Constrictive pericarditis: diagnosis, management and clinical outcomes

Updates on the Global Prevalence and Etiology of Constrictive Pericarditis: A Systematic Review

Constrictive pericarditis is a rare disease with poorly understood epidemiology. A systematic literature search was adopted to assess the region- and period-specific traits of constrictive pericarditis through Pubmed, EMBASE, and Scopus. Case reports and studies including less than 20 patients were excluded. The risk of bias was assessed through the Study Quality Assessment Tools developed by the National Heart Lung Blood Institute by 4 reviewers. Patient demographics, disease etiology, and mortality were the primary assessed outcomes. One hundred thirty studies with 11,325 patients have been included in this systematic review and meta-analysis. The age at diagnosis of constrictive pericarditis has markedly increased after 1990. Patients from Africa and Asia are considerably younger compared with those from Europe and North America. Moreover, there are differences in etiology, as tuberculosis remains the dominant cause of constrictive pericarditis in Africa and Asia but has been surpassed by history of previous chest surgery in North America and Europe. The human immunodeficiency virus affects 29.1% of patients from Africa diagnosed with constrictive pericarditis, a feature that is not observed on any other continent. The early mortality rate after hospitalization has improved. The variances of age at diagnosis and etiology of constrictive pericarditis should be considered by the clinician during the work-up of cardiac and pericardial diseases. An underlying human immunodeficiency virus infection complicates a significant portion of constrictive pericarditis cases in Africa. Early mortality has improved across the world but remains high.

Perioperative management of constrictive pericarditis with cardiac cirrhosis: A case report

INTRODUCTION

The interactions between the heart and liver have been known for a long time, pericarditis constrictive could cause congestive hepatopathy via right-sided heart failure. Liver cirrhosis correlates with a high risk of mortality so perioperative management greatly influences outcomes.

CASE PRESENTATION

An Indonesian man, 50 years old, complained of breath shortness. The patient had a history of pulmonary tuberculosis and was declared cured 30 years ago. The patient began experiencing fatigue 14 years ago, and the patient was diagnosed with constrictive pericarditis 5 years ago. Currently, the patient has an increased jugular venous pressure of 9 cmH2O and abnormal laboratory indicators, including a platelet count of 121,000/μL, albumin count of 3.41 g/L, direct bilirubin count of 0.7 mg/dL, total bilirubin count of 1.4 mg/dL, and INR of 1.4. Echocardiography revealed left ventricle hypertrophy, diastolic dysfunction, and right ventricle failure. Cardiac CT scan showed pericardial calcification. Abdominal ultrasound showed liver congestive and splenomegaly. Transient elastography showed severe fibrosis in liver and stiffness in spleen. The patient underwent pericardiectomy with CTP score of 6 and MELD of 12. The surgery was successful, and the complaint was reduced. The patient experienced an improvement in his condition and able to carry out activities well after 2 years post-surgery.

DISCUSSION

The patient has no contraindications to pericardiectomy, CTP class A (5-6) and MELD score <13.5 has a low risk of mortality.

CONCLUSION

CTP and MELD scores predict life expectancy in post-surgery cardiac cirrhosis patients.

Erdheim-Chester Disease presenting with constrictive pericarditis: A case report and review of the literature

Erdheim-Chester Disease (ECD) is a rare form of histiocytosis characterized by xanthomatous infiltration of affected organs. We present a case of a 62-year-old man with ECD initially presenting with constrictive pericarditis. Comprehensive imaging revealed systemic involvement, including the skeleton, orbit, pituitary, lung, kidney, and retroperitoneum, despite the absence of related symptoms. The diagnosis of ECD was eventually confirmed through histopathological evidence from a CT-guided biopsy. The patient responded well to interferon-α2b treatment, with gradual symptom amelioration and improvement in imaging and laboratory findings over a 5-month follow-up period. This case highlights the importance of considering ECD in the differential diagnosis of constrictive pericarditis and the utility of multimodal imaging for accurate diagnosis and management of this rare disease. The patient's positive response to treatment also highlights the potential for effective management of ECD, particularly with early diagnosis and intervention.

The Important Role of Preoperative D-Dimer in Constrictive Pericarditis

Background

The impact of coagulation indicators on postoperative outcomes of patients with constrictive pericarditis undergoing pericardiectomy has been poorly investigated. This study aimed to assess the prognostic role of preoperative coagulation indicators in these patients.

Methods

We retrospectively included 158 patients with constrictive pericarditis undergoing pericardiectomy. The diagnostic values of coagulation indicators for postoperative complications were evaluated by ROC curves. Patients were divided into two groups according to the cutoff value calculated by ROC curve. Postoperative outcomes were compared between the two groups. Logistic regression analysis was performed to identify risk factors of postoperative complications.

Results

ROC curve showed that among different coagulation indicators, preoperative D-dimer (DD) level could effectively identify patients with postoperative complications (AUC 0.771, 95% CI 0.696-0.847, P < 0.001). Patients were divided into the low DD group and the high DD group. The comparison of postoperative outcomes suggested that high preoperative DD level was significantly associated with longer durations of vasoactive agents using (P = 0.018), intubation (P = 0.020), ICU stay (P = 0.008), chest drainage (P=0.004) and hospital stay (P = 0.002). Multivariable analysis showed that high preoperative DD level was the independent risk factor of postoperative complications (OR 6.892, 95% CI 2.604-18.235, P < 0.001).

Conclusion

High preoperative DD level was significantly linked to poor postoperative outcomes and could provide an effective prediction ability for postoperative complications in patients with constrictive pericarditis.

Echocardiography-Based Deep Learning Model to Differentiate Constrictive Pericarditis and Restrictive Cardiomyopathy

BACKGROUND

Constrictive pericarditis (CP) is an uncommon but reversible cause of diastolic heart failure if appropriately identified and treated. However, its diagnosis remains a challenge for clinicians. Artificial intelligence may enhance the identification of CP.

OBJECTIVES

The authors proposed a deep learning approach based on transthoracic echocardiography to differentiate CP from restrictive cardiomyopathy.

