CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
AFRICA
305
mesothelioma. Both these patients had advanced heart failure
and were unresponsive to medical treatment. An independent
oncologist and lung specialist confirmed that expected lifespan
was more than one year for both patients. The remaining
patient had malignant cells on pericardial biopsy, indicative
of metastatic disease of unknown origin. This patient had
emergency surgery.
All tuberculous patients had a history of previous pulmonary
involvement for a period of one to six years. All patients
had documentation of completion of antituberculous treatment
prior to admission. Acid-fast bacterial testing was negative
pre-operatively on three separate occasions in all study patients.
Pre-operative echocardiography demonstrated a thickened
parietal or visceral pericardium in 10 patients (83.3%), plethored
inferior vena cava in 10 (83.3%), asymmetric septal movement
in 11 (91.6%), and variation in mitral inflow in seven (58.3%).
Overall, at least two criteria for CP were present, accompanied
by varying amounts of pericardial effusion in all patients.
The amount of pericardial effusion was slightly higher on
the right ventricular side (median 2.5 cm, interquartile range
2.1–3.3) than on the left ventricular side (median 2.3 cm,
interquartile range 1.8–3.1 cm) and posterior wall (median 2.1
cm, interquartile range 1.2–2.3 cm). However, this difference
was not found to be statistically significant (
p
=
0.076).
Five patients (41.7%) had tricuspid insufficiency, four
(33.3%) had mitral insufficiency, and seven (58.8%) had bi-atrial
dilatation. The left ventricular systolic function was within
normal ranges in all patients (median ejection fraction 60%,
interquartile range 51.25–65%).
The operation was elective in nine patients and emergency
in three patients who presented with acute tamponade. The
pericardial effusion consisted of free defibrinated blood in
seven patients and was serofibrinated or loculated in the others.
Samples of pericardial tissue and fluid were first sent for culture,
histopathology and other testing prior to evacuation and volume
measurement. Details of the operations performed are given in
Table 2.
Acute haemorrhage and conversion to urgent cardiopulmonary
bypass occurred in one patient. The bleeding was close to the
posterolateral wall of the left ventricle and was treated with
multiple pledgeted 4.0 polyprolene sutures. During peeling,
minor haemorrhages occurring in the ventricular and right atrial
wall were sutured using 5.0 polyprolene sutures. No coronary
artery rupture or any additional complications were observed
during the operation.
Pre-operatively, central venous pressure and pulmonary
capillary wedge pressure were both high (median 16.5 mmHg,
interquartile range 11.0–27.5; median 20.0 mmHg, interquartile
range 16.0–23.5, respectively). Postoperatively, both showed
a marked decrease. Central venous pressure decreased in
seven patients, increased in two, and was unchanged in three
(median 11.0 mmHg, interquartile range 10.0–16.0,
p
=
0.021).
Pulmonary capillary wedge pressure decreased in eight patients
and remained unchanged in four (median 15 mmHg, interquartile
range 12.5–17.5,
p
=
0.011) (Table 3).
There was no in-hospital mortality. Respiratory distress was
the most common postoperative complication, followed by
low-cardiac output syndrome and renal failure. Two patients
underwent re-operation for bleeding, although no particular site
of bleeding was found in either one (Table 4).
The follow-up period ranged from three months to nine years
(median three years). Overall, five patients (41.6%) died from
various causes. The three cancer patients died from disease
progression within two years postoperatively, whereas all five
tuberculous patients survived to the end of the follow-up period.
Cumulative survival was 55.6
±
1.5% at the end of the two-year
follow-up period (when the last death occurred). Seven patients
survived with a median follow up of five years (range nine
months to eight years) postoperatively (Table 5, Fig. 1).
Discussion
Our study emphasises the clinical importance of ECP. Survival
after pericardiectomy for ECP was lower than previously
reported.
13,14
Although ECP has been observed in only a minority
of pericarditis patients, we found that it represented a higher
proportion in pericardiectomy patients. Moreover, we found
that surgery for ECP was associated with substantial morbidity,
TABLE 3. PRE-OPERATIVEAND INTRA-OPERATIVE DATA
Patient
Aeti-
ology Age
Presen-
tation
Echocardiography
Catheterisation
Operation
CP
ELVS
(cm)
ERVS
(cm)
EPWS
(cm)
mRAP
(mmHg)
RVEDP
(mmHg)
LVEDP
(mmHg)
mPAP
(mmHg)
CVP 1
(mmHg)
PCWP 1
(mmHg)
Fluid
removed (ml)
CVP 2
(mmHg)
PCWP 2
(mmHg)
1
ID 48
HF + 2.5
2.6
2.8
25
30
30
22
11
18
500
7
14
2
HF 47
HF + 1.2
1.8
1.5
28
28
30
35
30
22
1400
16
18
3 MG 59
CT + 2.8
3.6
2.2
-
-
-
-
10
24
1000
10
20
4 MG 48
HF + 4.1
3.5
2.4
26
30
29
29
9
24
1000
11
16
5
TB 72
CT + 3.2
2.4
4.1
-
-
-
-
11
22
1500
11
14
6
ID 67
HF + 1.8
2.6
2.1
28
25
23
35
17
16
500
9
16
7 MG 50
HF + 1.5
3.6
2.2
10
10
12
25
20
16
750
11
16
8
TB 34
HF + 2.8
3.0
2.1
-
-
-
-
22
24
1500
16
14
9
ID 29 Dyspnoea + 1.8
1.9
1.2
20
12
12
25
21
12
250
21
12
10 ID 49
CT + 2.1
2.4
1.8
-
-
-
-
28
16
1200
16
10
11 TB 17
HF + 3.5
2.2
1.0
25
12
15
22
15
12
600
10
12
12 ID 42
HF + 2.2
2.1
1.2
21
23
23
18
16
22
400
19
18
ID: idiopathic, TB: tuberculosis, MG: malignancy, NYHA: NewYork Heart Association, CT: cardiac tamponade, CP: constrictive pericarditis, ELVS: effusion along left ventri-
cle side, ERVS: effusion along right ventricle side, EPWS: effusion along posterior wall side, mRAP: mean right atrial pressure, RVEDP: right ventricular end-diastolic pressure,
LVEDP: left ventricular end-diastolic pressure, mPAP: mean pulmonary artery pressure, CVP 1: central venous pressure before operation, CVP 2: central venous pressure after
operation, PCWP 1: pulmonary capillary wedge pressure before operation, PCWP 2: pulmonary capillary wedge pressure after operation. CVP and PCWP measurements were
performed using a Swan-Ganz catheter introduced via the internal jugular vein.
