedal edema 6 months prior, which resolved with diuretics. He had a history of tuberculosis treated with a 6-month course of antitubercular therapy. After a series of tests and analyses, it was evident that longitudinal contraction of the left ventricle was preserved, whereas the circumferential contraction was severely impaired. Pericardial calcification also could be seen encircling the left and right ventricles. Pericardial calcification is evident in around 25% of cases of constrictive pericarditis and predominantly seen in those with tubercular and pyogenic etiology. The subepicardial myocardial fibers are responsible for radial shortening and subendocardial fibers are responsible for longitudinal shortening. In constrictive pericarditis, the involvement of the subepicardial fibers leads to reduction in the circumferential shortening. The patient was referred for pericardiectomy.

Background: We aimed to investigate risk factors of multiorgan failure following pericardiectomy., Methods: This was a retrospective study of patients undergoing pericardiectomy between January 1994 and May 2021 at three hospitals., Results: 826 patients were included in the study and divided into two groups: group with multiorgan failure (n = 86) and group without multiorgan failure (n = 740). There were 86 patients with multiorgan failure (86/826, 10.4%). There were 66 operative deaths (66/826, 8.0%). The causes of operative deaths were multiorgan failure, including cardiogenic shock + AKI + ventricular fibrillation (13/66), cardiogenic shock + AKI (35/66), cardiogenic shock + AKI + hepatic failure + septicemia (8/66), cardiogenic shock + AKI + respiratory failure (10/66). Univariate and multivariate analyses showed the factors associated with multiorgan failure, including male (P = 0.006), time between symptoms and surgery (P < 0.001), thickness of pericardium (P < 0.001), intubation time (P < 0.001), ICU retention time (P < 0.001), hospitalized time postoperative (P < 0.001), preoperative central venous pressure (P < 0.001), postoperative central venous pressure (P < 0.001), D0 fluid balance (P < 0.001), D2 fluid balance (P < 0.001), postoperative chest drainage (P < 0.001), preoperative LVEDD(P < 0.001), postoperative LVEDD (P < 0.001), surgical duration (P < 0.001), bleeding during operation (P < 0.001), serum creatinine 24 h after surgery (P = 0.042), serum creatinine 48 h after surgery (P < 0.001), fresh-frozen plasma (P < 0.001), packed red cells (P < 0.001), blood lactate (P < 0.001)., Conclusion: In our study, incomplete pericardial dissection, fluid overload, delayed diagnosis and treatment are associated with multiorgan failure following pericardiectomy., (© 2022. The Author(s).)

Patients with constrictive pericarditis (CP) typically present with symptoms related to right-sided heart failure, such as cardiac ascites. Spontaneous bacterial peritonitis (SBP) usually arises in association with ascites secondary to hepatic cirrhosis. We herein report a rare case of CP in which SBP developed due to cardiac ascites, even in the absence of cirrhosis. In this case, pericardiectomy improved both the hemodynamics and the ascites, while therapy with diuretics alone was insufficient. It is important to consider SBP in the differential diagnosis when any abdominal symptoms or an inflammatory response is found in patients with heart failure and cardiac ascites.

Background: Chronic constrictive pericarditis (CCP) is usually caused by the fibroinflammatory reaction of the visceral and parietal pericardium that encase the heart. The cause of CCP is various including tuberculosis, trauma, prior surgery, radiation, and malignancy., Material and Methods: We examined the pericardiectomy specimen of a case of CCP in a 17-year-old boy., Results: The histopathology of the pericardium revealed pericardial ossification bony remodeling and hematopoiesis within the intertrabecular marrow spaces. No granulomatous or neoplastic etiology was identified., Conclusion: Idiopathic pericardial ossification can cause CCP in pediatric patients.