METHODS

Patients with a confirmed diagnosis of CP and cardiac amyloidosis (CA) (as the representative disease of restrictive cardiomyopathy) at Mayo Clinic Rochester from January 2003 to December 2021 were identified to extract baseline demographics. The apical 4-chamber view from transthoracic echocardiography studies was used as input data. The patients were split into a 60:20:20 ratio for training, validation, and held-out test sets of the ResNet50 deep learning model. The model performance (differentiating CP and CA) was evaluated in the test set with the area under the curve. GradCAM was used for model interpretation.

RESULTS

A total of 381 patients were identified, including 184 (48.3%) CP, and 197 (51.7%) CA cases. The mean age was 68.7 ± 11.4 years, and 72.8% were male. ResNet50 had a performance with an area under the curve of 0.97 to differentiate the 2-class classification task (CP vs CA). The GradCAM heatmap showed activation around the ventricular septal area.

CONCLUSIONS

With a standard apical 4-chamber view, our artificial intelligence model provides a platform to facilitate the detection of CP, allowing for improved workflow efficiency and prompt referral for more advanced evaluation and intervention of CP.

Surgical treatment of constrictive pericarditis at a single center: 10 years of experience

BACKGROUND

Constrictive pericarditis (CP) is a pericardial disease characterized by the pericardium becoming calcified or fibrotic as a result of chronic inflammation, which impairs diastolic filling by compressing the cardiac chambers. Pericardiectomy is a promising surgical option for treating CP. In this study, we reviewed over 10 years of preoperative, perioperative, and short-term postoperative follow-ups of patients who underwent pericardiectomy for constrictive pericarditis at our clinic.

METHODS

Between January 2012 and May 2022, 44 patients were diagnosed with constrictive pericarditis. Twenty-six patients underwent pericardiectomy for CP. Median sternotomy is the surgical approach of choice because it provides easy access for complete pericardiectomy.

RESULTS

The patient median age was 56 (min: 32, max: 71), and 22 out of 26 patients (84.6%) were male. Twenty-one patients (80.8%) complained of dyspnea, which was the most common reason for admission. Twenty-four patients (92.3%) were scheduled for elective surgery. Cardiopulmonary bypass (CPB) was used during the procedure in six patients (23%). The duration of intensive care stay was two days (min: 1, max: 11), and the total hospitalization was six days (min: 4, max: 21). No in-hospital mortality was observed.

CONCLUSION

The median sternotomy approach provides a critical advantage in terms of performing a complete pericardiectomy. Although CP is a chronic condition, early diagnosis and planning of pericardiectomy before irreversible deterioration of cardiac function leads to a notable reduction in mortality and morbidity.

Clinical Significance of Preoperative Pyrazinamide-Containing Therapy in Tuberculous Constrictive Pericarditis

Background

Tuberculous constrictive pericarditis (TCP) is recommended to be treated with anti-tuberculosis (TB) therapy before pericardiectomy. Whether different preoperative anti-TB regimens may lead to different outcomes is unclear.

Methods

We retrospectively collected patients diagnosed as TCP and received pericardiectomy from April 2016 to June 2023. The study patients were assigned into the active TCP (A-TCP) group and the inactive TCP (IA-TCP) group according to the results of Mycobacterium tuberculosis (MTB) culture and MTB RNA assay. Baseline characteristics including anti-TB regimens and surgical outcomes were compared between the two groups. Logistic regression analysis and subgroup analysis were conducted to identify the protective factors of A-TCP.

Results

Of the 102 study patients, 24 was in the A-TCP group and 78 was in the IA-TCP group. The rate of preoperative anti-TB regimen containing pyrazinamide was 37.5% in the A-TCP group, as compared with 74.4% in the IA-TCP group (P = 0.001). Multivariate analysis showed that preoperative use of pyrazinamide was the protective factor of A-TCP (OR 0.194, 95% CI 0.053-0.703, P = 0.013). Subgroup analysis based on age also showed consistent findings. In the analyses of surgical outcomes, A-TCP was the independent risk factor of postoperative cardiac complications (OR 4.231, 95% CI 1.317-13.593, P = 0.015) and associated with longer hospital stay (P = 0.004) and higher hospitalization cost (P = 0.001).

Conclusion

A strategy involving anti-TB regimen containing pyrazinamide before pericardiectomy was superior to that without pyrazinamide in the patients with TCP. The strategy was associated with lower risk of A-TCP and might lead to better postoperative recovery and cost-effectiveness.

Multimodal Imaging of Constrictive Pericarditis Induced by Long-term Pergolide Treatment for Parkinson's Disease

We herein report the first case of constrictive pericarditis (CP) induced by long-term pergolide treatment for Parkinson's disease that was assessed using multimodal imaging in a 72-year-old patient with leg edema and dyspnea. The patient was correctly diagnosed with CP using multimodal imaging and successfully treated with pericardiectomy. The treatment history of Parkinson's disease and pathological findings of the removed pericardium suggested that long-term pergolide was the cause of CP. Properly recognizing pergolide as the cause of CP and accurately diagnosing CP using multimodal imaging may contribute to the early detection and treatment of pergolide-induced CP.

Pericardiectomy for Successful Treatment of Constrictive Pericarditis in a Pediatric Patient

A 15-year-old girl with history of asthma and obesity presented with recurrent anasarca without systolic heart failure or significant renal disease. She was diagnosed with constrictive pericarditis and successfully underwent pericardiectomy with pericardial stripping and a waffle procedure. (Level of Difficulty: Advanced.).

Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

Chronic constrictive pericarditis: a rare cardiac involvement in primary Sjögren's syndrome

BACKGROUND

Constrictive pericarditis represents a chronic condition and systemic inflammatory diseases are a known, yet uncommon, cause. Pericardial involvement is seldom reported in primary Sjögren's syndrome, usually occurring in association with pericardial effusion or pericarditis. We report a case of constrictive pericarditis with an insidious course and unusual evolution associated with primary Sjögren's syndrome. Due to the challenging nature of the diagnosis, clinical suspicion and multimodality imaging are essential for early identification and prompt initiation of treatment. Long-term outcomes remain uncertain. To the best of our knowledge, no other cases linking this autoimmune disease to constrictive pericarditis have been reported.

