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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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2
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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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Abrantes JC, Turque F, Demier BF, Neves DG, Yahiro DS, Kubo TTA, Canale L, Mesquita CT. 3D Printing in Constrictive Pericarditis Assessment. Arq Bras Cardiol 2024; 121:e20220866. [PMID: 38597539 DOI: 10.36660/abc.20220866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/04/2023] [Indexed: 04/11/2024] Open
Affiliation(s)
| | - Fernanda Turque
- Universidade Federal Fluminense - Hospital Universitário Antônio Pedro, Niterói, RJ - Brasil
| | | | | | | | | | - Leonardo Canale
- Universidade Federal Fluminense - Hospital Universitário Antônio Pedro, Niterói, RJ - Brasil
| | - Claudio Tinoco Mesquita
- Universidade Federal Fluminense - Faculdade de Medicina - Departamento de Radiologia, Niterói, RJ - Brasil
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4
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Moros D, Zaki A, Tong MZY. Surgical Approaches for Pericardial Diseases: What Is New? Curr Cardiol Rep 2023; 25:1705-1713. [PMID: 37938424 DOI: 10.1007/s11886-023-01986-4] [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] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the evolving techniques and approaches for pericardiectomy, with a focus on the use of cardiopulmonary bypass (CPB) and the extent of radical pericardial resection. The review aims to highlight the benefits and considerations associated with these modifications in radical pericardiectomy. RECENT FINDINGS Recent studies have demonstrated that the use of CPB during pericardiectomy does not increase procedural risk or negatively impact survival. In fact, it has been shown to contribute to a more radical resection and improve postoperative outcomes, which is associated with less recurrence and better survival. The review emphasizes the importance of radical pericardiectomy and the use of CPB in achieving successful outcomes. Radical resection of the pericardium, facilitated by CPB, helps minimize the risk of recurrent constrictions and the need for reinterventions. The findings highlight the correlation between postoperative outcomes and survival, further supporting the use of CPB.
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Affiliation(s)
- David Moros
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Michael Zhen-Yu Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Oh NA, Hennecken C, Van den Eynde J, Doulamis IP, Avgerinos DV, Kampaktsis PN. Pericardiectomy and Pericardial Window for the Treatment of Pericardial Disease in the Contemporary Era. Curr Cardiol Rep 2022; 24:1619-1631. [PMID: 36029363 DOI: 10.1007/s11886-022-01773-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To summarize the contemporary practice of pericardiectomy and pericardial window. We discuss the indications, preoperative planning, procedural aspects, postprocedural management, and outcomes of each procedure. RECENT FINDINGS Surgical approaches for the treatment of pericardial disease have been around even before the emergence of cardiopulmonary bypass. Since the forthcoming of cardiopulmonary bypass, there have been significant changes in the epidemiology and diagnostic approach of pericardial diseases as well as advancements in the surgical techniques and perioperative management used in the care of these patients. Pericardiectomy has an average mortality of almost 7% and is typically performed in patients with advanced symptoms from constrictive pericarditis and relatively few comorbidities. Pericardial window is a safe procedure for the treatment of pericardial effusion that can be performed with different approaches.
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Affiliation(s)
- Nicholas A Oh
- Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carolyn Hennecken
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Irving Medical Center, 177 Fort Washington Av, New York, NY, 10032, USA
| | - Jef Van den Eynde
- The Johns Hopkins Hospital and School of Medicine, Helen B. Taussig Heart Center, Baltimore, MD, USA
- Department of Cardiovascular Sciences, KU Leuven, Louvain, Belgium
| | - Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dimitrios V Avgerinos
- Third Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Polydoros N Kampaktsis
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Irving Medical Center, 177 Fort Washington Av, New York, NY, 10032, USA.
