Surgery for pericardial disease

Pericardiectomy for constrictive pericarditis at a single Japanese center: 20 years of experience

OBJECTIVE

Constrictive pericarditis (CP) is a rare disease, and the diagnosis and surgical treatment of CP remain challenging. The aim of this study was to evaluate our Japanese single-center experience with isolated pericardiectomy for CP to elucidate the factors associated with improved outcomes.

METHODS

Over a 20-year period, 44 consecutive patients underwent isolated pericardiectomy at our institution. The cause of CP was: idiopathic (59%), postsurgical (32%), tuberculosis (7%), and postradiation (2%) of the patients. All patients were diagnosed with CP using multiple modalities, including echocardiography, cardiac catheterization, computed tomography, or magnetic resonance imaging (MRI). Median sternotomy was performed in 42 (95%) patients. Twenty-eight (68%) patients underwent radical pericardiectomy.

RESULTS

The postoperative diagnosis in all patients was CP. Among the multiple modalities, cardiac MRI had the greatest diagnostic sensitivity (97.2%). There were no operative or hospital deaths; late mortality occurred in seven (15.9%) patients in the series. Multivariable analysis showed that preoperative low LVEF was a risk factor for long-term mortality. Seven patients were readmitted for heart failure postoperatively. Multivariable analysis showed incomplete pericardiectomy and use of a preoperative inotrope were risk factors for readmission for heart failure.

CONCLUSIONS

The diagnosis using multimodality imaging for CP was effective in our institution and tagged cine MRI had the greatest sensitivity in diagnosing CP. Preoperative condition, including preoperative low LVEF or inotrope use, was correlated with long-term outcome after pericardiectomy. Pericardiectomy should be performed early and as radically as possible to prevent recurrent heart failure.

Effusive-constrictive pericarditis in the spectrum of pericardial compressive syndromes

When pericardial fluid accumulates and exceed the reserve volume of the pericardium or when the pericardium becomes scarred and inelastic, one of three pericardial compressive syndromes may ensue, namely, cardiac tamponade (CT), characterised by the accumulation of pericardial fluid under pressure; constrictive pericarditis (CP), the result of scarring and loss of the normal elasticity of the pericardial sac; and effusive-constrictive pericarditis (ECP), characterised by the concurrence of a tense pericardial effusion and constriction of the heart by the visceral pericardium. Although relatively uncommon, prevalence estimates vary widely and depend on the nature of the cohorts studied, the methods used to diagnose ECP and the manner in which ECP is defined. Most cases of ECP are idiopathic, reflecting the frequency of idiopathic pericardial disease in general, and other causes include radiation, malignancy, chemotherapy, infection and postsurgical/iatrogenic pericardial disease. The diagnosis of ECP often becomes apparent when pericardiocentesis fails to decrease the right atrial pressure by 50% or to a level below 10 mm Hg. Important non-invasive diagnostic modalities include echocardiography, cardiac magnetic resonance and, to a lesser extent, cardiac CT. In cases with clear evidence of pericardial inflammation, a trial of an anti-inflammatory regimen is warranted. A complete pericardiectomy should be reserved for refractory symptoms or clinical evidence of chronic CP.

A rare case of constrictive pericarditis as initial manifestation of paediatric anaplastic large cell lymphoma requiring urgent pericardiectomy

Constrictive pericarditis (CP) is a rare end stage inflammatory disorder affecting both parietal and visceral pericardium leading to a right heart failure. Malignancy is the least common cause of CP. Anaplastic large cell lymphoma (ALCL) accounts for 10-15% of all Non-Hodgkin lymphomas in children. Very few case reports have reported ALCL that is involving the heart and only two have been published involving pericardium but all were managed medically. We present an interesting case of an 11 year old child who presented with an effusive CP that required urgent Pericardiectomy for managing right heart failure. His histopathology was positive for ALK + ALCL.

