CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
304
AFRICA
three (25%), and decreased effort capacity in one (8.3%) who
had a recurrence of pericardial fluid accumulation. Overall,
failure of therapeutic pericardiocentesis combined with medical
treatment was the indication for surgery in 10 of the 12 patients
(Table 2).
Therapeutic pericardiocentesis was defined as percutaneous
evacuation of the pericardial fluid to relieve cardiac functions.
Pre-operatively, 10 patients had undergone at least one previous
attempt at therapeutic pericardiocentesis. The procedure was
routinely performed under echocardiographic guidance using a
5-F pigtail catheter inserted via the left infrasternal angle.
On admission, five patients underwent pericardiocentesis
under transthoracic echocardiographic guidance andwere referred
for surgery because the constriction persisted despite evacuation
of the fluid. For the remaining patients, pericardiocentesis
was not re-attempted in five patients because the effusion had
recurred after previous attempts (two attempts in four patients
and one attempt in one patient), and it was not attempted at all
in two patients due to multiple, dense septations observed on
echocardiography. Pericardiocentesis was always combined with
medical therapy, which consisted of oral administration of anti-
inflammatory agents. The use of corticosteroids was avoided.
During surgery, a median sternotomy was made in all
patients. Beginning at the ascending aorta and anterolateral
portion of the left ventricle, the anteroposterior extent of
dissection was extended between the two phrenic nerves and
included the superior vena cava–right atrium junction superiorly.
The diaphragmatic surface and the inferior vena cava–right
atrium junction defined the inferior extent of the excision. The
atria and vena cavae were decorticated, if it could be performed
without risk of haemorrhage.
For most patients, multiple sharp dissections were required
to establish a true dissection plane. In some situations, when
both layers were thickened without a clear boundary, some
areas of fragmented and firm adhesions were left
in situ
unless
ventricular motion was compromised. When ventricular motion
was not improved, the thickened visceral pericardium was further
divided into smaller fragments by electrocautery (epicardial
fragmentation).
Total pericardiectomy was defined as wide excision of the
anterior pericardium. Pericardiectomy was considered partial
if both ventricles could not be decorticated because of dense
adhesions.
Statistical analysis
All statistical analysis was performed using SPSS version 15.0
software. Continuous variables were defined by the median
±
interquartile ranges. Multiple measurements regarding the same
parameter were compared using the Friedmann test. Values
obtained pre- and postoperatively were compared using the
Wilcoxon signed-ranks test. Survival was calculated using the
lifetable method. A
p
-value of less than 0.05 was considered to
be statistically significant.
Results
Overall, four of 19 (21%) tuberculous patients, three of 10 (30%)
malignancy patients, and five of 33 (15%) idiopathic patients
had ECP. Nine patients had NYHA class
>
II symptoms, with the
duration of heart failure ranging from two to 15 months (median
nine months).
All except one patient were admitted for the first time, with
duration of symptoms lasting between two and 12 months, with
no identifiable cause of disease. The patient who had been
admitted previously had undergone pericardiocentesis one month
prior to the present admission. In this patient, histopathology
revealed non-specific inflammation.
Of three patients with cancer, one had a six-year history
of diffuse B-type cell lymphoma and one had a five-year
history of both gastric lymphoma and pulmonary malignant
TABLE 1. BASELINE CHARACTERISTICS
Variable
Value (%)
Clinical parameters
NYHA class III or IV
9 (75.0)
Jugular venous distension
10 (83.3)
Ascites
9 (75.0)
Hepatomegaly
6 (50.0)
Hypertension
2 (16.7)
Diabetes
4 (33.3)
COPD
2 (16.7)
Creatinine
>
1.5
µ
mol/l
4 (33.3)
Tobacco use
3 (25.0)
Pleural effusion
5 (41.7)
Echocardiography
Ejection fraction (%)
60 (51.25–65)
Tricuspid insufficiency
5 (41.7)
Mitral insufficiency
4 (33.3)
Septal bounce
11 (91.6)
Plethora in IVC
10 (83.3)
Pericardial effusion
12 (100)
Biatrial dilatation
9 (75)
NYHA: NewYork Heart Association
TABLE 2. DETAILS OF OPERATIONS PERFORMED
Patient
Aeti-
ology
Clinical status: indication for
operation
Operation Pericardiectomy
1
ID Advanced heart failure (NYHA IV)
unresponsive to medical treatment
Elective TP + epicardial
fragmentation
2 TB Heart failure (NYHA III)
Elective TP + epicardial
peeling
3 MG
†
Cardiac tamponade – CPR
Emergency PP + epicardial
fragmentation
4 MG
‡
Advanced heart failure (NYHA IV)
unresponsive to medical treatment
Elective TP
5 TB Cardiac tamponade
Emergency PP + epicardial
peeling
6
ID Heart failure (NHYA III)
Elective TP + epicardial
fragmentation
7 MG
§
Advanced heart failure (NYHA IV)
unresponsive to medical treatment
Elective TP
8 TB Heart failure (NYHA III)
Elective TP + epicardial
fragmentation
9
ID Dyspnea, decreased effort capacity
(NYHA II)
Elective TP
10 ID Cardiac tamponade
Emergency PP + epicardial
fragmentation
11 TB Heart failure (NYHA III)
Elective TP
12 ID Heart failure (NYHA III)
Elective TP
ID: idiopathic, TB: tuberculosis, MG: malignancy, NYHA: NewYork Heart Associa-
tion, HF: heart failure, TP: total pericardiectomy, PP: partial pericardiectomy.
†
Neoplastic cell invasion without definitive diagnosis,
‡
Pericardial involvement of malignant mesothelioma (epitolid type),
§
Pericardial involvement of high-grade diffuse
β
-type cell lymphoma.