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6
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Kumar S, Khubber S, Reyaldeen R, Agrawal A, Cremer PC, Imazio M, Kwon DH, Klein AL. Advances in Imaging and Targeted Therapies for Recurrent Pericarditis: A Review. JAMA Cardiol 2022; 7:975-985. [PMID: 35976625 DOI: 10.1001/jamacardio.2022.2584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Pericarditis is the most common form of pericardial disease. Recurrence of pericarditis affects 15% to 30% of patients after the initial episode of pericarditis. Up to 50% of patients with the first recurrence have additional recurrences. These patients often progress to have colchicine-resistant and corticosteroid-dependent disease. Rapidly evolving cardiac magnetic resonance imaging techniques and novel targeted therapies have paved the way for imaging-guided therapy for recurrent pericarditis. However, the optimal application of these recent advances remains unclear. Observations A search was conducted using the PubMed and Cochrane databases for English-language studies, management guidelines, meta-analyses, and review articles published until April 2022 on recurrent pericarditis. Following the 2015 European Society of Cardiology guidelines for the diagnosis and management of pericardial diseases, new clinical trials and registry data have emerged that demonstrate the efficacy of interleukin-1 blockers in recurrent pericarditis. In addition, new observational data have come to light supporting the use of cardiac magnetic resonance imaging in the diagnosis, risk stratification, and management of such patients. Conclusions and Relevance Advances in imaging and targeted therapies have led to a paradigm shift in the management of recurrent pericarditis. This narrative review summarizes the established and emerging data on the diagnosis and treatment of recurrent pericarditis with special emphasis on the role of cardiac magnetic resonance imaging and interleukin-1 blockers in the current era of tailored therapy for recurrent pericarditis.
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Affiliation(s)
- Sachin Kumar
- 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
| | - Shameer Khubber
- 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
| | - Reza Reyaldeen
- 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
| | - Ankit Agrawal
- 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
| | - Paul C Cremer
- 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
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital Santa Maria della Misericordia, Udine, Italy
| | - Deborah H 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, Cleveland, Ohio
| | - 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
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7
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Shao Y, Yang Z, Yin L, Wang Q, Wang J. The Clinical Efficacy of Cedilanid and Isosorbide Dinitrate plus Pericardial Dissection for Chronic Constrictive Pericarditis in the Elderly and Its Influence on Plasma Endothelin, Atrial Natriuretic Peptide, and Systemic Immune-Inflammation Index. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:5406649. [PMID: 35783532 PMCID: PMC9242774 DOI: 10.1155/2022/5406649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/13/2022] [Accepted: 05/27/2022] [Indexed: 12/03/2022]
Abstract
Objective To investigate the clinical efficacy of cedilanid and isosorbide dinitrate plus pericardial dissection for chronic constrictive pericarditis in the elderly. Methods Ninety elderly patients with chronic constrictive pericarditis admitted to our hospital from March 2018 to October 2020 were recruited and assigned to receive either cedilanid and isosorbide dinitrate (control group A), pericardial dissection (control group B), or cedilanid and isosorbide dinitrate plus pericardial dissection (combination group) via random number table method, with 30 patients in each group. Outcome measures included plasma endothelin, atrial natriuretic peptide, system immune-inflammation indices, treatment effect, quality of life, mental state, and treatment satisfaction. Results The combination group had significantly higher treatment satisfaction and treatment efficacy than control groups A and B (P > 0.05). The combination group showed the lowest levels of atrial natriuretic peptide and endothelin, followed by control group A, and group B (P < 0.001). The combined therapy resulted in significantly lower levels of system immunity index, lower Hospital Anxiety and Depression Scale (HAD) scores, and better General Quality of Life Inventory-74 (GQOLI-74) scores than those of the control group B, followed by group A (P < 0.001). Conclusion Cedilanid and isosorbide dinitrate plus pericardial dissection for elderly patients with chronic constrictive pericarditis enhances the level of plasma endothelin, atrial natriuretic peptide, and systemic immune-inflammation indexes of patients and improves their quality of life, which shows great potential for clinical promotion.
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Affiliation(s)
- Yan Shao
- Department of Cardiovascular Surgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Zhirong Yang
- Department of Cardiology, Qinghai Red Cross Hospital, Xining, Qinghai, China
| | - Lu Yin
- Department of Hyperbaric Oxygen, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Qiang Wang
- Department of Cardiovascular Surgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Jie Wang
- Department of Anesthesiology, Qinghai Provincial People's Hospital, Xining, Qinghai, China
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8
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Khan HMW, Munir A, Sud A, Moza A. Heart in a shell—a cascade of classical findings: a case report. Eur Heart J Case Rep 2022; 6:ytac231. [PMID: 35757583 PMCID: PMC9214780 DOI: 10.1093/ehjcr/ytac231] [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: 12/24/2021] [Revised: 01/18/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
Abstract
Background Idiopathic chronic constrictive pericarditis (CP) is an uncommon yet very important clinical entity as prompt diagnosis and early treatment are affiliated with improved outcomes. We describe an uncommon case of CP with a series of textbook findings and received successful treatment with surgical pericardiectomy (SP). Case summary A 58-year-old male presented to the emergency department with exertional dyspnoea and anasarca. The past medical history was negative for infections like tuberculosis, viral, etc., connective tissue disease, prior cardiac surgery, human immunodeficiency virus, or any radiation therapy. The vital signs were within normal limits except mild hypoxia while the physical examination was consistent with congestive heart failure. Further investigations with laboratory testing, imaging with chest X-ray, computed tomography, echocardiogram, and invasive study with right heart catheterization were all consistent with idiopathic chronic CP. The patient underwent successful SP with significant improvement in clinical condition. Discussion This case highlights the classical signs and symptoms along with important diagnostic features of CP. It is uncommon to see all the classical features of CP in one patient as described in the above case. Familiarity with these findings is crucial to make the diagnosis as early treatment is affiliated with improved outcomes.