CASE PRESENTATION

We present the case of a 48-year-old male patient with moderate alcohol habits and a history of two prior hospitalizations. On the first, the patient was diagnosed with primary Sjögren's syndrome after presenting with pleural effusion and ascites, and empirical corticosteroid regiment was initiated. On the second, two-years later, he was readmitted with complaints of dyspnea and abdominal distension. Thoracic computed tomography revealed a localized pericardial thickening and a thin pericardial effusion, both of which were attributed to his rheumatic disease. A liver biopsy showed hepatic peliosis, which was considered to be a consequence of glucocorticoid therapy. Diuretic therapy was adjusted to symptom-relief, and a tapering corticosteroid regimen was adopted. Four years after the initial diagnosis, the patient was admitted again with recurrent dyspnea, orthopnea and ascites. At this time, constrictive pericarditis was diagnosed and a partial pericardiectomy was performed. Although not completely asymptomatic, the patient reported clinical improvement since the surgery, but still with a need for baseline diuretic therapy.

CONCLUSION

Albeit uncommon, connective tissue disorders, such as primary Sjögren's syndrome, should be considered as a potential cause of constrictive pericarditis, especially in young patients with no other classical risk factors for constriction. In this case, after excluding possible infectious, neoplastic and autoimmune conditions, a primary Sjögren´s syndrome in association with constrictive pericarditis was assumed. This case presents an interesting and challenging clinical scenario, highlighting the importance of clinical awareness and the use of multimodal cardiac imaging for early recognition and treatment.

Pattern of pericardial calcification determines mid-term postoperative outcomes after pericardiectomy in chronic constrictive pericarditis

OBJECTIVES

Although pericardiectomy is an effective treatment for constrictive pericarditis (CP), clinical outcomes are not always successful. Pericardial calcification is a unique finding in CP, although the amount and localization of calcification can vary. We investigated how the pattern and amount of pericardial calcification affect mid-term postoperative outcomes after pericardiectomy to treat CP.

METHODS

All patients of total pericardiectomy in our hospital from 2010 to 2020 were enrolled. Preoperative Computed tomography (CT) scans of 98 consecutive patients were available and analyzed. Medical records were reviewed retrospectively. Cardiovascular events were defined as cardiovascular death or hospitalization associated with a heart failure symptom, and all-cause events were defined as any event that required admission. CT scans were analyzed, and the volume and localization pattern of peri-calcification were determined. Pericardium calcium scores are presented using Agatston scores.

RESULTS

Of the 98 patients, 25 (25.5%) were hospitalized with heart failure symptoms after pericardiectomy. The median follow-up duration for all patients was 172 weeks. The group with a cardiovascular event had a lower calcium score than patients without an event. Multivariate Cox proportional analysis showed that high ln(calcium score+1) before pericardiectomy was a dependent predictor of cardiovascular event (hazard ratio, 0.90; p = 0.04) after pericardiectomy. When we set the cut-off value (ln(calcium score+1) = 7.22), there was a significant difference in cardiovascular events in the multivariate Cox proportional analysis (p = 0.04).

CONCLUSION

A low burden of pericardial calcification was associated with a high rate of mid-term clinical events after pericardiectomy to treat CP.

Echocardiographic Criteria to Differentiate Constrictive Pericarditis From Restrictive Cardiomyopathy: A Meta-analysis

Background

To assess the diagnostic accuracy of the Mayo Clinic echocardiographic criteria for differentiating between constrictive pericarditis and restrictive cardiomyopathy.

Methods

We searched electronic databases for the date range from their inception to July 1, 2022. The index tests were the Mayo Clinic echocardiographic criteria. We performed a bivariate random-effects model to estimate the pooled sensitivity and specificity, each with 95% confidence interval (CI). The area under the curve of the summary receiver operator characteristic curves, with 95% CI, was also calculated.

Results

We included 17 case-control studies involving 889 patients. The pooled sensitivity and specificity (95% CI), respectively, were as follows: ventricular septal shift, 82% (60%-94%) and 78% (65%-87%); respiratory variation in mitral inflow ≥ 14.6%, 71% (51%-85%) and 82% (66%-91%); septal e' velocity ≥ 8 cm/s, 83% (80%-87%) and 90% (83%-95%); septal e' velocity/lateral e' velocity ≥ 0.88, 74% (64%-82%) and 81% (70%-88%); and hepatic vein ratio in expiration ≥ 0.79, 73% (65%-81%) and 71% (19%-96%). The area under the curve of the summary receiver operator characteristic curves varied from 0.75 to 0.85, with overlapping CIs across index tests.

Conclusions

Our meta-analysis suggests that all echocardiographic parameters from the Mayo Clinic criteria have good diagnostic accuracy for differentiating between constrictive pericarditis and restrictive cardiomyopathy.

Atypical Presentation of Constrictive Pericarditis With Constrictive Physiology on Cardiac MRI

Constrictive pericarditis (CP) is a disease primarily affecting the pericardial sac surrounding the heart. The constrictive physiology placed on the heart chambers can lead to clinical presentations mimicking heart failure and possibly primary liver disease. The diagnosis can often be missed and attributed to other etiologies until the patient undergoes extensive workup to rule out each potential etiology. Diagnosis can be delayed, leading to suboptimal outcomes and mortality rates. Here, we present a case of CP initially presenting with bilateral lower extremity and scrotal edema, initially attributed to alcoholic liver cirrhosis given the patient's history of alcohol abuse. Subsequent abdominal imaging found no evidence of cirrhosis, coupled with grossly normal echocardiogram that led to extensive workup and eventually the diagnosis of CP based on cardiac MRI. The patient later underwent pericardiectomy and made a full recovery. This case highlights the often ambiguous presentation of CP, the utility of cardiac MRI in diagnosis, and the need for specific criteria to help guide future diagnoses as imaging modalities continue to evolve.

Pediatric Pericarditis: Update

PURPOSE OF REVIEW

While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis.

RECENT FINDINGS

We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis.

CASE VIGNETTE

A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

Cardiotoxicity of Anti-Cancer Radiation Therapy: a Focus on Heart Failure

PURPOSE OF REVIEW

As the percentage of patients achieving long-term survival following treatment of their cancer grows, it is increasingly important to understand the long-term toxicities of cancer-directed treatment. In this review, we highlight the recent findings regarding radiation-induced cardiotoxicity across multiple disease sites, with a particular focus on heart failure.

