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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.)

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.

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.

Objective: To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis., Patients and Methods: Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity., Results: A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays., Conclusion: Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

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.)

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.

Background: Pericardiectomy is the final treatment for constrictive pericarditis. However, this greatest surgical approach is still very controversial. This study pursued to assess the outcomes in patients with recurrent chronic constrictive pericarditis undergoing reoperated pericardiectomy via median sternotomy versus left anterolateral thoracotomy and to explain which surgical approaches might be better for recurrent chronic constrictive pericarditis., Methods: A total of 24 patients were identified with recurrent chronic constrictive pericarditis and underwent reoperation with pericardiectomy between July 2003 and July 2015. The decision for this surgical approach was mainly dependent on the operating surgeon's preference. Out of 20 patients, 16 patients underwent pericardiectomy via median sternotomy and 8 patients via left anterolateral thoracotomy pericardiectomy. Their data were obtained retrospectively from the case notes., Results: Both groups of patients were similar in age, gender between two operations, and also in peripheral venous pressure, cardiac rhythm and New York Heart Association (NYHA) class distribution. The mortality rates were similar in both groups with one death (12.5%) due to low cardiac output syndrome in the left anterolateral thoracotomy group and two deaths (12.5%) in the median sternotomy group. All the deaths were associated with cardiac complications and happened in the perioperative period. NYHA functional class status enhanced in most of the patients. Patients in both groups had a similar and significant improvement in their NYHA status that improved from 3.4 ± 0.7 to 1.8 ± 0.1 (P = 0.001) in the left anterolateral thoracotomy group and reduced from 3.3 ± 0.6 to 1.9 ± 0.4 (P = 0.001) in the median sternotomy group. There was a significantly greater rate of pulmonary infection in the thoracotomy group than in the median sternotomy group (50% versus 25%, P = 0.02). Nevertheless, there was a significantly greater occurrence of wound infections in the median sternotomy group in 3 patients versus in one patient of the left anterolateral thoracotomy group (18.8% versus 12.5%, P = 0.02)., Conclusions: Left thoracotomy incision was preferred to sternotomy in the current setting of this situation and was done safely without CPB. It avoided life-threatening sternal infection and it also has showed an equal as well las significant enhancement of NYHA status of the patients.

Background: Cardiac filling pressures may be elevated due to abnormalities in the myocardium, heightened pericardial restraint, or both. The authors hypothesized that the relative contributions due to myocardium and pericardium could be estimated by the ratio between right atrial pressure and pulmonary arterial wedge pressure (RAP/PAWP), which would enable better discrimination of the extent of myocardial disease in patients with constrictive pericarditis (CP)., Objectives: This study investigated the relationships between RAP/PAWP and the pericardial thickness as well as echocardiographic parameters of myocardial function and assessed the prognostic implications of RAP/PAWP for long-term mortality in primary and mixed CP patients who underwent pericardiectomy., Methods: A total of 113 surgically confirmed CP patients who underwent echocardiography and cardiac catheterization within 7 days of each other between 2005 and 2013 were included in the study. The patients were classified into a high RAP/PAWP group (≥0.77; n = 56) or a low RAP/PAWP group (<0.77; n = 57) according to the median RAP/PAWP value. The primary outcome was prognostic implication of RAP/PAWP on long-term mortality and assessment of the relationship between RAP/PAWP and Doppler echocardiographic parameters in primary and mixed CP. In addition, the relationship between RAP/PAWP and the pericardial thickness was assessed., Results: RAP/PAWP was directly correlated with pericardial thickness (regression coefficient [β] = 8.34; p < 0.001). RAP/PAWP had a significant direct correlation with early diastolic velocity of medial mitral annulus (e') (β = 10.69; p < 0.001) and inverse relationship with early transmitral diastolic velocity (E) (β = -105.15; p < 0.001), resulting in an inverse relationship with the ratio of E/e' (β = -23.53; p < 0.001). Patients with high RAP/PAWP ratio had a better survival rate compared with those with low RAP/PAWP ratio (p = 0.01). Its prognostic value was significant in primary CP (p = 0.03) but not in mixed CP with concomitant myocardial disease (p = 0.89)., Conclusions: The RAP/PAWP ratio can reflect the degree of pericardial restraint versus restrictive myocardium and was associated with the long-term survival after pericardiectomy., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Prognosis after pericardiectomy for constrictive pericarditis (CP) is affected by the aetiology of the constriction as well as by concomitant cardiac and non-cardiac disease, including liver dysfunction. However, few data exist on the risk stratification that accounts for liver function in patients with CP. We evaluated the effectiveness of the model for end-stage liver disease (MELD) score, an established measure of liver dysfunction, in predicting long-term survival and identifying other risk factors for death., Methods: A total of 79 patients who underwent pericardiectomy for CP at a single centre between 2009 and 2016 were analysed. The prognostic utility of the MELD score was evaluated in our cohort. Logistic regression and Cox proportional hazard regression analyses were performed to assess the association of various clinical variables with 1-year and overall mortality rates., Results: With multivariable analysis, only the MELD score was an independent predictor of 1-year mortality (P < 0.001); apart from the MELD (P = 0.003) score, post-surgical CP (P = 0.016), total bilirubin level (P = 0.042) and the European System for Cardiac Operative Risk Evaluation score II (P = 0.002) were independent predictors of overall mortality after pericardiectomy. Overall survival decreased as the MELD score increased. Scores ≤ 7.5, 7.51-15.50 and >15.5 were associated with overall survival rates of 92.9%, 69.8% and 8.3%, respectively., Conclusions: In addition to the underlying aetiology, we demonstrated that assessment of liver dysfunction using the MELD score provides additional information about risk because it is associated with postoperative death in patients undergoing pericardiectomy for CP.