Objective: To describe the clinical characteristics, perioperative protocols, and outcomes in dogs diagnosed with ventricular fibrillation (VF) while undergoing pericardiectomy., Study Design: Retrospective, multi-institutional study., Animals: Sixteen client-owned dogs., Methods: Cases were accrued through a listserve request posted to 3 subspecialty veterinary societies. Dogs were included if they developed VF during a pericardiectomy performed through an open or thoracoscopic approach. Data collected included signalment, history and physical examination, surgical approach, histopathology, treatment, and outcome., Results: Indications for pericardiectomy included idiopathic chylothorax (n = 7), neoplasia (4), idiopathic pericardial effusion (4), and foreign body granuloma (1). Surgical approaches included thoracoscopy (12), intercostal thoracotomy (3) and median sternotomy (1). Electrosurgical devices were used to complete at least part of the pericardiectomy in 15 of 16 dogs. Ventricular fibrillation appeared to be initiated during electrosurgical use in 8/15 dogs. However, in 5/15 dogs it was not obviously associated with electrosurgical use. In 3/16 dogs the timing of initiation of VF was unclear. In 7/16 dogs, cardiac arrhythmias were noted prior to the development of VF. Fourteen of 16 dogs died from intraoperative VF., Conclusion: In most dogs ventricular fibrillation was a fatal complication of pericardiectomy. Ventricular fibrillation might be associated with the use of electrosurgical devices and cardiac manipulation during pericardiectomy although a causal link could not be established from the data in this study., Clinical Significance: Surgeons must be aware of the risk of VF during pericardial surgery. Electrosurgery might need to be used judiciously during pericardiectomy, particularly in dogs exhibiting cardiac arrythmias., (© 2022 American College of Veterinary Surgeons.)

Objective: Constrictive pericarditis (CP) is a rare disease, and the diagnosis and surgical treatment of CP remain challenging. The aim of this study was to evaluate our Japanese single-center experience with isolated pericardiectomy for CP to elucidate the factors associated with improved outcomes., Methods: Over a 20-year period, 44 consecutive patients underwent isolated pericardiectomy at our institution. The cause of CP was: idiopathic (59%), postsurgical (32%), tuberculosis (7%), and postradiation (2%) of the patients. All patients were diagnosed with CP using multiple modalities, including echocardiography, cardiac catheterization, computed tomography, or magnetic resonance imaging (MRI). Median sternotomy was performed in 42 (95%) patients. Twenty-eight (68%) patients underwent radical pericardiectomy., Results: The postoperative diagnosis in all patients was CP. Among the multiple modalities, cardiac MRI had the greatest diagnostic sensitivity (97.2%). There were no operative or hospital deaths; late mortality occurred in seven (15.9%) patients in the series. Multivariable analysis showed that preoperative low LVEF was a risk factor for long-term mortality. Seven patients were readmitted for heart failure postoperatively. Multivariable analysis showed incomplete pericardiectomy and use of a preoperative inotrope were risk factors for readmission for heart failure., Conclusions: The diagnosis using multimodality imaging for CP was effective in our institution and tagged cine MRI had the greatest sensitivity in diagnosing CP. Preoperative condition, including preoperative low LVEF or inotrope use, was correlated with long-term outcome after pericardiectomy. Pericardiectomy should be performed early and as radically as possible to prevent recurrent heart failure., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Abstract Objectives: Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge., Methods: A literature review was performed that included relevant prospective and retrospective studies on the subject., Results: PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention., Conclusions: Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The majority of cases of Shiga toxin-producing Escherichia coli are self-limited; however, the infection can occasionally be complicated by more severe phenomena, such as thrombotic microangiopathy, with resultant end-organ damage to the kidneys, colon, nervous system, and various other tissues. Shiga toxin-induced hemolytic uremic syndrome (ST-HUS)-the constellation of thrombocytopenia, hemolysis, and renal failure resulting from thrombotic microangiopathy in a subset of infections producing the Shiga toxin-is classically observed in the pediatric population. Nevertheless, the diagnosis should be considered in adults with this presentation, and especially in those with colonic findings suggestive of ischemia. ST-HUS must also be distinguished from other thrombotic microangiopathies and related conditions, such as disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and complement-mediated HUS, as these diagnoses prompt alternate management strategies. Here, we present a case of ST-HUS in a gentleman following pericardiectomy who was infected with non-O157:H7 E. coli producing Shiga toxin 2., (© 2021. Japanese Society of Gastroenterology.)

