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Al-Kazaz M, Klein AL, Oh JK, Crestanello JA, Cremer PC, Tong MZ, Koprivanac M, Fuster V, El-Hamamsy I, Adams DH, Johnston DR. Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 84:561-580. [PMID: 39084831 DOI: 10.1016/j.jacc.2024.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/09/2024] [Accepted: 05/01/2024] [Indexed: 08/02/2024]
Abstract
Remarkable advances have occurred in the understanding of the pathophysiology of pericardial diseases and the role of multimodality imaging in this field. Medical therapy and surgical options for pericardial diseases have also evolved substantially. Pericardiectomy is indicated for chronic or irreversible constrictive pericarditis, refractory recurrent pericarditis despite optimal medical therapy, or partial agenesis of the pericardium with a complication (eg, herniation). A multidisciplinary evaluation before pericardiectomy is essential for optimal patient outcomes. Overall, given the good outcomes reported, radical pericardiectomy on cardiopulmonary bypass, if feasible, is the preferred approach. Due to patient complexity, as well as the technical aspects of the surgery, pericardiectomy should be performed at high-volume centers that have the required expertise. The current review highlights the essential features of this multidisciplinary approach from diagnosis to recovery in patients undergoing pericardiectomy.
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Affiliation(s)
- Mohamed Al-Kazaz
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul C Cremer
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Bluhm Cardiovascular Institute, Division of Cardiology, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valentin Fuster
- The Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas R Johnston
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Maitz T, Shah S, Gupta R, Goel A, Sreenivasan J, Hajra A, Vyas AV, Lavie CJ, Hawwa N, Lanier GM, Kapur NK. Pathophysiology, diagnosis and management of right ventricular failure: A state of the art review of mechanical support devices. Prog Cardiovasc Dis 2024; 85:103-113. [PMID: 38944261 DOI: 10.1016/j.pcad.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The function of the right ventricle (RV) is to drive the forward flow of blood to the pulmonary system for oxygenation before returning to the left ventricle. Due to the thin myocardium of the RV, its function is easily affected by decreased preload, contractile motion abnormalities, or increased afterload. While various etiologies can lead to changes in RV structure and function, sudden changes in RV afterload can cause acute RV failure which is associated with high mortality. Early detection and diagnosis of RV failure is imperative for guiding initial medical management. Echocardiographic findings of reduced tricuspid annular plane systolic excursion (<1.7) and RV wall motion (RV S' <10 cm/s) are quantitatively supportive of RV systolic dysfunction. Medical management commonly involves utilizing diuretics or fluids to optimize RV preload, while correcting the underlying insult to RV function. When medical management alone is insufficient, mechanical circulatory support (MCS) may be necessary. However, the utility of MCS for isolated RV failure remains poorly understood. This review outlines the differences in flow rates, effects on hemodynamics, and advantages/disadvantages of MCS devices such as intra-aortic balloon pump, Impella, centrifugal-flow right ventricular assist devices, extracorporeal membrane oxygenation, and includes a detailed review of the latest clinical trials and studies analyzing the effects of MCS devices in acute RV failure.
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Affiliation(s)
- Theresa Maitz
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Swara Shah
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA.
| | - Akshay Goel
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | | | - Adrija Hajra
- Department of Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Apurva V Vyas
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Oshner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Nael Hawwa
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - Navin K Kapur
- Cardiovascular Center, Tufts Medical Center, Boston, MA, USA
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Duarte NF, de Aguiar Trigueirinho Ferreira S, Filho DAA, Vidal CHL, Lima RS, Martins AVV, Castro RO, de Assis ACR, Soares PR, Scudeler TL. Right ventricular dysfunction after pericardiectomy for tuberculous constrictive pericarditis: A case report. Clin Case Rep 2024; 12:e8899. [PMID: 38799540 PMCID: PMC11116479 DOI: 10.1002/ccr3.8899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 04/22/2024] [Accepted: 04/28/2024] [Indexed: 05/29/2024] Open
Abstract
Key Clinical MessageThis case report provides a peculiar case of tuberculous constrictive pericarditis (TCP) who presented with right ventricular dysfunction after pericardiectomy. Right ventricular dysfunction is one of the main postoperative complications after pericardiectomy. Rapid and accurate identification of right ventricular dysfunction confirmed by transthoracic echocardiography (TTE), associated with the rapid initiation of diuretics and inotropic therapy is necessary for the patient's complete recovery.AbstractTCP is a condition characterized by chronic inflammation and fibrosis of the pericardium. Pericardiectomy is the standard treatment for patients with constrictive pericarditis and persistent symptoms. One possible surgical complication is right ventricle (RV) failure. We report a case of a 44‐year‐old man who developed RV failure after pericardiectomy for TCP. A 41‐year‐old man with no medical history was referred to our hospital due to progressive dyspnea associated with edema of the lower limbs and significant weight loss (30 kg) over the past 5 months. TTE revealed significant pericardial thickening and mild pericardial effusion with normal RV function. Chest X‐ray showed moderate bilateral pleural effusion. The patient underwent pericardiectomy and bilateral pleural drainage. Histopathological examination showed tuberculosis granulomas with caseous necrosis, and antituberculosis medication was initiated. Postoperative TTEs showed normal RV function and mild pericardial thickening. The patient was discharged home after successful postoperative recovery. Three weeks later, the patient was admitted to the emergency department with dyspnea and hypoxemia. TTE revealed RV systolic dysfunction. Chest CT showed a recurrence of moderate pleural effusion, this time loculated, with restrictive atelectasis of the adjacent lung parenchyma. Diuretics and inotropic therapy were initiated, and the patient underwent lung decortication after confirmation of tuberculous empyema. The patient experienced significant clinical improvement. TTE before discharge showed a decreased RV chamber size with improved RV systolic function. The patient was discharged in a stable condition 30 days after admission with a low dose of oral furosemide. Four months after discharge, he remained asymptomatic with good functional status. Pericardiectomy for TCP may carry the risk of developing RV dysfunction. Furthermore, TCP itself may be associated with other complications, such as empyema. We emphasize the importance of conducting a thorough clinical evaluation for patients with TCP, particularly those undergoing pericardiectomy, to mitigate potential adverse outcomes.