Background: The aim of this retrospective study was to evaluate our experience with the surgical pericardiectomy procedure for patients suffering from isolated severe constrictive pericarditis., Methods: From 1995 to 2016, 39 patients underwent isolated pericardiectomy for constrictive pericarditis. Fifteen patients were excluded because of concomitant surgery. There were 31 male (79.5%) patients and 8 female (20.5%) patients, 28 to 76 years old (mean, 56.6 ± 13.6 years). The underlying etiologies were idiopathic pericarditis (74.5%), infection (10%), rheumatic disorders (8%), status post cardiac surgery (2.5%), tuberculosis (2.5%), and status post mediastinal irradiation (2.5%)., Results: Pericardiectomy was performed through midline sternotomy in all cases. Sixteen patients (41%) underwent pericardiectomy electively employing cardiopulmonary bypass with the heart beating, and 23 patients (59%) had surgery without extracorporeal circulation (ECC). The overall 30-day mortality rate was 50% if cardiopulmonary bypass was used (13.8% since 2007). If surgery was performed without a heart-lung machine, mortality was 0%. On-pump patients had a significantly longer intensive care unit (ICU) stay (12 ± 9 vs. 4 ± 4 days, p  = 0.013). Likewise, the duration of mechanical ventilation was much longer (171 ± 246 vs. 21 ± 40 hours, p  = 0.04). The hospital stay was comparable with 28 ± 10 and 24 ± 18 days ( p  = 0.21)., Conclusion: The present study demonstrates that pericardiectomy, without the use of cardiopulmonary bypass as treatment for constrictive pericarditis, is a safe procedure with an excellent outcome in critically ill patients., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Posttubercular constrictive pericarditis is prevalent pericardial disease in developing countries. Pericardiectomy is the treatment of choice but considered a procedure of high morbidity and mortality., Methods: From January 2003 to December 2013 we performed 130 pericardiectomies. The patients' mean age was 22.95 ± 12.55 years, and there were 92 (71%) male patients. All patients were symptomatic; 118 (91%) were in New York Heart Association functional class III or IV. Almost all patients were diagnosed to be of tubercular origin: 14 (11%) were histopathologically proven, 77 (59%) had definitive history, 39 (30%) were suspected to be of tubercular origin, and 91 (70%) received prior antitubercular treatment., Results: Anterior pericardiectomy was done without the use but with provision for cardiopulmonary bypass, which was required in 5 (3.8%) patients for repair of tear in right atrium. Following pericardiectomy central venous pressure dropped from 20.9 to 10.8 mm Hg. Early mortality was 10 (7.69%). Prolonged ventilation was required in 22 (16.92%) patients, 31 (23.84%) developed renal dysfunction, and there were 3 (3.12%) cases of new-onset atrial fibrillation. On analysis of univariate predictors for early mortality, low ejection fraction (p < 0.001) and preoperative atrial fibrillation (p < 0.001) were found to be significant. In a follow-up of 12 months, 85% patients were in New York Heart Association functional class I or II with mean ejection fraction of 52%. There was no recurrence of constriction from residual pericardium on 1-year follow-up., Conclusions: Anterior pericardiectomy is sufficient in patients with constrictive pericarditis of infective etiology. Preoperative low ejection fraction, atrial fibrillation, poor functional class, and constrictive effusive pericarditis results in poor surgical outcome., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background Chronic constrictive pericarditis is the most common diastolic disorder of the heart. Non-elasticity of the pericardium with impaired cardiac diastolic function is constriction. Chronic constrictive pericarditis is the result of scarring and fibrosis in mid and late diastole. The clinical presentation is similar to that of right heart failure. Historically, the etiology is helpful but not diagnostic. Echocardiography and a hemodynamic study are the main diagnostic tools. A thick pericardium of more than 4 mm is not necessarily constrictive, but thickness ≥7 mm is highly specific for constrictive features. Pericardiectomy is usually associated with early normalization of hemodynamics, which can be achieved via a mid-sternotomy or left anterolateral thoracotomy. Methods Data of 109 patients who underwent pericardiectomy from January 1987 to June 2016 were reviewed retrospectively. Results The outcome of our 109 cases consisted of mortality in 2 patients only. Conclusion Progressive, fibrotic, thickened, adherent inflammatory changes in response to various pathologies of the pericardium impairing diastolic filling can be treated by pericardiectomy. Pericardiectomy can be achieved by a mid-sternotomy or anterolateral thoracotomy without any difference in outcome. The initial hemodynamic and clinical result may not always be dramatic but continued improvement is definite because of progressive enlargement of left ventricular dimensions.

Background  Right ventricular failure is a life-threatening postoperative complication after pericardiectomy. We conducted a retrospective study with a special emphasis on right ventricular failure. Methods  Between June 1997 and September 2011, 69 patients underwent surgical pericardiectomy at our center. Mean age was 59 ( ±  15.5) years, and 49 (71%) patients were male. Causes of constrictive pericarditis included idiopathic (52%, n  = 36), tuberculosis (9%, n  = 6), postcardiotomy (12%, n  = 8), radiation (4%, n  = 3), renal insufficiency (12%, n  = 8), and autoimmune disease (12%, n  = 8). Concomitant cardiac surgery was performed in 33 (48%) patients. Results  In-hospital mortality rate was 14% (10/69 patients). Extracorporeal membrane oxygenation (ECMO) was necessary in 8 (12%) cases because of right ( n  = 7) or biventricular ( n  = 1) failure. Statistical analysis showed a significant correlation between early mortality and the following preoperative variables: postcardiotomy ( p  = 0.049), radiation ( p  = 0.009), pleural effusion ( p  = 0.012), ascites ( p  = 0.039), hepatic congestion ( p  = 0.023), absence of calcification on X-ray ( p  = 0.041), tricuspid valve insufficiency (TI, p  < 0.001), and low cardiac index ( p  = 0.003). Diuretic usage ( p  = 0.044), peripheral edema ( p  = 0.050), low voltage ( p  = 0.027), dip-plateau sign ( p  = 0.027), elevated GGT ( p  < 0.001), and decreased serum protein ( p  < 0.001) correlated with ECMO implantation. Binary logistic regression identified pleural effusion (OR = 16.2, 95% CI = 1.4-191.5), moderate/severe TI (OR = 28.8, 95% CI = 2.7-306.8) and low cardiac index (OR = 25.3, 95% CI = 2.0-315.6) as preoperative independent risk factors for early mortality, whereas elevated GGT (OR = 28.3, 95% CI = 2.4-329.2) and decreased protein (OR = 24.7, 95% CI = 1.8-343.7) could predict right ventricular failure with the need for ECMO. Conclusion  We recommend nondelayed ECMO support in case of significant postoperative right-sided heart failure. High-risk patients might benefit from elective pre- or intraoperative ECMO implantation., Competing Interests: Conflicts of Interest: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: International studies have reported the value of the clinical profile and laboratory findings in the diagnosis of constrictive pericarditis. However, Brazilian population data are scarce., Objective: To assess the clinical characteristics, sensitivity of imaging tests and factors related to the death of patients with constrictive pericarditis undergoing pericardiectomy., Methods: Patients with constrictive pericarditis surgically confirmed were retrospectively assessed regarding their clinical and laboratory variables. Two methods were used: transthoracic echocardiography and cardiac magnetic resonance imaging. Mortality predictors were determined by use of univariate analysis with Cox proportional hazards model and hazard ratio. All tests were two-tailed, and an alpha error ≤ 5% was considered statically significant., Results: We studied 84 patients (mean age, 44 ± 17.9 years; 67% male). Signs and symptoms of predominantly right heart failure were present with jugular venous distention, edema and ascites in 89%, 89% and 62% of the cases, respectively. Idiopathic etiology was present in 69.1%, followed by tuberculosis (21%). Despite the advanced heart failure degree, low BNP levels (median, 157 pg/mL) were found. The diagnostic sensitivities for constriction of echocardiography and magnetic resonance imaging were 53.6% and 95.9%, respectively. There were 9 deaths (10.7%), and the risk factors were: anemia, BNP and C reactive protein levels, pulmonary hypertension >55 mm Hg, and atrial fibrillation., Conclusions: Magnetic resonance imaging had better diagnostic sensitivity. Clinical, laboratory and imaging markers were associated with death.