Technologies for intrapericardial delivery of therapeutics and cells

The pericardium, which surrounds the heart, provides a unique enclosed volume and a site for the delivery of agents to the heart and coronary arteries. While strategies for targeting the delivery of therapeutics to the heart are lacking, various technologies and nanodelivery approaches are emerging as promising methods for site specific delivery to increase therapeutic myocardial retention, efficacy, and bioactivity, while decreasing undesired systemic effects. Here, we provide a literature review of various approaches for intrapericardial delivery of agents. Emphasis is given to sustained delivery approaches (pumps and catheters) and localized release (patches, drug eluting stents, and support devices and meshes). Further, minimally invasive access techniques, pericardial access devices, pericardial washout and fluid analysis, as well as therapeutic and cell delivery vehicles are presented. Finally, several promising new therapeutic targets to treat heart diseases are highlighted.

Long-term results of radical pericardiectomy for constrictive pericarditis in Korean population

Background

The extent of pericardiectomy is an important issue in constrictive pericarditis but its impact on long-term outcomes has been rarely reported. We compared long-term results of radical pericardiectomy with conventional phrenic to phrenic pericardiectomy.

Methods

Ninety patients who underwent pericardiectomies between February 1995 and April 2015 were reviewed retrospectively. They were classified into conventional (n = 37) and radical (n = 53) groups according to pericardiectomy being performed anterior or posterior to the phrenic nerves, respectively. The follow-up duration at outpatient clinic was 37.6 (11.7, 86.6) months and the survival data until 91.6 (54.5, 147.0) months were obtained. The last echocardiographies were done at 22.4 (4.35, 60.85) months.

Results

The early mortality rate was 4.4% (4/90). They all belonged to the conventional group and died of low cardiac output syndrome. The survival rate was higher in the radical group (P = .032, 74.7 ± 9.2% versus 50.4 ± 11.9% in 20 years). NYHA class of both groups had recovered until the last follow-up but the radical group showed better recovery (P < .001). The conventional pericardiectomy (HR = 6.181; 95% CI (1.042, 36.656)), redosternotomy (HR = 6.441; 95% CI (1.224, 33.889) and preoperative grade of tricuspid regurgitation (HR = 15.003; 95% CI (1.099, 204.894) were associated with late mortality. Right ventricular systolic pressure decreased, and pericardial thickening resolved only in the radical group with significant intergroup differences as time went on. Tricuspid regurgitation worsened after the operation in both groups, but it deteriorated more in the conventional group. However, it improved over time in the radical group.

Conclusions

Radical pericardiectomy led to greater improvement in right ventricular systolic pressure and lesser deterioration of tricuspid regurgitation with the passage of time than did the conventional procedure. Conventional pericardiectomy and preoperative higher grade tricuspid regurgitation were associated with long-term mortality.

Electronic supplementary material

The online version of this article (10.1186/s13019-019-0845-7) contains supplementary material, which is available to authorized users.

Effusive-Constrictive Pericarditis

Effusive-constrictive pericarditis (ECP) corresponds to the coexistence of a hemodynamically significant pericardial effusion and decreased pericardial compliance. The hallmark of ECP is the persistence of elevated right atrial pressure postpericardiocentesis. The prevalence of ECP seems higher in tuberculous pericarditis and lower in idiopathic cases. The diagnosis of ECP is traditionally based on invasive hemodynamics but the presence of echocardiographic features of constrictive pericarditis post-pericardiocentesisis can also identify ECP. Data on the prognosis and optimal treatment of ECP are still limited. Anti-inflammatory agents should be the first line of treatment. Pericardiectomy should be reserved for refractory cases.

Experience With Pericardiectomy for Constrictive Pericarditis Over Eight Decades

BACKGROUND

The purpose of this study was to review the surgical outcomes of pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period.

METHODS

We reviewed all patients who underwent pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990-2013) group (n = 807).