RECENT FINDINGS

Despite its relative lack of study historically, radiation-induced heart failure has now recently been implicated in several studies of breast cancer, lung cancer, esophageal cancer, and lymphoma as a non-trivial potential consequence of thoracic radiotherapy. Data regarding specific cardiac dosimetric endpoints relevant to cardiotoxicity continue to accumulate. Radiation-induced heart failure is a rare but significant toxicity of thoracic radiotherapy, that is likely underreported. Important areas for future focus include understanding the interplay between thoracic radiotherapy and concurrent cardiotoxic systemic therapy as well as development of potential mitigation strategies and novel therapeutics.

Case report: Mechanical-electric feedback and atrial fibrillation-Revelation from the treatment of a rare atrial fibrillation caused by annular constrictive pericarditis

Atrial fibrillation (AF) is one of the most common arrhythmias encountered in clinical practice. The pathophysiological mechanisms responsible for its development are complex, vary amongst individuals, and associated with predisposing factors. Here, we report a case of AF caused by annular constrictive pericarditis (ACP), which is extremely rare due to its unusual anatomical form. In our patient, AF was refractory to multiple antiarrhythmic medications; however, spontaneous conversion to sinus rhythm occurred when the ring encircling the right and left ventricular (RV and LV) cavities along the atrioventricular (AV) groove was severed. This suggests that atrial stretch due to atrial enlargement and increased left atrial (LA) pressure may contribute to the initiation and maintenance of AF. This report highlights the importance of the careful investigation of rare predisposing factors for AF using non-invasive diagnostic approaches and mechanical-electric feedback (MEF) as a pathophysiological mechanism for AF initiation and maintenance.

Severely Calcified Pericardium Causing Constrictive Pericarditis

Constrictive pericarditis (CP) is a type of diastolic heart failure caused by an inelastic pericardium that impairs cardiac filling. Diagnosing CP can be challenging, and a variety of imaging techniques may be necessary. We present a unique case of severely calcified pericardium leading to CP.

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.

Constrictive pericarditis following inactivated virus COVID-19 vaccine: a case report with review of the literature

Cardiac adverse effects of the COVID-19 vaccine are very rare, myocarditis and pericarditis are the most common amid them, and constrictive pericarditis (CP) is reported to be restricted to a few cases following mRNA COVID-19 vaccines. We report a case of a 72-year-old male patient who developed symptoms of right-sided heart failure, which started after 8 days of receiving the third dose of inactivated virus COVID-19 vaccine and his diagnostic tests comprising transthoracic echocardiography, chest CT scan, cardiac magnetic resonance were in favor of CP. Ultimately, invasive cardiac catheterization confirmed the diagnosis of CP. Due to the lack of satisfactory response to corticosteroid therapy, pericardiectomy was performed, which gave rise to symptom relief progressively and substantially. Considering the temporal course of the patient's symptoms and exclusion of other possible etiologies based on the patient's medical history and diagnostic evaluation, immunization with the COVID-19 vaccine was recognized as a culprit for developing CP. Despite being a scarce phenomenon, the COVID-19 vaccine could have a tendency to provoke pericardial inflammation in so far as causing CP. Hence, physicians should have a high index of suspicion in these circumstances and accelerate the diagnostic investigation.

Predictors of low cardiac output after isolated pericardiectomy: an observational study

Background

Low cardiac output is the main cause of perioperative death after pericardiectomy for constrictive pericarditis. We investigated the associated risk factors and consequences.

Methods

We selected constrictive pericarditis patients undergoing isolated pericardiectomy from January 2013 to January 2021. Postoperative low cardiac output was defined as requiring mechanical circulatory support or more than one inotrope to maintain a cardiac index > 2.2 L •min⁻¹ •m⁻² without hypoperfusion, despite adequate filling status. Uni- and multivariable analysis were used to identify factors associated with low cardiac output. Cox regression was used to identify factors associated with length of hospital stay.

Results

Among 212 patients with complete data, 55 (25.9%) developed low cardiac output within postoperative day 1 (quartiles 1 and 2), which caused seven of the nine perioperative deaths. The rates of atrial arrhythmia, renal dysfunction, hypoalbuminemia, modest-to-severe hyponatremia, and hyperbilirubinemia caused by constrictive pericarditis were 9.4%, 12.3%, 49.1%, 10.4%, and 81.6%. The mean preoperative central venous pressure and cardiac index were 18 ± 5 cmH₂O and 1.87 ± 0.45 L•min⁻¹•m⁻². Univariable analysis showed that low cardiac output patients had higher rates of atrial arrhythmia (OR 3.32 [1.35, 8.17], P = 0.007), renal dysfunction (OR 4.24 [1.94, 9.25], P < 0.001), hypoalbuminemia (OR 1.99 [1.06, 3.73], P = 0.031) and hyponatremia (OR 6.36 [2.50, 16.20], P < 0.001), greater E peak velocity variation (difference 2.8 [0.7, 5.0], P = 0.011), higher central venous pressure (difference 3 [2,5] cmH₂O, P < 0.001) and lower cardiac index (difference − 0.27 [− 0.41, − 0.14] L•min⁻¹•m⁻², P < 0.001) than patients without low cardiac output. Multivariable regression showed that atrial arrhythmia (OR 4.04 [1.36, 12.02], P = 0.012), renal dysfunction (OR 2.64 [1.07, 6.50], P = 0.035), hyponatremia (OR 3.49 [1.19, 10.24], P = 0.023), high central venous pressure (OR 1.17 [1.08, 1.27], P < 0.001), and low cardiac index (OR 0.36 [0.14, 0.92], P = 0.032) were associated with low cardiac output (AUC 0.79 [0.72–0.86], P < 0.001). Cox regression analysis showed that hyperbilirubinemia (HR 0.66 [0.46, 0.94], P = 0.022), renal dysfunction (HR 0.51 [0.33, 0.77], P = 0.002), and low cardiac output (HR 0.42 [0.29, 0.59], P < 0.001) were associated with length of hospital stay.