Background: The purpose of this study was to review the surgical outcomes of pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period., Methods: We reviewed all patients who underwent pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990-2013) group (n = 807)., Results: Patients in the contemporary group were older (61 versus 49 years; p < 0.001), more symptomatic (NYHA class III or IV in 79.6% versus 71.2%; p < 0.001), and more frequently underwent concomitant procedures (21.4% versus 5.4%; p < 0.001) compared with those in the historical group. In contrast to the historical cases in which the etiologies of constriction were mostly idiopathic (81.1%), nearly half of contemporary cases had a nonidiopathic etiology (postoperative 32.3%, radiation 11.4%). Although 30-day mortality decreased from 13.5% in the historical era to 5.2% in the contemporary era (p < 0.001), overall survival was similar after adjusting for patient characteristics. Risk factors of overall mortality in the contemporary group included NYHA class III or IV (HR 2.17, p < 0.001), etiology of radiation (HR 3.93, p < 0.001) or postcardiac surgery (HR 1.47, p < 0.001), and need for cardiopulmonary bypass (HR 1.35, p = 0.014)., Conclusions: There was a significant change in disease etiology over the study period. Long-term survival after pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Historically the most common causes of pericarditis necessitating pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients., Methods: From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. We identified 98 patients who underwent pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38-81 years), and 91 of the patients (93%) were men. The indication for pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%-71%) and median NYHA functional class was III (91% were class III/IV)., Results: The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03-3.7]; p = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years., Conclusions: The rate of early mortality for pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Constrictive pericarditis is the final stage of a chronic inflammatory process characterized by fibrous thickening and calcification of the pericardium that impairs diastolic filling, reduces cardiac output, and ultimately leads to heart failure. Transthoracic echocardiography, computed tomography, and cardiac magnetic resonance imaging each can reveal severe diastolic dysfunction and increased pericardial thickness. Cardiac catheterization can help to confirm a diagnosis of diastolic dysfunction secondary to pericardial constriction, and to exclude restrictive cardiomyopathy. Early pericardiectomy with complete decortication (if technically feasible) provides good symptomatic relief and is the treatment of choice for constrictive pericarditis, before severe constriction and myocardial atrophy occur. We describe our surgical approach to constrictive pericarditis, summarize our results in 93 patients, and provide a brief overview of the literature.

Background: We evaluated our early and late outcomes after pericardiectomy in patients with constrictive pericarditis (CP)., Patients and Methods: We retrospectively reviewed 31 patients who underwent pericardiectomy for CP from 1997 to 2015. Their mean age was 49.2 ± 18.5 years and 74.2 % of them were male. The vast majority had severe functional impairment (NYHA class III-IV) with a mean duration of symptoms of 14.2 ± 10.1 months., Results: Early mortality was 9.7 %: n = 3; multiorgan failure (MOF) in 1, respiratory failure in 1, and left heart failure in 1. Preoperative systolic pulmonary artery pressure over 60 mmHg (p = 0.038, odds ratio [OR] = 0.12) and postoperative low cardiac output syndrome (p = 0.005, OR = 13.5) were significant predictors of early mortality in univariate analysis. Mean follow-up time was 57.8 ± 61.9 months (4-216 months). Late mortality was 6.8 % (2/28 patients) and the cause was MOF secondary to end-stage right heart failure. In Kaplan-Meier analyses, actuarial (including early mortality) and event-free survival rates were 83.9 and 51.1 % at 216 months, respectively. At the end of follow-up, the majority of patients (23/26, 92.9 %) were in good functional status (NYHA class I-II). There were fewer patients under diuretic therapy in the postoperative than in the preoperative period; however, the difference was not statistically significant (12/31 vs. 4/26, p = 0.76). There was no significant difference between the preoperative and follow-up tricuspid annular plane systolic excursion values (15.5 ± 2.2 and 16.6 ± 2.2 mm, respectively, p = 0.088). Left ventricular systolic function was preserved in all patients postoperatively., Conclusion: Although early mortality after pericardiectomy remains high, the procedure provides significant improvement in functional status in the long term.

Background: Constrictive pericarditis (CP) is characterized by impaired diastolic cardiac function leading to heart failure. Pericardiectomy is considered effective treatment for CP, but data on long-term clinical outcomes after pericardiectomy are limited.Methods and Results:We retrospectively investigated 45 consecutive patients (mean age, 59±14 years) who underwent pericardiectomy for CP. Preoperative clinical factors, parameters of cardiac catheterization, and cardiac events were examined. Cardiac events were defined as hospitalization owing to heart failure or cardiac death.Median follow-up was 5.7 years. CP etiology was idiopathic in 16 patients, post-cardiac surgery (CS) in 21, tuberculosis-related in 4, non-tuberculosis infection-related in 2, infarction-related in 1, and post-radiation in 1. The 5-year event-free survival was 65%. Patients with idiopathic CP and tuberculosis-related CP had favorable outcomes compared with post-CS CP (5-year event-free survival: idiopathic, 80%; tuberculosis, 100%; post-CS, 52%). Higher age (hazard ratio: 2.51), preoperative atrial fibrillation (3.25), advanced New York Heart Association class (3.92), and increased pulmonary artery pressure (1.06) were predictors of cardiac events. Patients with postoperative right-atrial pressure ≥9 mmHg had lower event-free survival than those with right-atrial pressure <9 mmHg (39% vs. 75% at 5 years, P=0.013)., Conclusions: Long-term clinical outcomes after pericardiectomy among a Japanese population were related to the underlying etiology and the patient's preoperative clinical condition. Postoperative cardiac catheterization may be helpful in the prediction of prognosis after pericardiectomy.

