CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
AFRICA
303
Surgical management of effusive constrictive
pericarditis
FUAT BUYUKBAYRAK, ERAY AKSOY, SERPIL TAS, KAAN KIRALI
Abstract
Background:
The surgical approach for effusive constric-
tive pericarditis (ECP) has not been extensively studied. We
present our institution’s early and long-term results of peri-
cardiectomy in our cohort of patients with ECP.
Methods:
Diagnosis was made primarily by echocardiog-
raphy. 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 (thick-
ened 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, respec-
tively). 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%.
Conclusion:
Pericardiectomy for ECP was effective, in terms
of our early results, in patients unresponsive to medical ther-
apy. Long-term survival depends on the underlying disease.
Keywords:
effusive constrictive pericarditis, surgery, pericar-
diectomy
Submitted 6/2/13, accepted 7/6/13
Published online 17/9/13
Cardiovasc J Afr
2013;
24
: 303–307
DOI: 10.5830/CVJA-2013-042
Effusive constrictive pericarditis (ECP) is a distinct entity
in which diastolic filling is compromised by two combined
mechanisms. First, increased intrapericardial pressure adversely
affects volumetric expansion by causing external chamber
compression. Second, loss of epicardial elasticity precludes
myocardial relaxation.
ECP is defined, on the basis of simultaneous catheterisation
and pericardiocentesis findings, as the persistence of high
intracardiac pressures despite percutaneous drainage of the
pericardial fluid. The definition should not be misinterpreted,
as ECP differs from CP only in being accompanied by fluid
collection around the heart. Rather, what makes ECP a distinct
entity is the involvement of the visceral pericardium. The fluid
collection is a consequence of the underlying inflammatory
process, and may directly relate to treatment outcomes.
1,2
The prevalence of ECP ranges from 1.4–14.8%,
3
and as high
as 24% in patients requiring pericardiectomy.
4
Although ECP has
commonly been linked with tuberculosis, numerous case reports
associate it with a variety of clinical conditions, including cancer,
renal failure, connective tissue disease, previous cardiac surgery
and mediastinal radiation.
5-10
Although the risk of developing
CP is higher after tuberculous pericarditis,
11
and ECP has
been assumed to be a precursor to permanent constriction, the
prevalence of tuberculous ECP is lower than that of idiopathic
ECP.
3
Although most patients with pericardial effusion respond well
to medical therapy (especially of tuberculous aetiology),
12
more
than half of patients with ECP eventually need pericardiectomy
due to persistent heart failure. The purpose of pericardiectomy
(removal of the visceral pericardium) is to improve ventricular
contractility; however, the early results and prognosis are still
unknown in the surgical treatment of ECP.
Methods
Twelve patients who underwent pericardiectomy and evacuation
of pericardial fluid for ECP were included. These patients were
among a total of 62 (19.2%) patients (50% male, median age
48 years, range 17–72) who underwent pericardiectomy for
CP (15.8%) between November 2004 and March 2012. Patient
registry information, medical records and hospital archives were
systematically reviewed.
The underlying aetiology was idiopathic in five patients
(41.6%), tuberculosis in four (33%), and malignancy in three
(25%). Pre-operatively, all patients were receiving optimal
medical therapy for congestive heart failure and non-steroidal
anti-inflammatory drugs to decrease the pericardial effusion
(Table 1).
Diagnosis was made primarily by echocardiography. ECP
was diagnosed when widely accepted criteria for CP were met
(thickening of parietal or visceral pericardium, asymmetric
septal movement, plethored inferior vena cava, and variation in
mitral or tricuspid inflow), accompanied by pericardial effusion.
All patients met these echocardiographic criteria.
Right heart catheterisation (RHC) was performed in eight
patients and equalisation of end-diastolic pressures within both
ventricles was considered to be definitive for the presence of
pericardial constriction. RHC was not performed in four patients;
three who presented with acute cardiac tamponade underwent
emergency surgery, and one patient had clear evidence of parietal
pericardial thickening on transthoracic echocardiography.
Operative indications were advanced heart failure (i.e. NYHA
class
≥
III) in eight patients (66.6%), acute cardiac tamponade in
Kartal Kosuyolu Heart and Research Hospital, Istanbul,
Turkey
FUAT BUYUKBAYRAK, MD
ERAY AKSOY, MD,
SERPIL TAS, MD
KAAN KIRALI, MD, PhD