RESULTS

Patients in the contemporary group were older (61 versus 49 years; p < 0.001), more symptomatic (NYHA class III or IV in 79.6% versus 71.2%; p < 0.001), and more frequently underwent concomitant procedures (21.4% versus 5.4%; p < 0.001) compared with those in the historical group. In contrast to the historical cases in which the etiologies of constriction were mostly idiopathic (81.1%), nearly half of contemporary cases had a nonidiopathic etiology (postoperative 32.3%, radiation 11.4%). Although 30-day mortality decreased from 13.5% in the historical era to 5.2% in the contemporary era (p < 0.001), overall survival was similar after adjusting for patient characteristics. Risk factors of overall mortality in the contemporary group included NYHA class III or IV (HR 2.17, p < 0.001), etiology of radiation (HR 3.93, p < 0.001) or postcardiac surgery (HR 1.47, p < 0.001), and need for cardiopulmonary bypass (HR 1.35, p = 0.014).

CONCLUSIONS

There was a significant change in disease etiology over the study period. Long-term survival after pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

Surgical Management of Pericardial Diseases

Disease of the pericardium represents a relatively rare indication for cardiac surgery, and there exist no widely accepted guidelines for surgical management. As such, the surgical approach to the pericardium has relied largely on institutional experience with a slow evolution based on published studies. In particular, management of pericardial constriction has varied widely from surgeon to surgeon and institution to institution, in large part due to a perception of inherent high risk to the procedure. This review covers the current practice of surgery for disease of the pericardium, with particular focus on the evolution of indications for pericardiectomy, new applications in inflammatory or relapsing pericarditis, and the progressive refinement in surgical technique and operative planning which have led to significantly improved outcomes in experienced centers.

Robotic Endoscopic Off-Pump Total Pericardiectomy in Constrictive Pericarditis

Objective

Although rare, constrictive pericarditis is a serious condition with debilitating symptoms and often severe heart failure. Total pericardiectomy is the most effective treatment and is traditionally performed via median sternotomy. With the increasing use of minimally invasive techniques, there have been reports of partial pericardiectomy via thoracoscopy but with suboptimal exposure and difficulty identifying both phrenic nerves. Robotic surgery offers both small incisions and enhanced visualization. We present four cases of robotic endoscopic off-pump total pericardiectomy for constrictive pericarditis.

Methods

Four patients underwent off-pump total pericardiectomy with robotic assistance for constrictive pericarditis. All had constrictive physiology demonstrated by right heart catheterization and/or echo-cardiogram. One was also found to have coronary artery disease and underwent concurrent totally endoscopic coronary artery bypass grafting left internal mammary artery to left anterior descending artery. Ports were placed in the left second, fourth, and sixth intercostal spaces. The left lung was isolated and deflated with CO2 insufflation, aiding in exposure. With the use of electrocautery, the pericardium was removed first posterior to the left phrenic nerve, then anteriorly all the way to the right phrenic nerve, and caudally from the diaphragmatic reflection to the great vessel cephalad. A stabilizer in the subcostal fourth robotic arm was used to assist in the dissection.

Results

Two of four patients were extubated within 6 hours after surgery and transferred to the floor on postoperative day 1. Both were discharged home by postoperative day 5. Two of four patients had preoperative sequelae from chronic constriction and necessitated longer hospital and intensive care unit stays but had improvement in symptoms and were discharged home within 3 weeks.

Conclusions

Total pericardiectomy for constrictive pericarditis can be performed using a robotic approach. In contrast to thoracoscopy, it offers better visualization of both phrenic nerves, avoids injury, and allows a thorough pericardial dissection. In our experience, the robotic left chest approach has proven more efficacious in removing the posterior pericardium than is allowed with median sternotomy.

Atrial flutter ablation in a case of diuretic resistant constrictive pericarditis

We present a 66 year old gentleman with constrictive pericarditis and persistent atrial flutter. Initial management with oral loop diuretics was successful until he developed persistent atrial flutter. Once in atrial flutter the patient developed progressive signs of right heart failure resistant to high dose intravenous loop diuretics. He was referred to a tertiary electrophysiology service where he underwent successful isthmus catheter ablation and reverted to sinus rhythm. His responsiveness to diuretics improved immediately. His symptoms improved and he was discharged 48 h later on oral diuretics. He remains well one month after discharge. This is the first reported case of symptomatic improvement in a patient with constrictive pericarditis and persistent atrial flutter with targeted treatment of the dysrhythmia. This offers a possible short-term palliation option in a group of patients where definitive surgical management carries too high a risk.