Objectives: Outcome after pericardiectomy depends on many factors, but no large study has provided clarity on the effects of patient variables or cause of pericarditis on patient survival. We report early and late results from a 20-year experience with isolated pericardiectomy., Methods: From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. In order to establish a homogeneous population to analyze the impact of pericardiectomy, we excluded patients with prior chest radiation, malignancy, and concomitant valvular or coronary procedures. We identified a cohort of 521 who underwent isolated pericardiectomy; of these, 513 patients gave consent for research and comprise the cohort for this analysis; median age at operation was 57 years (range, 18-84 years) and 363 (71%) were men. Indications for pericardiectomy were effusive/chronic relapsing pericarditis in 158 (31%) and pericardial constriction in 355 (69%). Prior coronary artery bypass grafting had been performed in 84 patients (14%). Median preoperative left ventricular ejection fraction was 60% (range, 24%-80%), and 77% of patients were in New York Heart Association (NYHA) functional class III/IV., Results: Surgical approach was median sternotomy in 412 (80%), left thoracotomy in 71 (14%), and clamshell in 30 (5%). Extent of pericardial resection was radical in 414 (81%), subtotal in 71 (14%), and completion in 28 (5%). Cardiopulmonary bypass was used in 205 (40%). Overall mortality was 12/513 (2.3%); 3/158 (1.9%) for the effusive/chronic relapsing group versus 9/355 (2.5%) for the constriction group (P = .65). In the absence of multivariate predictors, which could not be identified, univariate predictors associated with increased risk of early death included lower left ventricular ejection fraction (hazard ratio [HR], 1.09; P = .03) and preoperative renal insufficiency (HR, 9.9; P < .001). Median duration of follow-up was 29 months (maximum 20.5 years) and overall 5-, 10-, and 15-year survival was 80%, 60%, and 38%, respectively. Overall survival according to surgical indication was higher in the effusive/chronic relapsing group when compared with the constriction cohort (P < .001). Independent predictors associated with increased risk of overall mortality identified on multivariate analysis included older age (HR, 1.05; 95% confidence interval [CI], [1.03, 1.07]; P < .001), congestive heart failure (HR, 1.49; 95% CI, [1.03, 2.2]; P = .02), diabetes (HR, 1.83; 95% CI, [1.2, 2.7]; P = .004), completion pericardiectomy (HR, 2.4; 95% CI, [1.2, 4.7]; P = .01), and chronic obstructive pulmonary disease (HR, 2.45; 95% CI, [1.5, 3.9]; P = .004). During the follow-up period, 80% of patients were free from NYHA functional class III/IV symptoms at 5 years and 78% at 10 years., Conclusions: Whereas early mortality after isolated pericardiectomy is low irrespective of the indication for surgery, late follow-up demonstrates better outcomes after pericardiectomy for effusive/chronic relapsing pericarditis compared with pericardial constriction. Importantly, the majority of patients were free from significant heart failure symptoms during follow-up., (Copyright © 2016. Published by Elsevier Inc.)