Background: We aimed to investigate risk factors of early mortality following pericardiectomy., Methods: This was a retrospective study of patients undergoing pericardiectomy between January 1994 and May 2021 at The People's Hospital of Guangxi Zhuang Autonomous Region, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, and The People's Hospital of Liuzhou City., Results: This study included 826 patients, who were divided into two groups: group with operative deaths (N = 66) and group without operative deaths (N = 760). There were 66 operative deaths (66/826, 8.0%). The causes of operative deaths were multiorgan failure (86/826, 10.4%). Preoperative CVP (P < 0.001), chest drainage (P < 0.001), surgical duration (P < 0.001), fluid balance postoperative day D2 (P < 0.001), and tuberculosis pericarditis (P = 0.001) in group with operative deaths were significantly higher than those in group without operative deaths. Univariate and multivariate analyses showed that factors associated with operative deaths include male (P < 0.001), age (P < 0.001), ICU retention time (P < 0.001), postoperative hospitalization time (P < 0.001), preoperative central venous pressure (P = 0.018), postoperative central venous pressure (P < 0.001), D0 fluid balance (P < 0.001), D2 fluid balance (P < 0.001), postoperative chest drainage (P = 0.029), surgical duration (P = 0.003), serum creatinine baseline (P = 0.002), serum creatinine 24h after surgery (P < 0.001), serum creatinine 48h after surgery (P < 0.001), blood lactate (P < 0.001), and tuberculosis pericarditis (P = 0.033)., Conclusion: In our study, incomplete pericardial dissection, fluid overload, and tuberculosis pericarditis are associated with operative deaths following pericardiectomy.

Mulibrey ( Mu scle- Liv er- Br ain- Ey e) Nanism syndrome is an extremely rare genetic disorder with multiorgan involvement. Constrictive pericarditis and diastolic dysfunction are the most common causes of mortality. We present a case of a patient with Mulibrey nanism syndrome who underwent pericardiectomy at 12 years old and was able to live 44 years more with relatively stable and asymptomatic diastolic congestive heart failure (CHF). This case highlights the importance of early recognition and treatment of constrictive pericarditis in these patients.

Although well documented, constrictive pericarditis is a rare entity and an uncommon cause of heart failure. A stiff and noncompliant pericardium creates the disease's unique hemodynamics and leads to elevated venous pressures, hepatic sinusoidal congestion, and draining of protein-rich fluid into the peritoneal cavity presenting as ascites. The low incidence in addition to its varied and subtle clinical presentations can often lead to a delay in diagnosis. Here, we present 2 clinical cases of constrictive pericarditis in which ascitic fluid analysis was important-one patient who presented with new-onset ascites with concern for cirrhosis and another patient who presented with symptoms concerning for heart failure with ascites. Through their hospital course and workup, we highlight the importance of diagnostic sampling of ascitic fluid to prompt the consideration of constrictive pericarditis followed by utilizing advanced diagnostics, such as echocardiogram and cardiac catheterization to reach the correct diagnosis in an otherwise often overlooked pathology.

Chronic constrictive pericarditis (CCP) is one of the common causes of cardiogenic cirrhosis; it is rare for a patient to have both CCP and recurrent black stool, so we consider that CCP causes cardiogenic cirrhosis. Cardiogenic cirrhosis caused portal hypertension which then resulted in gastrointestinal bleeding. Herein, we report a case of a 40-year-old Chinese woman suffering from CCP who had upper gastrointestinal bleed and had to undergo emergency surgery. Two years after the emergency surgery, multiple reexaminations showed significantly improved cardiac functions, hemoglobin, and WBC levels and gastrointestinal functions.

A juvenile boxer dog was diagnosed with gastroesophageal intussusception that occurred after the induction of emesis with apomorphine. A ventral midline coeliotomy and diaphragmotomy were performed and the intussusception was manually reduced. Despite initial satisfactory recovery, the dog was diagnosed with cardiac tamponade 1 week post-operatively. Escherichia coli was cultured from pericardial and pleural effusion samples. During subtotal pericardiectomy surgery the pericardium was found to be markedly thickened with adhesions to the epicardium, thoracic wall and diaphragm. Substantial haemorrhage and refractory hypotension necessitated the administration of a blood transfusion during surgery. The dog entered cardiac arrest in the immediate post-operative period and cardiopulmonary resuscitation was unfortunately unsuccessful. Gastroesophageal intussusception should be considered a possible severe adverse effect of administering apomorhine to induce emesis in dogs. Additionally, septic pericardial and pleural effusions may occur post-reduction of gastroesophageal intussusception., (© 2021 British Small Animal Veterinary Association.)