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Affiliation(s)
- Natânia Ferreira Duarte
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | - Daniel Abdalla Added Filho
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Carlos Henrique Lopes Vidal
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Roger Sales Lima
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Ana Vitória Vitoreti Martins
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Rafael Oliveira Castro
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Arthur Cicupira Rodrigues de Assis
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Paulo Rogério Soares
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Thiago Luis Scudeler
- Emergency Department of Instituto do Coração (InCor)Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
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Shi C, Dong C, Yao L, Weiss N, Liu H. Anesthesia management for pericardiectomy- a case series study. BMC Anesthesiol 2023; 23:191. [PMID: 37264299 DOI: 10.1186/s12871-023-02155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Constrictive pericarditis (CP) is an uncommon disease that limits both cardiac relaxation and contraction. Patients often present with right-sided heart failure as the pericardium thickens and impedes cardiac filling. Pericardiectomy is the treatment of choice for improving hemodynamics in CP patients; however, the procedure carries a high morbidity and mortality, and the anesthetic management can be challenging. Acute heart failure, bleeding and arrhythmias are all concerns postoperatively. METHODS After IRB approval, we performed the retrospective analysis of 66 consecutive patients with CP who underwent pericardiectomy from July 2018 to May 2022. RESULTS Most patients had significant preoperative comorbidities, including congestive hepatopathy (75.76%), New York Heart Association Type III/IV heart failure (59.09%) and atrial fibrillation (51.52%). Despite this, 75.76% of patients were extubated within the first 24 h and all but 2 of the patients survived to discharge (96.97%). CONCLUSIONS Anesthetic management, including a thorough understanding of the pathophysiology of CP, the use of advanced monitoring and transesophageal echocardiography (TEE) guidance, all played an important role in patient outcomes.
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Affiliation(s)
- Chunxia Shi
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Chao Dong
- Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Nicole Weiss
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, 4150 V Street, Suite 1200, Sacramento, CA, 95817, USA
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, 4150 V Street, Suite 1200, Sacramento, CA, 95817, USA.
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Raizada V, Sato K, Alashi A, Kumar A, Kwon D, Ramchand J, Dillenbeck A, Zumwalt RE, Vangala AS, Earley TD, Klein A. Depressed right ventricular systolic function in heart failure due to constrictive pericarditis. ESC Heart Fail 2021; 8:3119-3129. [PMID: 34137193 PMCID: PMC8318427 DOI: 10.1002/ehf2.13418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 12/22/2022] Open
Abstract
Aims Heart failure in constrictive pericarditis (CP) is attributed to impaired biventricular diastolic filling. However, diseases that cause CP due to myocardial infiltration and fibrosis can also impair biventricular systolic function (sf) and contribute to heart failure. This study of patients with CP examined biventricular sf and the effect of myocardial infiltration by pericardial diseases and the resulting fibrosis on ventricular sf. Methods and results Histopathologic examinations of right ventricular (RV) and left ventricular (LV) myocardia and pericardia were performed on three autopsied hearts of patients with pericardial diseases. Additionally, in 40 adults with clinical heart failure and 40 healthy adults (controls), sf of both ventricles was examined by echocardiography, including strain measurements, and biventricular diastolic filling and pulmonary artery pressures were assessed by cardiac catheterization. Cardiac histopathology indicated thickening of the pericardium with fibrosis, disease infiltrating the myocardium, greater infiltration of the RV than the LV, and an association of pericardial thickness with myocardial infiltrations. Functional analysis indicated that RVsf was impaired on all echo indices, including strain measurement, but LVsf was preserved. Conclusions Diseases causing CP are not restricted to the pericardium but also infiltrate the biventricular myocardium and affect the thin‐walled RV more than the thick‐walled LV, resulting in depressed RVsf. The present results help explain clinical heart failure in the presence of restricted diastolic filling in CP. Depression of RVsf due to progression of fibrosis in the RV myocardium may increase the risk of delayed pericardiectomy.
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Affiliation(s)
- Veena Raizada
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 2211 Lomas Blvd, Albuquerque, NM, 87131, USA
| | - Kimi Sato
- Department of Internal Medicine, Cardiology Division, University of Tsukuba, Tsukuba, Japan
| | - Alaa Alashi
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Arnav Kumar
- Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Deborah Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Jay Ramchand
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Amy Dillenbeck
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Ross E Zumwalt
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 2211 Lomas Blvd, Albuquerque, NM, 87131, USA
| | - Adarsh S Vangala
- Department of Internal Medicine, Arizona Health Sciences Center, Tucson, AZ, USA
| | - Tyler D Earley
- Department of Internal Medicine, Samaritan Health Services, Corvallis, OR, USA
| | - Allan Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
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