Introduction and Objectives: Some reports have described a change in the etiologic spectrum of constrictive pericarditis. In addition, data on the relationship between its clinical presentation and etiology are lacking. We sought to describe the etiologies of the disease, their relationship with its clinical presentation and surgical findings, and to identify predictors of poor outcome., Methods: We analyzed 140 consecutive patients who underwent surgery for constrictive pericarditis over a 34-year period in a single center., Results: The etiology was idiopathic in 76 patients (54%), acute idiopathic pericarditis in 24 patients (17%), tuberculous pericarditis in 15 patients (11%), purulent pericarditis in 10 patients (7%), and cardiac surgery, radiation and uremia in 5, 3 and 2 patients respectively (4%, 2% and 1%). Mean duration of symptoms before pericardiectomy was 19 months (standard deviation, 44 months), the most acute presentation being for purulent pericarditis (26 days [range, 7-60 days]) and the most chronic for idiopathic cases (29 months [range, 4 days-360 months]). Perioperative mortality was 11%. There was no difference in mortality between etiologies. Median follow-up was 12 years (range, 0.1-33.0 years) in which 50 patients died. In a Cox-regression analysis, age at surgery, advanced New York Heart Association functional class (III to IV) and previous acute idiopathic pericarditis were associated with increased mortality during follow-up., Conclusions: Most cases of constrictive pericarditis are idiopathic. Cardiac surgery and radiation accounted for a minority of cases. Etiologic investigations are warranted only in acute or subacute presentations. Age, advanced functional class, and previous acute idiopathic pericarditis are associated with increased mortality., (Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: Constrictive pericarditis (CP) is an uncommon disease with multiple causes and unclear clinical outcomes. To date, few publications have clearly defined risk factors of poor outcomes after surgery for CP. We performed a retrospective analysis of almost 100 patients undergoing surgical treatment for CP at a single institution in order to identify risk factors for perioperative and long-term mortality., Methods: A total of 97 consecutive patients (67.0% male) undergoing surgery for CP at our institution from 1995 to 2012 were included in the study. CP was diagnosed either preoperatively by cardiac catheterization and appropriate imaging or during surgery. Preoperative and intraoperative risk factors for 30-day and late mortality were analysed using stepwise multivariate logistic and Cox regression analyses. Median follow-up was 1.23 ± 3.96 years (mean 3.08 ± 3.96 years)., Results: The mean patient age was 60.0 ± 12.5 years and the underlying aetiology was idiopathic (50.5%), prior cardiac surgery (15.5%), prior mediastinal radiation (9.3%), and miscellaneous (24.7%). All patients underwent either radical (55.2%) or partial (44.8%) pericardiectomy. Concomitant procedures were performed in 54 (55.7%) patients. The total procedure time was 197.0 ± 105.0 min. Cardiopulmonary bypass (CPB) was used in 62 patients with a corresponding CPB time of 124.8 ± 68.4 min. In those patients who underwent CPB, cardioplegic arrest was performed in 53.2% of patients with a mean cross-clamp time of 74.9 ± 41.9 min. Overall 30-day, 1-year and 5-year survival rates were 81.4, 66.5 and 51.6%, respectively, without significant differences according to the underlying aetiology. Multivariate analysis revealed patients with reduced left ventricular ejection fraction (LVEF) [P = 0.01, odds ratio (OR) 3.6] and preoperative right ventricular dilatation (P = 0.04, OR 3.5) to be at significant risk of early mortality. Long-term mortality was independently predicted by the presence of coronary artery disease (CAD) [P < 0.001, hazard ratio (HR) 6.44], chronic obstructive pulmonary disease (P = 0.001, HR 4.21) and preoperative renal insufficiency (P = 0.012, HR 1.8). Concomitant tricuspid valve repair (TVR) appeared to provide protective effect on the long-term survival (P = 0.07)., Conclusions: Surgery for CP is associated with a significant risk based on the poor preoperative patient status. Whenever justified, partial over radical pericardiectomy should be preferred and TVR should be indicated liberally. Reduced LVEF and right ventricular dilatation were independent predictors for early mortality, whereas CAD, chronic obstructive pulmonary disease and renal insufficiency were risk factors for late mortality. Thus, an optimal timing for surgery on CP remains crucial to avoid secondary morbidity with an even worse natural prognosis., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors., Methods: Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV., Results: Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases., Conclusions: The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Low-flow, low-gradient aortic stenosis (AS), associated with a poor prognosis, can be caused by a reduced stroke volume despite a preserved ejection fraction (left ventricular ejection fraction). We hypothesized that impaired ventricular diastolic filling secondary to constrictive pericarditis (CP) could contribute to reduced transaortic gradients in patients with AS+CP. We sought to examine the characteristics and outcomes of this unique cohort., Methods and Results: We analyzed 84 patients with different degrees of AS and preserved left ventricular ejection fraction (≥50%): 28 diagnosed with concomitant CP by echocardiography and 56 patients without CP matched by age, sex, and AS severity during 1998 to 2013. Prior mediastinal radiation (32.1% versus 5.4%; P=0.0072) and cardiac surgery (50.0% versus 3.6%; P=0.0016) were more common in AS+CP patients than those with AS only. AS+CP patients had lower left ventricular stroke volume index and mean transaortic gradients. Five-year survival was 34.3% for AS+CP patients and 89.1% for those with AS only (P<0.001). In univariate analysis, prior mediastinal radiation (hazard ratio, 8.35; 95% confidence interval, 3.38-20.62; P<0.001), reduced left ventricular stroke volume index of <35 mL/m(2) (hazard ratio, 12.52; 95% confidence interval, 3.97-39.48; P<0.001), and concomitant CP (hazard ratio, 13.65; 95% confidence interval, 4.85-38.41; P<0.001) were highly associated with increased mortality., Conclusions: Our findings highlighted the possibility of CP as a pathophysiological mechanism for low-flow, low-gradient AS. Left ventricular stroke volume index and transaortic gradients were commonly reduced in AS in the setting of CP despite a preserved left ventricular ejection fraction, which may result in underestimation of AS severity. Prior mediastinal radiation, lower left ventricular stroke volume index, and concomitant CP were associated with poorer survival in AS patients., (© 2015 American Heart Association, Inc.)

Constrictive pericarditis is a clinical condition characterized by the appearance of signs and symptoms of right heart failure due to loss of pericardial compliance. Cardiac surgery is now one of the most frequent causes in developed countries, while tuberculosis remains the most prevalent cause in developing countries. Malignancy is a rare cause but usually has a poor prognosis. The diagnosis of constrictive pericarditis remains a clinical challenge and requires a combination of noninvasive diagnostic methods (echocardiography, cardiac magnetic resonance and computed tomography); in some cases, cardiac catheterization is needed to confirm the diagnosis. The authors present the case of a 51-year-old man, hospitalized due to cardiac tamponade. Diagnostic investigation was suggestive of tuberculous etiology. Despite directed medical therapy, the patient developed effusive-constrictive physiology. He underwent pericardiectomy and anatomopathologic study suggested a neoplastic etiology. The patient died in the postoperative period from biventricular failure., (Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Objective: The causes of constrictive pericarditis and predictors of perioperative outcome after pericardiectomy have not been clearly elucidated, especially in Africa, where the disease characteristics differ from those in developed countries. Furthermore, the effect of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) on pericardial constriction and outcomes after surgery is unknown. We investigated the causes of constrictive pericarditis, outcomes after pericardiectomy, and predictors of mortality in Cape Town, South Africa, during a 22-year period of high HIV/AIDS prevalence., Methods: A retrospective review of the medical records of all patients who had undergone pericardiectomy for constrictive pericarditis at Groote Schuur Hospital from January 1, 1990 to December 31, 2012 was performed., Results: Of 121 patients, 36 (29.8%) had proven tuberculosis, 74 (61.2%) had presumed tuberculosis, 6 (5%) had idiopathic causes, and 5 (4%) had miscellaneous causes of constrictive pericarditis. Seventeen patients (14%) died perioperatively with low cardiac output syndrome the main cause of mortality. On multivariable analysis, serum sodium (hazard ratio, 0.88; 95% confidence interval, 0.80-0.97; P = .009) and preoperative New York Heart Association class IV (hazard ratio, 3.42; 95% confidence interval, 1.29-9.08; P = .014; vs combined class I-III) were independent predictors of early mortality. Of the 121 patients, 14 (11.6%) were HIV positive, with a mean CD4 cell count of 284 ± 133 cells/μL. No early deaths occurred in the HIV-positive patients., Conclusions: Tuberculosis is the main cause of constrictive pericarditis in South Africa. Despite its efficacy at relieving the symptoms of heart failure, pericardiectomy is associated with high perioperative mortality that was not influenced by HIV status. New York Heart Association functional class IV and hyponatremia predict for early mortality after pericardiectomy., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Constrictive pericarditis has multiple etiologies and can lead to disabling symptoms and severe heart failure with poor quality of life. Surgical pericardiectomy is the cornerstone of management. All patients undergoing pericardiectomy at our institution were reviewed with the goal of analyzing preoperative and intraoperative factors that may be associated with long-term outcomes., Methods: A retrospective review of our cardiac surgery database identified all patients who underwent pericardiectomy for constrictive pericarditis between 1997 and 2012. Demographic, comorbidity, operative, and outcome data were analyzed., Results: Thirty-six patients underwent pericardiectomy for constrictive pericarditis over 15 years. Etiologies included idiopathic (n = 20, 55.6%), postoperative (n = 11, 30.5%), postradiation (n = 3, 8.3%), and tuberculosis (n = 2, 5.6%). Total pericardiectomy was performed in 35 patients. The average preoperative cardiac index was 2.6 L/min/m(2) with a significant increase to 3.1 L/min/m(2) noted in the immediate postoperative period (p = 0.03). There were no perioperative mortalities. The 1-year, 5-year, 10-year, and 15-year survival rates were 97.2%, 94.6%, 86.5%, and 78.3%, respectively. On multivariate analysis, preoperative heart failure (hazard ratio 2.2, p = 0.06), elevated preoperative total bilirubin (>2.7 mg/dL, hazard ratio 6.8, p = 0.02), and elevated creatinine (>1.4 mg/dL, hazard ratio 3.1, p = 0.05) were risk factors for increased long-term mortality. Kaplan-Meier survival analysis showed a significant decrease in overall survival associated with postradiation etiology (p = 0.05)., Conclusions: Pericardiectomy can be performed with low mortality and immediate improvement in hemodynamics. Those patients with compromised cardiac output, abnormal hepatic or renal function, or with previous radiation therapy have reduced long-term survival., (© 2014 Wiley Periodicals, Inc.)