Background: Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery., Methods: In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA 2 DS 2 -VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete., Findings: Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA 2 DS 2 -VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen., Interpretation: Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications., Funding: None., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Worsening tricuspid regurgitation (TR) severity may occur after pericardiectomy surgery for constrictive pericarditis patients; however, its mechanisms and predictors are not well established. We evaluated the clinical characteristics, associated factors, and outcomes of worsening TR after pericardiectomy., Methods: Consecutive patients undergoing pericardiectomy for constrictive pericarditis without tricuspid valve surgery and with pre- and postoperative echocardiography available during 2000 to 2017 were retrospectively studied. Clinical, imaging, hemodynamic, and mortality characteristics were analyzed by those with and without worsening TR by at least one grade., Results: Among 381 patients (age 61 [17] years, 318 [83.5%] male), 193 (50.7%) had worsening TR post-operatively, and 75 died during the 2.5 (5.4) years follow-up. In univariable analysis, worsening TR was associated with a history of congestive heart failure (47.2% versus 31.9%, P =0.003), increased left atrial volume indexed (23 versus 20 mL/m 2 , P =0.020), reduced right ventricular fractional area change (47% versus 54%, P <0.001), and worsening mitral regurgitation (39.7% versus 16.6%, P <0.001). Worsened TR had a trend toward reduced survival during follow-up (log-rank P =0.080), especially those with worsened TR but no recovery of TR grade on subsequent echocardiography within the first year compared with those without worsened TR (log-rank P =0.02). In multivariable analysis, right ventricular fractional area change, left atrial volume indexed, left ventricular mass indexed, pulmonary artery systolic pressure, and right atrial pressure/pulmonary capillary wedge pressure ratio were most associated with worsened TR, while blood urea nitrogen, hematocrit, lateral and medial e' tissue Doppler and heart rate were most associated with mortality during follow-up., Conclusions: Worsening TR severity was prevalent after pericardiectomy and had a trend toward reduced survival, especially if TR severity did not recover on subsequent echocardiography. Presence of parameters associated with worsened TR and reduced survival should alert clinicians to carefully manage these patients during follow-up.

Background: The operative mortality of pericardiectomy still is high. This retrospective study was conducted to determine the risk factors of early mortality and multiorgan failure., Methods: We retrospectively analyzed patients undergoing pericardiectomy from January 2009 to June 2020 at our hospital. Pericardiectomy was performed via sternotomy. Histopathologic studies of pericardium tissue from every patient were done. All survivors were monitored to the end date of the study., Results: Ninety-two consecutive patients undergoing pericardiectomy for constrictive pericarditis were included in the study. Postoperatively, central venous pressure significantly decreased, and left ventricular end diastolic dimension and left ventricular ejection fractions significantly improved. The overall mortality rate was 5.4%. The common postoperative complications include acute renal injury (27.2%), and multiorgan failure (8.7%). Analyses of risk factors showed that fluid balance of the second day following operation is associated with early mortality and multiorgan failure. In this series from Guangxi, China, characteristic histopathologic features of tuberculosis (60/92, 65.2%) of pericardium were the most common histopathologic findings, and 32 patients (32/92, 34.8%) had the histopathologic findings of chronic nonspecific inflammatory changes. The functional status of the patients improved after pericardiectomy; 6 months later postoperatively 85 survivors were in class I (85/87, 97.7%) and two were in class II (2/87, 2.3%)., Conclusions: Tuberculosis is the most common cause of constrictive pericarditis in Guangxi, China. Fluid balance of the second day following operation is associated with early mortality and multiorgan failure after pericardiectomy for constrictive pericarditis in our study.