[Diagnostics and therapy of pericarditis and pericardial effusion]

This article describes the diagnostics, differential diagnostics, multimodal imaging, medicinal and invasive diagnostic therapy of acute and chronic pericarditis, constrictive pericarditis, pericardial effusion and cardiac tamponade under etiological aspects and on the basis of the guidelines of the European Society of Cardiology (ESC). The starting point of the decision tree is the symptomatic patient with echocardiographic evidence of pericardial effusion. The principle feature of the diagnostics is the etiopathogenetic allocation of the pericardial disease which influences the clinical picture, course therapy and prognosis. Infectious pericarditis (e.g. viral, bacterial and tuberculous) is differentiated from sterile autoreactive pericarditis and from neoplastic pericardial effusion by the cytology of the effusion and immunohistological and molecular investigations of the pericardial and epicardial biopsies. Pericardioscopy plays an important role in the recognition of suspicious areas. In many cases intrapericardial administration of cisplatin for neoplastic pericardial effusion and instillation of triamcinolone for autoreactive pericarditis prevent recurrence just as a treatment of several months with colchicine.

Constrictive pericarditis--a curable diastolic heart failure

Constrictive pericarditis can result from a stiff pericardium that prevents satisfactory diastolic filling. The distinction between constrictive pericarditis and other causes of heart failure, such as restrictive cardiomyopathy, is important because pericardiectomy can cure constrictive pericarditis. Diagnosis of constrictive pericarditis is based on characteristic haemodynamic and anatomical features determined using echocardiography, cardiac catheterization, cardiac MRI, and CT. The Mayo Clinic echocardiography and cardiac catheterization haemodynamic diagnostic criteria for constrictive pericarditis are based on the unique features of ventricular interdependence and dissociation of intrathoracic and intracardiac pressures seen when the pericardium is constricted. A complete pericardiectomy can restore satisfactory diastolic filling by removing the constrictive pericardium in patients with constrictive pericarditis. However, if inflammation of the pericardium is the predominant constrictive mechanism, anti-inflammatory therapy might alleviate this transient condition without a need for surgery. Early diagnosis of constrictive pericarditis is, therefore, of paramount clinical importance. An improved understanding of how constrictive pericarditis develops after an initiating event is critical to prevent this diastolic heart failure. In this Review, we discuss the aetiology, pathophysiology, and diagnosis of constrictive pericarditis, with a specific emphasis on how to differentiate this disease from conditions with similar clinical presentations.

Immortalization protocols used in cell culture models of human breast morphogenesis

Defining the key players in normal breast differentiation is instrumental to understanding how morphogenesis becomes defective during breast cancer progression. During the past 2 decades much effort has been devoted to the development of technologies for purification and expansion of primary human breast cells in culture and optimizing a relevant microenvironment, which may help to define the niche that regulates breast differentiation and morphogenesis. In contrast to the general property of cancer, normal human cells have a finite lifespan. After a defined number of population doublings, normal cells enter an irreversible proliferation-arrested state referred to as replicative senescence. To overcome this obstacle for continuous long-term studies, replicative senescence can be bypassed by treatment of cells with chemical agents such as benzopyrene, by radiation or by transfection with viral oncogenes or the gene for human telomerase (human telomerase reverse transcriptase, hTERT). A drawback of some of these protocols is a concurrent introduction of chromosomal changes, which sometimes leads to a transformed phenotype and selection of a subpopulation, which may not be representative of the tissue of origin. In recent years, we have sought to establish immortalized primary breast cells, which retain crucial characteristics of their original in situ tissue pattern. This review discusses various approaches to immortalization of breast-derived epithelial and stromal cells and the application of such cell lines for studies on human breast morphogenesis.