Objective: To share our results of a case series of 8 patients who underwent pericardiectomy for constrictive pericarditis that developed secondary to a known neoplastic disease., Patients and Methods: The underlying neoplasia was lung cancer in 5 (62.5%) patients, malignant pleural mesothelioma in 2 (25%), and Hodgkin lymphoma in 1 (12.5%). A diagnosis of constrictive pericarditis was made primarily by echocardiography, and right heart catheterization was performed in 6 (75%) patients. Total pericardiectomy was defined as wide excision of the anterior pericardium. Follow-up information was obtained by telephone interview and the civil registry database., Results: Time from initial diagnosis of the neoplastic disease ranged from 1 to 15 years. Total pericardiectomy was performed in 6 (75%) patients. Histopathological examination revealed atypical cells in evacuated fluid and pericardial material in 6 patients. Nonspecific inflammation and fibrosis were observed in the other 2 cases. Hospital death occurred in 1 (12.5%) patient. Postoperative low cardiac output syndrome occurred in 7 (87.5%) patients. Follow-up ranged from 2.92 to 26.78 months. Mean survival was 14.82 ± 4.4 months., Conclusion: Pericardial constriction may develop a long time after the initial presentation of certain neoplastic diseases, and the prognosis after pericardiectomy is poor.

Objective: Prognosis after pericardiectomy remains to be clearly elucidated, especially in Asian countries, where the causes of constrictive pericarditis differ from those in Western countries. We aimed to investigate the preoperative prognostic factors and clinical outcomes after pericardiectomy in patients with chronic constrictive pericarditis., Methods: Preoperative clinical and imaging characteristics were evaluated in 85 consecutive patients with chronic constrictive pericarditis without other valvular or ischemic heart diseases who underwent pericardiectomy. Causes were idiopathic in 49 patients (57.6%) and tuberculous in 36 patients (42.4%). All-cause death was observed for a median of 38.5 months., Results: Of 85 patients, 15 (17.6%) died during follow-up. These 15 patients who died during follow-up had higher aspartate aminotransferase, smaller left ventricular end-systolic dimension index, and higher early diastolic mitral inflow velocity before pericardiectomy than the 70 patients who survived. Multivariate Cox proportional analysis showed that diabetes mellitus (hazard ratio, 4.610; P = .024) and high early diastolic mitral inflow velocity (hazard ratio, 1.050/cm/s; P = .002) before pericardiectomy were independent predictors of mortality after pericardiectomy. The preoperative cutoff value for early diastolic mitral inflow velocity in predicting mortality after pericardiectomy was 71 cm/s (sensitivity of 84.6% and specificity of 52.2%), and there was a significant difference in survival between groups divided by this cutoff value of early diastolic mitral inflow velocity (P = .029)., Conclusions: Preoperative high early diastolic mitral inflow velocity and diabetes mellitus were predictors of poor prognosis after pericardiectomy in patients with chronic constrictive pericarditis. These results suggest that preoperative Doppler echocardiographic evaluation may be valuable not only for diagnosing constrictive pericarditis but also for predicting prognosis after pericardiectomy., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Constrictive pericarditis causes hepatic congestion, which results in congestive hepatopathy and finally leads to cardiac cirrhosis. However, in previous studies, risk stratification from the viewpoint of liver dysfunction was not performed in patients who underwent pericardiectomy for constrictive pericarditis., Methods: Sixty-four patients with constrictive pericarditis who were operated on with de novo radical pericardiectomy through a left anterolateral thoracotomy in our institute were entered into the study. Patients with a Child-Pugh score less than 7 (class A) were assigned to group CP-A (n = 45) and those with a score of 7 or higher (class B or C) were assigned to group CP-BC (n = 19). Actuarial survival of patients after operation was studied in each group, and prognostic factors were analyzed with Cox regression analysis., Results: Survival after radical pericardiectomy in group CP-BC (Child-Pugh score ≥ 7) was significantly worse than in group CP-A (37.9% versus 80.8% for 5-year survival; p = 0.0001, log-rank test). After multivariate Cox analysis, a Child-Pugh score of 7 or more (hazard ratio [HR] 4.316; p = 0.0028), mediastinal irradiation (HR, 23.872; p < 0.0001), age (HR, 1.064; p = 0.0042), and end-stage renal disease (HR, 4.670; p = 0.029) were identified as independent prognostic factors for mortality after radical pericardiectomy., Conclusions: It is meaningful to apply the Child-Pugh scoring system for the prediction of mortality after radical pericardiectomy in patients with constrictive pericarditis., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The surgical approach for effusive constrictive pericarditis (ECP) has not been extensively studied. We present our institution's early and long-term results of pericardiectomy in our cohort of patients with ECP., Methods: Diagnosis was made primarily by echocardiography. Right heart catheterisation was performed in eight patients. Pre-operatively, 10 patients had undergone at least one previous attempt at therapeutic pericardiocentesis. Pericardiectomy was performed where appropriate (thickened or inflamed)., Results: Of our 12 patients (50% male, median age 48 years, range 17-72 years), the underlying aetiology included idiopathic in five (41.6%), tuberculosis in four (33%), and malignancy in three patients (25%). Elective surgery was performed in nine patients. Median values of both central venous pressure and pulmonary capillary wedge pressure decreased markedly postoperatively (from 16.5 to 11.0 mmHg, p = 0.02; 20.0-15.0 mmHg, p = 0.01, respectively). There was no in-hospital mortality. Follow up ranged from three months to nine years (median three years). Five (41.6%) patients died during the follow-up period, and cumulative two-year survival was 55.6 ± 1.5%., Conclusions: Pericardiectomy for ECP was effective, in terms of our early results, in patients unresponsive to medical therapy. Long-term survival depends on the underlying disease.