Conclusions

Early recognition and management of hyponatremia, renal dysfunction, fluid retention, and hyperbilirubinemia may benefit constrictive pericarditis patients after pericardiectomy.

Deep venous thrombosis and acute pericarditis associated with severe acute respiratory syndrome coronavirus 2 infection in a Congolese infant with sickle cell disease: a case report

Background

Since the beginning of the pandemic, no severe pediatric coronavirus disease 2019 cases have been described in Congo.

Case

We studied a 3-month-old male child of Congolese origin who was admitted to the pediatric department with 7-day history of fever, unilateral lower leg swelling, and dyspnea. There was no known history of contact with a coronavirus disease 2019 patient, and all the family members were asymptomatic. Nasopharyngeal swabs done at admission did not detect severe acute respiratory syndrome coronavirus 2. However, serology tests for severe acute respiratory syndrome coronavirus 2 antibodies were positive for immunoglobulin M and negative for immunoglobulin G. Hemoglobin electrophoresis showed hemoglobin A1, hemoglobin A2, hemoglobin F, and hemoglobin S of 46.2%, 2.5%, 19.9%, and 38.4%, respectively. Chest X-ray showed retrocardiac pneumonia in the left lung, and Doppler ultrasound of the left lower limb showed a recent total femoropopliteal venous thrombosis. At day 10 of hospitalization, our patient had classical signs of cardiac tamponade with a voluminous pericardial effusion seen on echocardiographic examination and elevated C-reactive protein, compatible with a diagnosis of constrictive pericarditis. To the best of the authors’ knowledge, this is the first report of a case of plausible severe acute respiratory syndrome coronavirus 2 infection associated with venous thrombosis and acute pericarditis in Congo.

Conclusion

We hypothesized that this case of venous thrombosis and acute pericarditis in a Congolese child with heterozygous sickle cell disease was related to severe acute respiratory syndrome coronavirus 2 infection.

Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts

Purpose of Review

The unique pathophysiological changes of constrictive pericarditis (CP) can now be identified with better imaging modalities, thereby helping in its early diagnosis. Through this review, we outline the pathophysiology of CP and its translation into symptomology and various imaging findings which then are used for both diagnosis and guiding treatment options for CP.

Recent Findings

Multimodality imaging has provided us with the capability to recognize early stages of the disease and identify patients with a potential for reversibility and can be treated with medical management. Additionally, peri-procedural planning and prediction of post-operative complications has been made possible with the use of advanced imaging techniques.

Summary

Advanced imaging has the potential to play a greater role in identification of patients with reversible disease process and provide peri-procedural risk stratification, thereby improving outcomes for patients with CP.

Constrictive Pericarditis with Cardiac Ascites Caused Spontaneous Bacterial Peritonitis

Patients with constrictive pericarditis (CP) typically present with symptoms related to right-sided heart failure, such as cardiac ascites. Spontaneous bacterial peritonitis (SBP) usually arises in association with ascites secondary to hepatic cirrhosis. We herein report a rare case of CP in which SBP developed due to cardiac ascites, even in the absence of cirrhosis. In this case, pericardiectomy improved both the hemodynamics and the ascites, while therapy with diuretics alone was insufficient. It is important to consider SBP in the differential diagnosis when any abdominal symptoms or an inflammatory response is found in patients with heart failure and cardiac ascites.

The Interventricular Septum: Structure, Function, Dysfunction, and Diseases

Vertebrates developed pulmonary circulation and septated the heart into venous and arterial compartments, as the adaptation from aquatic to terrestrial life requires more oxygen and energy. The interventricular septum (IVS) accommodates the ventricular portion of the conduction system and contributes to the mechanical function of both ventricles. Conditions or diseases that affect IVS structure and function (e.g., hypertrophy, defects, other) may lead to ventricular pump failure and/or ventricular arrhythmias with grave consequences. IVS structure and function can be evaluated today using current imaging techniques. Effective therapies can be provided in most cases, although definitions of underlying etiologies may not always be easy, particularly in the elderly due to overlap between genetic and acquired causes of IVS hypertrophy, the most common being IVS abnormality. In this review, state-of-the-art information regarding IVS morphology, physiology, physiopathology, and disease is presented.

The way to a man's heart is through his stomach? A unique case report of transient constrictive pericarditis secondary to infarction of herniated omentum following bariatric surgery

Background

Intrapericardial diaphragmatic hernias are a rare form of diaphragmatic hernia. The presentation is usually acute due to trauma or from iatrogenic causes. In some instances however, these patients can present years later. We describe an unusual case of transient constrictive pericarditis associated with herniation of omentum through a diaphgragmatic hernia extending into the pericardial space, which infarcted following recent bariatric surgery. A multi-disciplinary approach was required with surgical correction of the diaphragmatic defect and removal of omentum from the pericardial space.

Case summary

A 38-year-old gentleman with a history of a remote abdominal stab wound and recent laparoscopic gastric sleeve procedure presented with sharp central chest pain radiating to the shoulder. Chest imaging [echocardiography, computed tomography (CT), and cardiac magnetic resonance imaging (MRI)] revealed the presence of an intrapericardial diaphragmatic hernia and herniation of devascularized omentum into the pericardial space. Surgery was undertaken to remove the pericardial omentum. Echocardiography and cardiac MRI revealed changes of pericardial constriction which resolved with anti-inflammatories.

Discussion

A multi-disciplinary approach was required in this case with surgical correction of the diaphragmatic defect and removal of omentum from the pericardial space. Multi-modal imaging proved essential in the diagnosis of this rare condition, aiding in timely diagnosis, ongoing management decisions, and for assessing therapeutic response.

The role of multi-modality cardiovascular imaging in a patient presenting with acute liver failure secondary to constrictive pericarditis: a case report

Background

Constrictive pericarditis is a rare cause of heart failure which often presents a diagnostic challenge to clinicians.