Background: Acute kidney (renal) injury (AKI) is a severe and common complication that occurs in ~40% of patients undergoing cardiac surgery. AKI has been associated with increased mortality and worse prognosis. This prospective study was conducted to determine the risk factors for AKI after pericardiectomy and decrease the operative risk of mortality and morbidity., Methods: This was a prospective, observational cohort study of patients with constrictive pericarditis undergoing pericardiectomy. All patients underwent pericardiectomy via median sternotomy. Serum creatinine was used as the diagnostic standard of AKI according to Kidney Disease Improving Global Outcomes classification. All survivors were monitored to the end date of the study., Results: Consecutive patients (N = 92) undergoing pericardiectomy were divided into 2 groups: with AKI (n = 25) and without AKI (n = 67). The incidence of postoperative AKI was 27.2% (25/92). Hemodialysis was required for 10 patients (40%), and there were 5 operative deaths. Mortality, intubation time, time in intensive care unit, fresh-frozen plasma, and packed red cells of the group with AKI were significantly higher than those of the group without AKI. Both univariate and multivariate analyses showed that statistically significant independent predictors of AKI include intubation time, chest drainage, fresh-frozen plasma, and packed red cells. The latest follow-up data showed that 85 survivors were New York Heart Association class I (97.7%) and 2 were class II (2.3%)., Conclusions: AKI after pericardiectomy is a serious complication and contributes to significantly increased morbidity and mortality. Prevention of AKI development after cardiac surgery and optimization of pre-, peri-, and postoperative factors that can reduce AKI, therefore, contribute to a better postoperative outcome and leads to lower rates of AKI, morbidity, and mortality.

Pericardiectomy is commonly used to treat constrictive pericarditis (CP); however, persistent calcification can complicate recovery. An 82-year-old man presented with CP following an inadequate pericardiectomy at another hospital two years earlier. He was referred to our hospital with a diagnosis of recurrent CP. Pre-operative computed tomography revealed that the pericardium was not calcified on the anterior of the heart, while the inferior, posterior and lateral surfaces exhibited calcification. Notably, calcification along the inferior portion of the heart formed a calcium envelope structure. Pericardiectomy via re-sternotomy without cardiopulmonary bypass was performed. While dissecting the calcium envelope, a paste-like substance was exuded. Cardiac function improved after pericardiectomy, although the postoperative recovery from heart failure was prolonged. Calcified pericardium should be removed to the extent possible to enhance the efficacy of pericardiectomy, which contributes to improved early surgical results and prevents CP recurrence.

Background: Low cardiac output syndrome is the main cause of death after pericardiectomy., Methods: Patients who underwent pericardiectomy for constrictive pericarditis from January 2009 to October 2020 at our hospital were included in the study. Histopathologic studies of pericardium tissue from every patient were performed. All survivors were followed up., Results: Ninety-two consecutive patients underdoing pericardiectomy were included in the study. The incidence of postoperative low cardiac output syndrome was 10.7% (10/92). There were five operative deaths. Mortality and incidence of LCOS in the group with pericardial effusion were significantly higher than those in the group without pericardial effusion. Tuberculosis of the pericardium (60/92, 65.2%) was the most common histopathologic finding in this study. Both univariate and multivariate analyses showed that preoperative pericardial effusion is associated with increased rate of low cardiac output syndrome. Eighty-five survivors were in NYHA class I (85/87, 97.7%), and two were in class II (2/87, 2.3%) at the latest follow up., Conclusions: Preoperative pericardial effusion is associated with low cardiac output syndrome after pericardiectomy. Tuberculosis of the pericardium was the most common histopathologic finding in this study. For constrictive pericarditis caused by tuberculous bacteria, systematic antituberculosis drugs should be given. Preoperative pericardial effusion is associated with increased rate of low cardiac output syndrome. Perfect preoperative preparation is very important to reduce the incidence of postoperative low cardiac output syndrome and mortality. It is very important to use a large dose of diuretics with cardiotonic or vasopressor in a short time after the operation.

