Successful surgical management for severe mitral regurgitation unmasked after pericardiectomy for chronic constrictive pericarditis

Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review

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.

Outcomes and Risk Factors Associated with Pericardiectomy in Patients with Constrictive Pericarditis: A Retrospective Study from China

PURPOSE

Pericardiectomy is the definitive treatment option for constrictive pericarditis and is associated with a high prevalence of morbidity and mortality. However, information on the associated outcomes and risk factors is limited. We aimed to report the mid-term outcomes of pericardiectomy from a single center in China.

METHODS

We retrospectively reviewed data collected from patients who underwent pericardiectomy at our institute from April 2018 to January 2023.

RESULTS

Eighty-six consecutive patients (average age, 46.1 ± 14.7 years; 68.6 men) underwent pericardiectomy through midline sternotomy. The most common etiology was idiopathic (n = 60, 69.8%), and 82 patients (95.3%) were in the New York Heart Association function class III/IV. In all, 32 (37.2%) patients underwent redo sternotomies, 36 (41.9%) underwent a concomitant procedure, and 39 (45.3%) required cardiopulmonary bypass. The 30-day mortality rate was 5.8%, and the 1-year and 5-year survival rates were 88.3% and 83.5%, respectively. Multivariable analysis revealed that preoperative mitral insufficiency (MI) ≥moderate (hazard ratio [HR], 6.435; 95% confidence interval [CI] [1.655-25.009]; p = 0.007) and partial pericardiectomy (HR, 11.410; 95% CI [3.052-42.663]; p = 0.000) were associated with increased 5-year mortality.

CONCLUSION

Pericardiectomy remains a safe operation for constrictive pericarditis with optimal mid-term outcomes.

Unmasking of severe mitral regurgitation after pericardiectomy

Mitral valve prolapse in the young is the most common cause of mitral regurgitation (MR). Constrictive pericarditis (CP) is a chronic and end-stage manifestation of the inflammatory process of the pericardium. Apart from equalization of diastolic pressure of the chambers as well as increased ventricular interdependence, the thickened pericardial sheath in end-stage pericarditis fails to accommodate the intrathoracic venous return due to restricted cardiac chamber filling. Intracardiac valvular pathologies might co-exist in CP. This report presents a case in which effusive CP was associated with MR and highlights the pivotal role of intraoperative transesophageal echocardiography (TEE) in the decision-making of such co-existent lesions.

Mitral Valve Repair for Severe Mitral Regurgitation Masked by Constrictive Pericarditis Revealed After Pericardiectomy

A case of severe mitral regurgitation (MR) that was masked by constrictive pericarditis and revealed after pericardiectomy is presented. Diagnosis was made intraoperatively with transesophageal echocardiography. Mitral valve repair was performed using a mitral annuloplasty ring. In some cases, worsening MR after pericardiectomy has been demonstrated to return to baseline with time. In the patient described, MR was severe with secondary ischemic pathology; therefore the decision was made to repair the mitral valve. Intraoperative transesophageal echocardiography played a major role in the decision making.

Inflammation in diabetic kidney disease

Diabetes mellitus entails significant health problems worldwide. The pathogenesis of diabetes is multifactorial, resulting from interactions of both genetic and environmental factors that trigger a complex network of pathophysiological events, with metabolic and hemodynamic alterations. In this context, inflammation has emerged as a key pathophysiology mechanism. New pathogenic pathways will provide targets for prevention or future treatments. This review will focus on the implications of inflammation in diabetes mellitus, with special attention to inflammatory cytokines.

Surgery for pericardial disease

The pericardium is an important structure, and there are many diseases that affect the pericardium and the heart. Often, surgery is required for drainage or removal of the pericardium, but techniques are not standardized, and there is controversy, especially with regard to treatment of constrictive pericarditis. This paper reviews surgical methods for the treatment of inflammatory and constrictive pericarditis and presents early and late outcome of operation.