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Affiliation(s)
| | - Ahmad Munir
- Department of Cardiovascular Disease, Michigan State University/McLaren , 48532 Flint, MI , USA
| | - Anup Sud
- Department of Cardiothoracic Surgery, Michigan State University/McLaren , 48532 Flint, MI , USA
| | - Ankush Moza
- Department of Cardiovascular Disease, Michigan State University/McLaren , 48532 Flint, MI , USA
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9
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Lak HM, Anthony CM, Furqan MM, Verma BR, Gad M, Chawla S, Yasmin F, Kwon DH, Johnston DR, Klein AL. Refractory Recurrent Pericarditis After Pericardiectomy in a Young Woman. JACC Case Rep 2021; 3:1877-1882. [PMID: 34917971 PMCID: PMC8642733 DOI: 10.1016/j.jaccas.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/21/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022]
Abstract
Pericardiectomy is the recommended treatment for patients with recurrent pericarditis and refractory symptoms despite optimal anti-inflammatory therapy. We present a case of a 40-year-old woman who underwent total pericardiectomy after multiple episodes of pericarditis that was refractory to optimal guideline-derived medical therapy, including anti-inflammatory and biologic agents, who continued to have relapsing symptoms even after pericardiectomy. (Level of Difficulty: Intermediate.)
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Affiliation(s)
| | - Chris M Anthony
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Muhammad M Furqan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Beni Rai Verma
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Gad
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sanchit Chawla
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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10
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Tabucanon RS, Wang TKM, Chetrit M, Furqan MM, Chan N, Pande A, Jellis CL, Cremer PC, Kwon DH, Johnston D, Klein AL. Worsened Tricuspid Regurgitation Following Pericardiectomy for Constrictive Pericarditis. Circ Cardiovasc Imaging 2021; 14:e012948. [PMID: 34607446 DOI: 10.1161/circimaging.121.012948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Worsening tricuspid regurgitation (TR) severity may occur after pericardiectomy surgery for constrictive pericarditis patients; however, its mechanisms and predictors are not well established. We evaluated the clinical characteristics, associated factors, and outcomes of worsening TR after pericardiectomy. METHODS Consecutive patients undergoing pericardiectomy for constrictive pericarditis without tricuspid valve surgery and with pre- and postoperative echocardiography available during 2000 to 2017 were retrospectively studied. Clinical, imaging, hemodynamic, and mortality characteristics were analyzed by those with and without worsening TR by at least one grade. RESULTS Among 381 patients (age 61 [17] years, 318 [83.5%] male), 193 (50.7%) had worsening TR post-operatively, and 75 died during the 2.5 (5.4) years follow-up. In univariable analysis, worsening TR was associated with a history of congestive heart failure (47.2% versus 31.9%, P=0.003), increased left atrial volume indexed (23 versus 20 mL/m2, P=0.020), reduced right ventricular fractional area change (47% versus 54%, P<0.001), and worsening mitral regurgitation (39.7% versus 16.6%, P<0.001). Worsened TR had a trend toward reduced survival during follow-up (log-rank P=0.080), especially those with worsened TR but no recovery of TR grade on subsequent echocardiography within the first year compared with those without worsened TR (log-rank P=0.02). In multivariable analysis, right ventricular fractional area change, left atrial volume indexed, left ventricular mass indexed, pulmonary artery systolic pressure, and right atrial pressure/pulmonary capillary wedge pressure ratio were most associated with worsened TR, while blood urea nitrogen, hematocrit, lateral and medial e' tissue Doppler and heart rate were most associated with mortality during follow-up. CONCLUSIONS Worsening TR severity was prevalent after pericardiectomy and had a trend toward reduced survival, especially if TR severity did not recover on subsequent echocardiography. Presence of parameters associated with worsened TR and reduced survival should alert clinicians to carefully manage these patients during follow-up.