To the best of our knowledge there are no publications about Tunisian experience in constrictive pericarditis (CP); the aim of this study was therefore to review our twenty-one years' experience in terms of clinical and surgical outcomes and risk factors of death after pericardiectomy. An analytic bicentric and retrospective study carried out on 25 patients (20 male) with CP underwent pericardiectomy, collected over a 21-years period. The mean age was 40.46±16.74 years [7.5-72]. The commonest comorbid factor was tabagism (52%). The most common etiology was tuberculosis (n = 11, 44%). Dyspnea was the most common functional symptom (n = 21, 84%). Pericardiectomy was performed in all our patients within 2.9±3.19 months after confirmation of diagnosis. It was subtotal in 96% of cases. The commonest postoperative complications are pleural effusion (20%). Dyspnea was regressed within 1.8 months in 80% of cases and clinical signs of right heart failure within a mean duration of 1.62 months in 53% of cases. Perioperative mortality was 12% (3 deaths), late mortality was 4% (1 patient). Cardiopulmonary bypass, New York Heart Association (NYHA) over class II and right ventricular dysfunction are the prognostic factors of mortality (p = 0.001, 0.046, 0.019). Tuberculosis as etiology of CP had no impact on mortality. CP is a rare disease, with non-specific clinical signs. Pericardiectomy is effective with a significant improvement of the functional status of patients and favorable outcome at short and long term nevertheless hospital mortality is not negligible and depends on many factors., Competing Interests: The authors declare no competing interests., (Copyright: Taamallah Karima et al.)

Background: Although surgery is the sole therapeutic option for patients with constrictive pericarditis (CP), reports on high postoperative mortality rates have led to hesitant surgery referral. The aim of this study was to report the short- and long-term outcomes of surgical pericardiectomy (SP) from a large tertiary center., Methods: Between January 2005 and January 2017, 55 consecutive patients underwent SP after comprehensive echocardiography, computed tomography, and hemodynamic studies. Detailed clinical, imaging, surgical techniques and follow-up outcomes were recorded., Results: The most common etiology was idiopathic ( n  = 27, 49%) and 33 patients (60%) were in functional class 3/4. Sixteen patients (29%) underwent concomitant interventions during SP, and cardiopulmonary bypass (CPB) was used in these, as well as in four additional cases. Complete resection, independent of CPB, was achieved in 96%. One patient died during the index hospitalization, and four (7%) needed re-explorations due to bleeding. While 12 patients (22%) died during a mean follow-up of 52 ± 39 months, only 1 death was due to right heart failure. Functional class significantly improved (with a p -value < 0.001), diuretics were discontinued in all, and significant reductions of right atrial pressures were recorded. None of these outcomes differed as a result of concomitant interventions at the time of SP., Conclusion: Short- and long-term outcomes of SP, performed either alone or concomitantly with other procedures, indicate high safety and favorable clinical and hemodynamic efficacy for the treatment of CP., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: The risk factors of postoperative outcomes after pericardiectomy in tuberculous constrictive pericarditis have still been unclear. This study aimed to investigate the predictors of postoperative complication and prolonged intensive care unit (ICU) stay in the patients with tuberculous constrictive pericarditis undergoing pericardiectomy., Methods: A total of 88 patients with tuberculous constrictive pericarditis undergoing pericardiectomy were retrospectively enrolled. Logistic regression and Cox regression analysis were performed to identify the predictors of postoperative complication and prolonged ICU stay, respectively., Results: All patients underwent complete pericardiectomy and 35 (39.8%) had postoperative complication with no mortality within 30 days after surgery and no in-hospital deaths. Postoperative complication prolonged postoperative ICU stay (P < 0.001), duration of chest drainage (P < 0.001) and postoperative hospital stay (P < 0.001). Preoperative NYHA functional class (P = 0.004, OR 4.051, 95%CI 1.558-10.533) and preoperative central venous pressure (CVP) (P = 0.031, OR 1.151, 95%CI 1.013-1.309) were independent risk factors of postoperative complication. Postoperative complication (P < 0.001, HR 4.132, 95%CI 2.217-7.692) was the independent risk factor for prolonged ICU stay., Conclusion: Complete pericardiectomy was associated with high risk of postoperative complication in tuberculous constrictive pericarditis. Poor preoperative NYHA functional class and high preoperative CVP were shown to predict postoperative complication which was the predictor of prolonged ICU stay.