Case summary

We describe the case of a 62-year-old male who presented to our institution with symptoms and signs suggestive of acute liver failure. Abdominal imaging demonstrated congestive hepatopathy. Clinical suspicion despite a 'normal' echocardiogram and sub-threshold NT-proBNP led to multi-modality cardiovascular imaging investigations to determine the cause of the heart failure syndrome. His cardiovascular magnetic resonance scan confirmed ventricular interdependence and extensive late enhancement in the pericardium with associated pericardial effusion. An 18F-fluorodeoxyglucose-positron emission tomography scan confirmed active pericardial inflammation. Cardiac computed tomography showed minimal pericardial calcification. Following confirming the diagnosis of effusive-constrictive pericarditis with evidence of active pericardial inflammation on imaging, a discussion within the Heart multidisciplinary team concluded that a trial of medical therapy with steroids is justifiable to avoid high-risk pericardiectomy. The patient was successfully treated with a combination of ibuprofen, colchicine, and prednisolone resulting in clinical improvement and remission of his symptoms. The imaging investigations were repeated 6 months later and confirmed radiological remission and medical therapy was discontinued.

Discussion

We stress the importance of multi-modality cardiovascular imaging in the diagnosis of constrictive pericarditis and also emphasize its role in identifying the subset of patients who may respond to medical therapy, therefore reducing the risk of high need surgical pericardiectomy.

Predictive value of matrix metalloprotease 9 on surgical outcomes after pericardiectomy

BACKGROUND

The effects of matrix metalloproteases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) expressions on the patients with constrictive pericarditis undergoing pericardiectomy remain unclear. This study explored the associations of MMPs and TIMPs expressions with postoperative outcomes in these patients.

METHODS

Pericardial specimens were obtained during pericardiectomy from the patients with constrictive pericarditis. The levels of MMP1, MMP2, MMP9 and TIMP1 in pericardium were analyzed by quantitative real-time polymerase chain reaction. The enrolled patients were divided into two groups according to the optimal cutoff value of gene expression predicting postoperative complications. Postoperative outcomes were compared between the two groups. Binary logistic regression analysis was performed to determine the degree of contribution of gene expression on postoperative outcomes.

RESULTS

A total of 22 patients and their pericardial specimens were included. The level of MMP9 was significantly associated with postoperative complications and the optimal cutoff value predicting postoperative complications was 3.67. The patients with low level of MMP9 (< 3.67) had lower incidence of postoperative complications (P = 0.002), shorter postoperative intensive care unit (P = 0.040) and hospital stay (P = 0.043) in comparison to those with high level of MMP9 (≥ 3.67). Binary logistic regression analysis showed that high level of MMP9 increased the risk of postoperative complications (OR 27.096, 95% CI 1.166-629.886, P = 0.040).

CONCLUSIONS

High level of MMP9 in the pericardium was associated with poor postoperative outcomes and was the independent risk factor of postoperative complications. The level of MMP9 could be used as a potential marker for prediction of surgical outcomes.

A Prediction Model for Acute Kidney Injury After Pericardiectomy: An Observational Study

Objectives

Acute kidney injury is a common complication after pericardiectomy for constrictive pericarditis, which predisposes patients to worse outcomes and high medical costs. We aimed to investigate potential risk factors and consequences and establish a prediction model.

Methods

We selected patients with constrictive pericarditis receiving isolated pericardiectomy from January 2013 to January 2021. Patients receiving concomittant surgery or repeat percardiectomy, as well as end-stage of renal disease were excluded. Acute kidney injury was diagnosed and classified according to the KDIGO criteria. Clinical features were compared between patients with and without postoperative acute kidney injury. A prediction model was established based on multivariable regression analysis.

Results

Among two hundred and eleven patients, ninety-five (45.0%) developed postoperative acute kidney injury, with fourty-three (45.3%), twenty-eight (29.5%), and twenty-four (25.3%) in mild, moderate and severe stages, respectively. Twenty-nine (13.7%) patients received hemofiltration. Nine (4.3%) patients died perioperatively and were all in the acute kidney injury (9.5%) group. Eleven (5.2%) patients were considered to have chronic renal dysfunction states at the 6-month postoperative follow-up, and eight (72.7%) of them experienced moderate to severe stages of postoperative acute kidney injury. Univariable analysis showed that patients with acute kidney injury were older (difference 8 years, P < 0.001); had higher body mass index (difference 1.68 kg·m⁻², P = 0.002); rates of smoking (OR = 2, P = 0.020), hypertension (OR = 2.83, P = 0.004), and renal dysfunction (OR = 3.58, P = 0.002); higher central venous pressure (difference 3 cm H₂O, P < 0.001); and lower cardiac index (difference −0.23 L·min⁻¹·m⁻², P < 0.001) than patients without acute kidney injury. Multivariable regression analysis showed that advanced age (OR 1.03, P = 0.003), high body mass index (OR 1.10, P = 0.024), preoperative atrial arrhythmia (OR 3.12, P = 0.041), renal dysfunction (OR 2.70 P = 0.043), high central venous pressure (OR 1.12, P = 0.002), and low cardiac index (OR 0.36, P = 0.009) were associated with a high risk of postoperative acute kidney injury. A nomogram was established based on the regression results. The model showed good model fitness (Hosmer-Lemeshow test P = 0.881), with an area under the curve value of 0.78 (95% CI: 0.71, 0.84, P < 0.001).

Conclusion

The prediction model may help with early recognition, management, and reduction of acute kidney injury after pericardiectomy.

Case Report: “Gourd-Shaped” Heart Strangled by Localized Annular Calcification of the Left Ventricle: A Rare Case of Constrictive Pericarditis

We report a rare case of a 43-year-old woman with calcific annular constrictive pericarditis (CP) encircling the basal segment of the right ventricle and the mid-segment of the left ventricle (LV) lateral wall. Over time, localized calcification has caused LV to be tightly strangled and shaped like a gourd. However, multimodality imaging confirmed no significantly clinical constriction associated with decreased cardiac movement and function. Additionally, cardiac magnetic resonance feature tracking confirmed the relatively preserved diastolic function and the characteristic “plateau” pattern of CP. The treatment strategy of this case is challenging and dialectical.

Cardiovascular complications of mantle field radiation: a case series

Background

Mantle field radiotherapy has been known to cause cardiovascular complications even years after therapy. Complications include pericardial disease, coronary artery disease, and conduction abnormalities.

