Cardiovascular Journal of Africa: Vol 32 No 3 (MAY/JUNE 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 3, May/June 2021

168

AFRICA

Exacerbation of severe constrictive pericarditis after

prior inadequate pericardiectomy

Yoshinori Kuroda, Tetsuro Uchida, Masahiro Mizumoto, Kentaro Akabane, Mitsuaki Sadahiro

Abstract

Pericardiectomy is commonly used to treat constrictive peri-

carditis (CP); however, persistent calcification can complicate

recovery. An 82-year-old man presented with CP following

an inadequate pericardiectomy at another hospital two years

earlier. He was referred to our hospital with a diagnosis of

recurrent CP. Pre-operative computed tomography revealed

that the pericardium was not calcified on the anterior of the

heart, while the inferior, posterior and lateral surfaces exhib-

ited calcification. Notably, calcification along the inferior

portion of the heart formed a calcium envelope structure.

Pericardiectomy via re-sternotomy without cardiopulmonary

bypass was performed. While dissecting the calcium enve-

lope, a paste-like substance was exuded. Cardiac function

improved after pericardiectomy, although the postoperative

recovery from heart failure was prolonged. Calcified pericar-

dium should be removed to the extent possible to enhance the

efficacy of pericardiectomy, which contributes to improved

early surgical results and prevents CP recurrence.

Keywords:

constrictive pericarditis, recurrent pericarditis, peri-

cardiectomy

Submitted 2/10/19, accepted 14/7/20

Published online 22/7/20

Cardiovasc J Afr

2021;

: 168–170

www.cvja.co.za

DOI: 10.5830/CVJA-2020-027

Constrictive pericarditis (CP) is a clinical condition of the heart

in which the myocardium is enveloped in a calcified and fibrotic

pericardium. CP induces diastolic and systolic dysfunction of the

heart, thereby greatly reducing cardiac function. Pericardiectomy

is an effective surgical technique for improving cardiac function.

Herein, we describe a surgical case of re-pericardiectomy for

recurrent CP with an atypically calcified pericardium after prior

inadequate pericardiectomy.

Case report

An 82-year-old man with CP underwent pericardiectomy at

another hospital to resect only the anterior portion of the

calcified pericardium, which did not satisfactorily resolve the

condition. Two years after the operation, the patient again

experienced heart failure, and he was referred to our hospital

with a diagnosis of recurrent CP.

Computed tomography before the previous operation had

shown a single layer of calcified pericardium enveloping the entire

surface of the heart (Fig. 1A, B). Computed tomography before the

operation described herein revealed that the pericardium was not

calcified on the anterior of the heart, while the inferior, posterior

and lateral surfaces exhibited calcification. Notably, calcification

along the inferior portion of the heart formed a calcium envelope

structure (Fig. 2A, B). Echocardiography revealed that the wall

motion was globally reduced and that the ejection fraction was

43%. Pre-operative coronary angiography indicated no significant

coronary artery stenosis. The causes of heart failure were believed

to be diastolic dysfunction due to calcified pericardium and

compression by the inferior calcified mass.

The patient was diagnosed with exacerbated CP. The

right femoral artery and vein were exposed, and although

cardiopulmonary bypass (CPB) was kept on standby, re-sternot-

omy for pericardiectomy was performed without CPB being

required. The pericardiectomy was started at the anterior surface

of the right ventricle. Although it was difficult to locate the border

between the calcified tissue and the heart, we identified the edge

of the calcium plate at the lower anterior margin of the right

ventricle. The calcified pericardium was gently removed from the

heart using an electric knife and ultrasonic scalpel (Fig. 3). While

cutting into the calcified mass enveloping the inferior portion

of the heart, a paste-like substance was exuded. The calcified

pericardium and the inferior mass were removed completely.

Cardiac contraction improved as resection of the pericardium

progressed. The cardiac index increased from 1.2 l/min/m

the time of anaesthesia induction to 3.2 l/min/m

after the

pericardiectomy. Total pericardiectomy was also completed

without CPB being required.

The pathological diagnosis was recurrent idiopathic CP,

while the paste-like substance inside the calcium envelope

was determined to be haematoma. We found no evidence of

infection. The postoperative course was uneventful, although the

duration of recovery from heart failure was prolonged.

Discussion

CP is a type of pericardial disease whose causes could be idiopathic

Division of Cardiovascular Surgery, Department of Surgery

II, Yamagata University Faculty of Medicine, Yamagata,

Japan

Yoshinori Kuroda, MD, PhD,

y-kuroda@med.id.yamagata-u.ac.jp

Tetsuro Uchida, PhD

Masahiro Mizumoto, MD

Kentaro Akabane, MD

Mitsuaki Sadahiro, PhD

Case Reports