Background: Post-thoracotomy adhesions are frequent postoperative complications. It has been reported that insoluble hyaluronic acid may prevent adhesions., Materials and Methods: This study had two objectives: first, to determine the in vivo degradation and absorption process, as well as the intrathoracic retention, of solid insoluble hyaluronic acid membrane; and second, to elucidate the association between postoperative intrathoracic retention and the morphological changes of insoluble hyaluronic acid in 12 Wistar rats. Insoluble hyaluronic acid membranes were cut into 2.0 cm × 1.0 cm rectangles in a dry state. After weighing, the test membranes were soaked and washed with saline to be implanted after pericardiotomy via thoracotomy. At Days 4, 7, 10, 14, and 28 after implantation, the rats were euthanized, the chest was opened, and the condition and implantation site of the inserted test membrane were examined., Results: Although approximately 10 days were required for the test membrane to decrease to half in the thoracic cavity, the intrathoracic remnant decreased to a mean of ~2% just 4 days later., Conclusion: This study clarified the time-dependent degradation process and remnants of insoluble hyaluronic acid in the thoracic cavity. A close relationship between the intrathoracic remnant of insoluble hyaluronic acid and its morphological change associated with degradation was demonstrated.

Background: The first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection., Case Presentation: A 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell's Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5 cm × 2 cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4 cm × 4 cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31 mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient's hemodynamics stabilized. A vented Gore-Tex 6 cm × 6 cm patch was sewn along the pericardial edges with interrupted 4-0 prolene to close the pericardial defect., Conclusion: This potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3 cm × 3 cm that extends from the mid- to inferior portions of the heart.

Background: Post-pericardiotomy syndrome (PPS) is a major cause of pericarditis, yet data on the risk of recurrence are limited, and the impact of steroids and colchicine in this context is unknown., Objectives: To examine the effect of prednisone and colchicine on the rate of recurrence of PPS., Methods: Medical files of patients diagnosed with PPS were reviewed to extract demographic, echocardiographic, X-ray imaging, and follow-up data., Results: The study comprised 132 patients (57% men), aged 27-86 years. Medical treatment included prednisone in 80 patients, non-steroidal anti-inflammatory agents in 41 patients, colchicine monotherapy in 2 patients, and no anti-inflammatory therapy in 9 patients. Fifty-nine patients were given colchicine for prevention of recurrence. The patients were followed for 5-110 months (median 64 months). Recurrent episodes occurred in 15 patients (11.4%), 10 patients had a single episode, 4 patients had two episodes, and one patient had three episodes. The rate of recurrence was lower in patients receiving colchicine compared to patients who did not (8.5% vs. 13.7%), and in patients not receiving vs. receiving prednisone (7.7% vs. 13.8%) but the differences were non-significant. Twenty-three patients died and there were no recurrence-related deaths., Conclusions: The rate of recurrence after PPS is low and multiple recurrences are rare. The survival of patients with recurrent PPS is excellent. Prednisone pre-treatment was associated with a numerically higher rate of recurrence and colchicine treatment with a numerically lower rate, but the differences were non-significant.