Background: Autologous haemopoietic stem-cell transplantation (HSCT) benefits patients with systemic sclerosis but has been associated with significant treatment-related mortality and failure to improve diffusion capacity of carbon monoxide (DLCO). We aimed to assess efficacy of HSCT and use of rigorous cardiac screening in this group., Methods: We assessed patients with diffuse systemic sclerosis or limited systemic sclerosis and interstitial lung disease who were treated with HSCT as part of a study or on a compassionate basis at Northwestern University (Chicago, IL, USA) or the University of São Paulo (Ribeirão Preto, Brazil). Unselected peripheral blood stem cells were harvested with cyclophosphamide (2 g/m(2)) and filgrastim. The transplant regimen was a non-myeloablative regimen of cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulin (rATG; 4·5-6·5 mg/kg). We followed patients up to 5 years for overall survival, relapse-free survival, modified Rodnan skin score, and pulmonary function tests., Findings: Five (6%) of 90 patients died from treatment-related causes. Despite standard guidelines that recommend echocardiogram for screening before transplantation, four treatment-related deaths occurred because of cardiovascular complications (one constrictive pericarditis, two right heart failures without underlying infection, and one heart failure during mobilisation), and one death was secondary to sepsis without documented underlying heart disease. Kaplan-Meier analysis showed survival was 78% at 5 years (after eight relapse-related deaths) and relapse-free survival was 70% at 5 years. Compared with baseline, we noted improvements after HSCT in modified Rodnan skin scores at 1 year (58 patients; p<0·0001), 2 years (42 patients; p<0·0001), and 3 years (27 patients; p<0·0001) and forced vital capacity at 1 year (58 patients; p=0·009), 2 years (40 patients; p=0·02), and 3 years (28 patients; p=0·004), but total lung capacity and DLCO were not improved significantly after HSCT. Overall mean DLCO was significantly improved in patients with normal baseline echocardiograms (p=0·005) or electrocardiographs (p=0·05)., Interpretation: Autologous HSCT with a non-myeloablative regimen of cyclophosphamide and rATG with a non-selected autograft results in sustained improvement in skin thickness and forced vital capacity. DLCO is affected by baseline cardiac function. Guidelines for cardiac screening of patients with systemic sclerosis to assess treatment-related risk from pulmonary artery hypertension, primary cardiac involvement, or pericardial disease should be reconsidered and updated., Funding: None., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

We reviewed the records of 45 patients (mean age, 46.6 ± 14.9 yr; range, 21-84 yr) with a diagnosis of constrictive pericarditis who had undergone pericardiectomy from 1994 through 2006. Preoperatively, 2 of the patients (4.4%) were in New York Heart Association (NYHA) functional class I, 20 (44.4%) in class II, 22 (48.9%) in class III, and 1 (2.2%) in class IV. Pericardial calcification was detected in 20% of plain chest radiographs. Constrictive pericarditis was caused by tuberculosis in 22.2%, chronic renal failure in 8.9%, a history of sternotomy in 4.4%, and malignancy in 4.4%. The cause was idiopathic in 60% of the patients. Low-output state was the most common postoperative problem (22.2%). The mean follow-up period was 40 ± 18 months (range, 3-144 mo). Three months postoperatively, only 1 of 43 available patients (2.3%) was in NYHA class III, while the rest were in class I (36 patients; 83.7%) or II (6 patients; 14%). The overall mortality rate was 4.4%: 1 patient with tuberculosis died of respiratory insufficiency while hospitalized, and 1 died of metastatic adenocarcinoma during follow-up. Our results show that pericardiectomy remains an effective procedure in the treatment of constrictive pericarditis. Tuberculosis is still an important cause of constrictive pericarditis in Iran, despite intensive vaccination and use of antitubercular drugs.

The aim of this study was to describe the etiology, clinical findings, diagnostic methods, treatment, outcome and long-term prognosis of 35 patients with chronic constrictive pericarditis (CCP) that were prospectively analyzed according to a pericardial disease protocol performed in our Institution. Etiology of CCP was idiopathic in 24 patients (68%), and specific in 11 (32%). The majority (34 patients, 97%) underwent pericardiectomy. Perioperative mortality was 12% (4/33) no deaths were registered among patients with idiopathic CCP. Median follow-up was 5.6 years (percentile 25-75: 2.4-7.4 years). The cumulative actuarial survival probability was 97% at 1 year (confidence interval [CI] 80% to 99%); 83% at 5 years, (95% CI 65% to 93%); 78% at 7 years, (95% CI 60% to 90%), and 69% at 10 years (95% CI 50% to 84%). In conclusion, nowadays CCP is generally an idiopathic disease with late diagnosis. The clinical course of the disease produces severe symptoms of congestive heart failure. In a 10 years follow-up 2/3 of patients are alive and improved their quality of life. Idiopathic form of pericarditis did not show mortality during early postoperative period.

Three men, aged 67 years, 80 years and 53 years, respectively, developed signs and symptoms of progressive right-sided heart failure following open heart surgery. They were diagnosed with constrictive pericarditis based on echocardiography, cardiac magnetic resonance and cardiac catheterisation. Following pericardiectomy, two of the patients fully recovered, while one, the 80-year-old man, died during convalescence. When signs and symptoms of progressive right-sided heart failure develop after open heart surgery, a diagnosis of constrictive pericarditis should be considered. Constrictive pericarditis after open heart surgery may be caused by inflammation of the pericardium; an old, fibrotic haemopericardium, which may be diffuse or loculated; pericardial adhesions; or a combination of these entities. Diagnosing constrictive pericarditis is difficult and may take a long time. However, it is important to recognise this disorder early before it has progressed to an advanced stage. Pericardiectomy is the only effective therapy. When performed too late, survival is significantly reduced.

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1-9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover.