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Affiliation(s)
- Ray S Tabucanon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Michael Chetrit
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Muhammad M Furqan
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Nicholas Chan
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Amol Pande
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Christine L Jellis
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Paul C Cremer
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Douglas Johnston
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
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11
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Tzani A, Doulamis IP, Tzoumas A, Avgerinos DV, Koudoumas D, Siasos G, Vavuranakis M, Klein A, Kampaktsis PN. Meta-Analysis of Population Characteristics and Outcomes of Patients Undergoing Pericardiectomy for Constrictive Pericarditis. Am J Cardiol 2021; 146:120-127. [PMID: 33539860 DOI: 10.1016/j.amjcard.2021.01.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 01/05/2023]
Abstract
We sought to systematically describe the epidemiology, etiology, clinical and operative characteristics as well as outcomes of patients who underwent pericardiectomy for constrictive pericarditis in the contemporary era. We conducted a systematic search of the MEDLINE, Embase, and Cochrane databases from their inception to April 1, 2020 for studies assessing the outcomes of pericardiectomy in patients with constrictive pericarditis. Studies with patients enrolled before 1985, pediatric patients or studies including >10% tuberculous pericarditis were excluded. The impact of pericarditis etiology on outcomes was evaluated with a meta-analysis. We analyzed 27 eligible studies and 2,114 patients. Etiology was most commonly idiopathic (50.2%), followed by after-cardiac surgery (26.2%) and radiation (6.9%). Patients were mostly men (76%), mean age 58 and with advanced symptoms (NYHA III/IV 70.1%). Total pericardiectomy was preferred (85.8%) and concomitant cardiac surgery was relatively common (23.8%). Operative mortality was 6.9% and 5-year mortality was 32.7%. Radiation and after-cardiac surgery patients had 3 and 2 times higher long-term risk for mortality respectively compared with idiopathic. A sensitivity analysis did not result in changes in the results. Thirty percent of included studies had more than low bias primarily originating from follow up and selection. Pericardiectomy is therefore performed mostly in middle-aged men with advanced symptoms and low co-morbidity burden and still caries significant operative mortality. Radiation and after-cardiac surgery patients have a significantly higher mortality risk compared with idiopathic. Several methodological issues and significant heterogeneity limit the generalization of these data and randomized controlled trials may have to be considered.
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Affiliation(s)
- Aspasia Tzani
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andreas Tzoumas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Dimitrios Koudoumas
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah, Salt lake city, Utah
| | - Gerasimos Siasos
- 1st Cardiology Clinic, National and Kapodistrian University of Athens Medical School, Greece
| | - Manolis Vavuranakis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens Medical School, Greece
| | - Allan Klein
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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12
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Liu VC, Fritz AV, Burtoft MA, Martin AK, Greason KL, Ramakrishna H. Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 35:3797-3805. [PMID: 33722460 DOI: 10.1053/j.jvca.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/17/2023]
Abstract
Constrictive pericarditis is caused by pericardial inflammation and fibrosis, leading to diastolic heart failure. The diagnosis requires a high index of suspicion because it often can mimic restrictive myocardial disease and cardiac tamponade and can be associated with severe tricuspid regurgitation and chronic liver disease. Patients who remain undiagnosed can experience a 90% mortality rate, and for those who undergo pericardiectomy, the survival rate varies significantly, depending on the underlying etiology and preoperative functional class of the patient. In this article, the authors review the pathophysiology, echocardiographic findings, management, and surgical outcomes of constrictive pericarditis to aid the cardiothoracic anesthesiologist in the perioperative management of this disorder.
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Affiliation(s)
- Victor C Liu
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ashley V Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Melissa A Burtoft
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer K Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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13
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Chetrit M, Natalie Szpakowski N, Desai MY. Multimodality imaging for the diagnosis and treatment of constrictive pericarditis. Expert Rev Cardiovasc Ther 2019; 17:663-672. [DOI: 10.1080/14779072.2019.1657832] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Michael Chetrit
- Department of Cardiovascular Medicine, Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Natalie Natalie Szpakowski
- Department of Cardiovascular Medicine, Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Milind Y. Desai
- Department of Cardiovascular Medicine, Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
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14
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