Long-Term Effects of Pericardiectomy on Left Ventricular Mechanics Evaluated by Using Speckle Tracking Echocardiography in Patients with Constrictive Pericarditis

Pericardiectomy and Pericardial Window for the Treatment of Pericardial Disease in the Contemporary Era

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.

Evaluation of Long-Term Impact of Pericardiectomy on Left Atrial Functions in Patients with Constrictive Pericarditis Using Speckle Tracking Echocardiography

The aims of this study were to explore the long-term impact of pericardiectomy on left atrial (LA) functions in patients with constrictive pericarditis (CP) using speckle tracking echocardiography (STE) and to correlate post-operative LA functions with clinical status. Echocardiographic examinations were undertaken in 29 patients with CP 1 wk before and 1, 6 and 12 mo after pericardiectomy. STE was performed to obtain LA global longitudinal strain, including strain during the conduit phase (LAScd), strain during the contraction phase (LASct) the sum of the latter and strain during the reservoir phase (LASr). Control patients consisted of 29 age- and sex-matched healthy volunteers. LASct, LAScd and LASr obtained 6 mo after pericardiectomy improved significantly compared with pre-operative values, but were still lower than the values for control patients. Further increases were observed gradually with normalization of LASct 12 mo after pericardiectomy. However, there were still significant differences between LAScd and LASr obtained in control patients and those obtained 12 mo after pericardiectomy. Moreover, the improvements in LAScd, LASct and LASr 12 mo after pericardiectomy correlated well with symptomatic clinical alleviation (p < 0.01). These results indicate that LA strains analyzed with STE might be useful in evaluating the long-term impact of pericardiectomy on LA functions.

Left ventricular strain is associated with acute postoperative refractory hypotension in patients with constrictive pericarditis and preserved ejection fraction

Background

Pericardiectomy is an effective treatment for constrictive pericarditis (CP). Early postoperative complications such as refractory hypotension and congestive heart failure occur in these patients and are associated with increased morbidity and mortality. We hypothesized that left ventricular (LV) myocardial strain measured by two-dimensional speckle tracking echocardiography (2DSTE) could identify early cardiac dysfunction and relate to acute postoperative adverse events in CP patients.

Methods

Forty-four CP patients with preserved left ventricular ejection fraction (LVpEF, 64%±8%) and 44 age- and sex-matched controls were enrolled. Conventional 2DSTE was performed before pericardiectomy. Global and segmental peak systolic strain values were measured. The primary endpoint was a composite of postoperative refractory hypotension, congestive heart failure and cardiogenic death. Refractory hypotension was defined as hypotension requiring prolonged usage of intravenous inotropic medication (IVIM) (≥2 days).

Results

Postoperative refractory hypotension occurred in 26 cases, and no patients experienced congestive heart failure or cardiogenic death. Compared to controls, CP patients had decreased absolute global and segmental circumferential strain (CS), radial strain (RS), and longitudinal strain (LS) except septal LS. Patients with refractory hypotension exhibited lower epicardial CS (P=0.04). Epicardial CS was an independent risk factor correlated with postoperative adverse outcome [P=0.014, OR =1.236 (1.044-1.464)] while LVEF was not. Lower absolute value of epicardial CS was related to higher (P=0.02) and longer usage of intravenous furosemide (P=0.04) to keep negative fluid balance perioperatively.

Conclusions

LV strain value is markedly reduced in patients with CP and LVpEF. Lower preoperative epicardial CS value is associated with greater risk of early refractory hypotension and more aggressive fluid management.