Objective and Method: We retrospectively analysed 56 consecutive patients with a confirmed diagnosis of chronic constrictive pericarditis over a period of 23 years. The objective was to analyse the evolution of the annual frequency of constrictive pericarditis, its aetiology and to define the prognostic factors for mortality., Results: The annual frequency of constrictive pericarditis has not diminished over the 23 years of this study, remaining at 2.4 cases per year. Cases with a tuberculous origin have diminished progressively, being replaced by complications of cardiac surgery and mediastinal radiotherapy. Pericardectomy was performed in 41 patients and the average follow up was 9.5 +/- 8.6 years. By the end of the study, 34 patients had died (61.8%), 18 from a cardiovascular cause (38.3%). The independent predictive factors for overall mortality were a history of mediastinal radiotherapy, the age, and plasma sodium level. Only the presence of first degree atrio-ventricular block was an independent predictive factor for cardiovascular mortality. In the pericardectomy group, 24 patients died (60%). A history of mediastinal radiotherapy and the presence of pre-operative hyponatraemia were independent predictive factors for overall mortality., Conclusion: Constrictive pericarditis remains a serious pathology. Pericardectomy allows a clear functional improvement, but following pericardectomy more than 60% of patients will die within 10 years of the diagnosis being made.

Background: This study was designed to compare the outcomes after total versus partial pericardiectomy clinically, echocardiographically, and hemodynamically., Methods: Three hundred ninety-five patients undergoing pericardiectomy for constrictive pericarditis between January 1985 and December 2004 were studied. Age was 10 months to 71 years (mean, 25.1 +/- 13.4 years). Three hundred thirty-eight patients (85.6%) underwent total pericardiectomy (group I), and 57 patients (14.4%) underwent partial pericardiectomy (group II)., Results: Operative and late mortality rates were 7.6% and 4.9%, respectively. Preoperative high right atrial pressure, hyperbilirubinemia, renal dysfunction, atrial fibrillation, pericardial calcification, thoracotomy approach, and partial pericardiectomy were significant risk factors for death. The risk of death was 4.5 times higher (95% confidence interval: 2.05 to 9.75) in patients undergoing partial pericardiectomy. At a mean follow-up of 17.9 +/- 0.3 years (95% confidence interval: 17.3 to 18.6), actuarial survival was 83.8% +/- 0.04% in group I and 73.9% +/- 0.06% in group II (p = 0.004). At their last follow-up, 96.3% survivors of group I and 79.1% survivors of group II were in New York Heart Association class I/II (p < 0.001)., Conclusions: Total pericardiectomy is associated with lower perioperative and late mortality, and confers significant long-term advantage by providing superior hemodynamics that appear to be independent of the etiology of constrictive pericarditis.

Background: Tuberculous pericarditis is common in Transkei (Eastern Cape). Two randomized trials showed benefits at two years for prednisolone in patients with constrictive pericarditis, and open drainage plus prednisolone in patients with pericardial effusion., Aim: To see whether the advantages of prednisolone and open drainage were maintained up to 10 years., Design: Follow-up of randomized, double-blind, placebo-controlled trials., Methods: All 383 patients (143 constriction, 240 effusion) received the same anti-tuberculosis chemotherapy. They were randomized to prednisolone or placebo for the first 11 weeks, and were followed-up over 10 years. Among the 240 with effusion, 122 were also randomized to immediate open surgical drainage of pericardial fluid versus pericardiocentesis as required. Adverse outcomes were: death from pericarditis, pericardiectomy, repeat pericardiocentesis, and subsequent open drainage., Results: The 10-year follow-up rate was 96%. In constriction patients, adverse outcomes occurred in 19/70 (27%) prednisolone vs. 28/73 (38%) placebo (p = 0.15), deaths from pericarditis being 2 (3%) vs. 8 (11%), respectively (p = 0.098, Fisher's exact test). In effusion patients, adverse outcomes occurred in 14/27 (52%) with neither drainage nor prednisolone, vs. 4/29 (14%) drainage and prednisolone, 4/35 (11%) drainage and placebo, and 6/31 (19%) prednisolone and no drainage (p = 0.08 for interaction). Drainage eliminated the need for repeat pericardiocentesis. In the 176 with effusion and no drainage, adverse outcomes occurred in 17/88 (19%) prednisolone vs. 35/88 (40%) placebo patients (p = 0.003), with repeat pericardiocentesis 20 (23%) placebo vs. 9 (10%) prednisolone (p = 0.025). In a multivariate survival analysis (stratified by type of pericarditis), prednisolone reduced the overall death rate after adjusting for age and sex (p = 0.044), and substantially reduced the risk of death from pericarditis (p = 0.004). At 10 years, the great majority of surviving patients in all treatment groups were either fully active or out and about, even if activity was restricted., Discussion: In the absence of a clear contraindication, a corticosteroid should be used in addition to antituberculosis chemotherapy in the management of patients with tuberculous pericarditis.

Objectives: We sought to determine the association of etiology of constrictive pericarditis (CP), pericardial calcification (CA), and other clinical variables with long-term survival after pericardiectomy., Background: Constrictive pericarditis is the result of a spectrum of primary cardiac and noncardiac conditions. Few data exist on the cause-specific survival after pericardiectomy. The impact of CA on survival is unclear., Methods: A total of 163 patients who underwent pericardiectomy for CP over a 24-year period at a single surgical center were studied. Constrictive pericarditis was confirmed by the surgical report. Vital status was obtained from the Social Security Death Index., Results: Etiology of CP was idiopathic in 75 patients (46%), prior cardiac surgery in 60 patients (37%), radiation treatment in 15 patients (9%), and miscellaneous in 13 patients (8%). Median follow-up among survivors was 6.9 years (range 0.8 to 24.5 years), during which time there were 61 deaths. Perioperative mortality was 6%. Idiopathic CP had the best prognosis (7-year Kaplan-Meier survival: 88%, 95% confidence interval [CI] 76% to 94%) followed by postsurgical (66%, 95% CI 52% to 78%) and postradiation CP (27%, 95% CI 9% to 58%). In bootstrap-validated proportional hazards analyses, predictors of poor overall survival were prior radiation, worse renal function, higher pulmonary artery systolic pressure (PAP), abnormal left ventricular (LV) systolic function, lower serum sodium level, and older age. Pericardial calcification had no impact on survival., Conclusions: Long-term survival after pericardiectomy for CP is related to underlying etiology, LV systolic function, renal function, serum sodium, and PAP. The relatively good survival with idiopathic CP emphasizes the safety of pericardiectomy in this subgroup.