Case summary

We present a case series of two patients who developed cardiovascular complications years after receiving mantle radiation. Patient 1 is a 52-year-old man who presented with symptoms of heart failure. He had a neurostimulator which precluded him from cardiac magnetic resonance imaging. Haemodynamic findings on right heart catheterization raised suspicion for constrictive pericarditis and pericardiectomy was performed. Histopathological analysis reported dense, sclerotic fibrous tissue consistent with radiation-related changes. Patient 2 is a 37-year-old man with a 2-month history of chest pain and exertional dyspnoea who was admitted for management of coronary artery disease. Coronary angiography demonstrated bilateral subclavian artery stenosis and an elevated left ventricular end-diastolic pressure (50 mmHg). He had bilateral percutaneous subclavian artery stenting. Both patients had complete resolution of symptoms on follow-up.

Discussion

Our case series emphasizes the need for an index of suspicion for radiation-related cardiovascular changes in patients who have a history of mantle radiation, especially in younger patients. This was especially pertinent in the case of our first patient who presented a diagnostic challenge due to certain patient factors. Our second patient is a case of subclavian artery stenosis which is less frequently reported as a complication of mantle radiation in the literature.

Dialysis-related constrictive pericarditis: old enemies may sometimes come back

Cardiovascular disease is the main cause of death in patients with chronic kidney disease (CKD). Several heart conditions have been associated with CKD, including myocardial and pericardial diseases. This paper describes a case of Dialysis-related constrictive pericarditis in a patient diagnosed with sudden hypotension during a hemodialysis session. A 65-year-old man diagnosed with hypertension, diabetes, obesity, and cirrhosis on hemodialysis for two years complained of symptoms during one of his sessions described as malaise, lipothymia, and confusion. The patient had a record of poor compliance with the prescribed diet and missed dialysis sessions. He was sluggish during the physical examination, and presented hypophonetic heart sounds, a blood pressure of 50/30mmHg, and a prolonged capillary refill time. The patient was referred to the intensive care unit and was started on antibiotics and vasoactive drugs. His workup did not show signs of infection, while electrocardiography showed low QRS-wave voltage. His echocardiogram showed signs consistent with a thickened pericardium without pericardial effusion. Cardiac catheterization showed equalization of diastolic pressures in all heart chambers indicative of constrictive pericarditis. The patient underwent a pericardiectomy. Examination of surgical specimens indicated he had marked fibrosis and areas of dystrophic calcification without evidence of infection, consistent with Dialysis-related constrictive pericarditis. Hypotension for unknown causes must be considered in the differential diagnosis of dialysis patients.

Ascitic Fluid Analysis Leading to the Diagnosis of Constrictive Pericarditis in 2 Patients

Although well documented, constrictive pericarditis is a rare entity and an uncommon cause of heart failure. A stiff and noncompliant pericardium creates the disease's unique hemodynamics and leads to elevated venous pressures, hepatic sinusoidal congestion, and draining of protein-rich fluid into the peritoneal cavity presenting as ascites. The low incidence in addition to its varied and subtle clinical presentations can often lead to a delay in diagnosis. Here, we present 2 clinical cases of constrictive pericarditis in which ascitic fluid analysis was important-one patient who presented with new-onset ascites with concern for cirrhosis and another patient who presented with symptoms concerning for heart failure with ascites. Through their hospital course and workup, we highlight the importance of diagnostic sampling of ascitic fluid to prompt the consideration of constrictive pericarditis followed by utilizing advanced diagnostics, such as echocardiogram and cardiac catheterization to reach the correct diagnosis in an otherwise often overlooked pathology.

The optimal duration of anti-tuberculous therapy before pericardiectomy in constrictive tuberculous pericarditis

BACKGROUND

It is unclear about the duration of anti-tuberculous therapy before pericardiectomy (DATT) in the patients with constrictive tuberculous pericarditis. This study aims to explore the optimal DATT and its impact on surgical outcomes in these patients.

METHODS

We retrospectively enrolled 93 patients with constrictive tuberculous pericarditis undergoing pericardiectomy and divided them into two groups according to the optimal cutoff value of DATT which was determined by the receiver operating characteristic (ROC) curve and Youden Index. Postoperative and survival outcomes were compared between the two groups.

RESULTS

The optimal cutoff value of DATT was 1.05 (months). The enrolled patients were divided into the DATT ≤ 1.05 group and the DATT > 1.05 group, with 24 (25.8%) and 69 (74.2%) cases, respectively. Comparing with the DATT ≤ 1.05 group, the DATT > 1.05 group had shorter postoperative ICU stay (P = 0.023), duration of chest drainage (P = 0.002), postoperative hospital stay (P = 0.001) and lower incidence of postoperative complications (P < 0.001). There were no statistical differences between the two groups in recurrence and survival outcomes.

CONCLUSIONS

It would be of potential benefit to enhance recovery after pericardiectomy if DATT lasted for at least 1 month in the patients with constrictive tuberculous pericarditis.

Pericardial constriction with calcified cystic mass compressing the right ventricle and right coronary artery

Constrictive pericarditis is characterized by fibrosis and calcification of the pericardium that progressively impair the diastolic filling of the heart, causing heart failure. Uncommonly, pericardial constriction may be localized leading to a focal cystic mass formation that may compress nearby cardiac structures. We describe a unique case of a patient presenting with right heart failure due to idiopathic calcific constrictive pericarditis that was associated with a large pericardial cystic mass compressing the right ventricular free wall. This led to reduced cardiac output and possibly severe focal stenosis of the proximal right coronary artery that was resolved after pericardiectomy, the only definitive treatment for chronic progressive constrictive pericarditis. <Learning objective: Constrictive calcified pericarditis with localized cystic mass formation may lead to focal compression of nearby cardiac structures, causing right heart failure with cirrhosis-like symptoms and reduced cardiac output. Uncommonly, epicardial coronary obstruction is encountered, which may be reversible after pericardiectomy. Multi-modality imaging is often necessary to establish diagnosis, especially when unexplained heart failure exists.>.

Effects of Intraoperative Fluid Management on Postoperative Outcomes After Pericardiectomy

Background: The effects of intraoperative fluid management on the patients with constrictive pericarditis undergoing pericardiectomy remain unclear. This study explored the relationship between intraoperative fluid management and postoperative outcomes in these patients.