We hypothesized that tricuspid valve regurgitation was associated with increased risk of mortality after pericardiectomy for constrictive pericarditis. We reviewed the records of 518 patients who received pericardiectomy for constrictive pericarditis between January 2000 and December 2016. We excluded cases of radiation induced constrictive pericarditis, tuberculous-related constrictive pericarditis, and concomitant tricuspid valve intervention. Patients were classified according to preoperative transthoracic echocardiography tricuspid regurgitation grade: none/trivial in 276 (53%) patients, mild in 191 (37%), and moderate/severe in 51 (10%). A multivariable Cox proportional hazards regression model was used to determine an association between tricuspid valve regurgitation grade and mortality. Primary endpoint of this study was mortality. Median patient age was 62 years (interquartile range 51-69), sex was male in 409 (79%) patients, and left ventricular ejection fraction was 60% (54-65). Clinical follow-up was obtained in all patients at a median of 7.6 years (3.6-11.3). Kaplan-Meier estimates of mortality were 10.6% at 1 year, 23.5% at 5 years, and 39.0% at 10 years. Multivariable analysis demonstrated increased mortality risk with mild tricuspid valve regurgitation vs none/trivial (hazard ratio 1.64; 95% confidence interval 1.11-2.43; P = 0.012) and moderate/severe tricuspid valve regurgitation vs none/trivial (hazard ratio 2.27; 95% confidence interval 1.39-3.69; P = 0.001). These findings were independent of right ventricular function. Tricuspid valve regurgitation is a common and clinically important comorbidity in patients operated with pericardiectomy for constrictive pericarditis. Mild or greater tricuspid valve regurgitation is associated with an increased risk of mortality following operation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Predictors of early and late failure of pericardiectomy for constrictive pericarditis (CP) have not been established. Early and late outcomes of a cumulative series of 81 (mean age 60 years; mean EuroSCORE II, 3.3%) consecutive patients from three European cardiac surgery centers were reviewed. Predictors of a combined endpoint comprising in-hospital death or major complications (including multiple transfusion) were identified with binary logistic regression. Non-parametric estimates of survival were obtained with the Kaplan-Meier method. Predictors of poor late outcomes were established using Cox proportional hazard regression. There were 4 (4.9%) in-hospital deaths. Preoperative central venous pressure > 15 mmHg (p = 0.005) and the use of cardiopulmonary bypass (p = 0.016) were independent predictors of complicated in-hospital course, which occurred in 29 (35.8%) patients. During follow-up (median, 5.4 years), preoperative renal impairment was a predictor of all-cause death (p = 0.0041), cardiac death (p = 0.0008), as well as hospital readmission due to congestive heart failure (p = 0.0037); while partial pericardiectomy predicted all-cause death (p = 0.028) and concomitant cardiac operation predicted cardiac death (p = 0.026), postoperative central venous pressure < 10 mmHg was associated with a low risk both of all-cause and cardiac death (p < 0.0001 for both). Ten-year adjusted survival free of all-cause death, cardiac death, and hospital readmission were 76.9%, 94.7%, and 90.6%, respectively. In high-risk patients with CP, performing pericardiectomy before severe constriction develops and avoiding cardiopulmonary bypass (when possible) could contribute to improving immediate outcomes post-surgery. Complete removal of cardiac constriction could enhance long-term outcomes.

Objective: The clinical profile and surgical outcomes of patients with constrictive pericarditis were compared in HIV-positive and -negative individuals., Methods: This study was a retrospective analysis of patients diagnosed with constrictive pericarditis at Inkosi Albert Luthuli Central Hospital, Durban, over a 10-year period (2004-2014)., Results: Of 83 patients with constrictive pericarditis, 32 (38.1%) were HIV positive. Except for pericardial calcification, which was more common in HIV-negative subjects (n = 15, 29.4% vs n = 2, 6.3%; p = 0.011), the clinical profile was similar in the two groups. Fourteen patients died preoperatively (16.9%) and three died peri-operatively (5.8%). On multivariable analysis, age (OR 1.17; 95% CI: 1.03-1.34; p = 0.02), serum albumin level (OR 0.63; 95% CI: 0.43-0.92; p = 0.016), gamma glutamyl transferase level (OR 0.97; 95% CI: 0.94-0.1.0; p = 0.034) and pulmonary artery pressure (OR 1.49; 95% CI: 1.07-2.08; p = 0.018) emerged as independent predictors of pre-operative mortality rate. Peri-operative complications occurred more frequently in HIV-positive patients [9 (45%) vs 6 (17.6%); p = 0.030]., Conclusions: Without surgery, tuberculous constrictive pericarditis was associated with a high mortality rate. Although peri-operative complications occurred more frequently, surgery was not associated with increased mortality rates in HIV-positive subjects.

We report the case of a 61-year-old gentleman who underwent pericardiectomy for constrictive pericarditis. Constrictive pericarditis was diagnosed through echocardiogram, computed tomography chest and cardiac magnetic resonance imaging. An elective decision was made for commencing venoarterial extracorporeal membrane oxygenation (ECMO) immediately postoperatively to prevent significant right ventricular failure (RVF). Postoperatively, the patient remained on ECMO for 4 days in a stable condition, showing no further signs of RVF. Venoarterial ECMO may be of use as an elective adjunct in cases at high risk of RVF following pericardiectomy., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)