Methods: We retrospectively studied 92 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to the restrictive group and the liberal group according to the intraoperative total fluid infusion rate. Postoperative outcomes were compared between the two groups. Binary logistic regression analysis was performed to determine the relationship between the intraoperative total fluid infusion rate and postoperative outcomes.

Results: There were 46 (50.0%) cases in the restrictive group and 46 (50.0%) cases in the liberal group. Compared with the liberal group, the restrictive group had significantly lower incidences of postoperative complications and cardiac complications (P = 0.005 and P = 0.006, respectively). Binary logistics regression analysis also showed the increased risks of postoperative complications (OR, 3.551; 95% CI, 1.192–10.580; P = 0.023) and cardiac complications (OR, 6.037; 95% CI, 1.472–25.052; P = 0.013) at the liberal group. In addition, the restrictive group had shorter postoperative hospital stay (P = 0.026) in comparison to the liberal group.

Conclusion: In patients with constrictive pericarditis undergoing pericardiectomy the intraoperative total fluid infusion rate was significantly associated with postoperative outcomes. Restrictive fluid management strategy was related to the positive effects on enhanced recovery after surgery and could be advised as the preferred intraoperative fluid management policy.

Cardiac magnetic resonance imaging in unclear cases of ventricular interdependence: a case series

BACKGROUND

Diagnosis of constrictive pericarditis requires demonstration of interventricular interdependence which can prove difficult even with invasive haemodynamics. Its treatment requires invasive surgical procedures prior to which diagnostic certainty is necessary. Cardiac magnetic resonance imaging (MRI) is an underutilized tool for identification of this pathology.

CASE SUMMARY

We present two cases of heart failure due to interventricular interdependence with inconclusive invasive haemodynamic. Prior to recommending invasive surgical treatment, confirmation of the diagnosis was required. This was achieved using cardiac MRI leading to pericardiectomy followed by clinical improvement.

DISCUSSION

These cases demonstrate the clinical utility, sensitivity, and specificity of cardiac MRI for ventricular interdependence.

Fifteen-year experience with pericardiectomy at a tertiary referral center

Purpose

Pericardiectomy has traditionally carried relatively high perioperative mortality and morbidity, with few published reports of intermediate- and long- term outcomes. We investigated our 15-year experience performing pericardiectomy at our institution.

Methods

Retrospective study of all patients who underwent pericardiectomy at our institution between 2005 and 2019. Baseline demographics, intraoperative details, and postoperative outcomes including long-term survival were analyzed.

Results

Sixty-three patients were included in the study. 66.7% of subjects underwent isolated pericardiectomy while 33.3% underwent pericardiectomy concomitantly with another cardiac surgical procedure. The most common indications for pericardiectomy were constrictive (79.4%) and hemorrhagic (9.5%) pericarditis. Preoperatively, 76.2% of patients were New York Heart Association class II and III, while postoperatively, 71.4% were class I and II. One-, three-, five-, and ten- year overall mortality was 9.5, 14.3, 20.6, and 25.4%, respectively. Overall pericarditis recurrence rate was 4.8%.

Conclusion

Pericardiectomy carries relatively high overall mortality rates, which likely reflects underlying disease etiology and comorbidities. Patients with prior cardiac intervention, history of dialysis, and immunocompromised state are associated with worse outcomes.

Coronavirus disease 2019 (COVID-19)-associated constrictive pericarditis

This report documents a rare case of COVID-19-associated constrictive pericarditis (CP) in the setting of a recent COVID-19 infection. A 55-year-old man with a history of hypertension and gout presented with acute hypoxic respiratory failure and was diagnosed with COVID-19 pneumonia with progression to acute respiratory distress syndrome. His hospital course was complicated by a large pericardial effusion; an emergent bedside transthoracic echocardiography was concerning for cardiac tamponade, so pericardiocentesis was performed. A workup with cardiac magnetic resonance imaging showed changes consistent with a diagnosis of CP. Viral and idiopathic aetiologies are the most common cause of CP in the developed world, with COVID-19 now a proposed predisposing viral illness. The virus induces systemic inflammation and pericardial changes that can lead to CP physiology. Imaging modalities including echocardiogram and cardiac magnetic resonance play an integral role in confirming the diagnosis.

Multimodality imaging of constrictive pericarditis in H syndrome

This is the first report of constrictive pericarditis (CP) in a 16-year-old boy with H syndrome with pericardial involvement predominantly over the right ventricle with favorable response to anti-inflammatory treatment. H syndrome, first reported in 2008, is a new auto-inflammatory syndrome with multiorgan involvement due to mutation in the SLC29A3 gene. We described the echocardiographic characteristics of asymmetric pericardial involvement and presented the cardiac computed tomography angiographic and magnetic resonance imaging findings. We reviewed the echocardiographic signs of CP, introduced tricuspid E/A respiratory alternans as a novel echocardiographic sign of right ventricular dominant CP, and explained the underlying mechanism.

Clinical significance of pulse index contour continuous cardiac output monitoring in patients with constrictive pericarditis undergoing pericardiectomy

OBJECTIVES

The efficacy of pulse index contour continuous cardiac output (PiCCO) monitoring in patients with constrictive pericarditis undergoing pericardiectomy remains unclear. The goal of this study was to explore whether PiCCO monitoring could improve clinical outcomes in these patients.

METHODS

We retrospectively studied 74 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to a PiCCO group and a control group. Postoperative and survival outcomes were compared between the 2 groups.

RESULTS

There were 33 (44.6%) cases in the PiCCO group and 41 (55.4%) cases in the control group. The baseline characteristics were comparable between the 2 groups. In comparison to the control group, the PiCCO group showed more intraoperative fluid infusion (P = 0.003), higher postoperative central venous pressure (P = 0.007) and lower levels of postoperative brain natriuretic peptide (P = 0.021). The incidence of postoperative complications (P = 0.004) including cardiac complications (P = 0.033) was also lower in the PiCCO group. Despite no difference in survival outcomes, duration of chest drainage (P = 0.032), length of stay in the intensive care unit (P < 0.001) and the postoperative hospital stay (P = 0.044) were significantly shorter in the PiCCO group.

CONCLUSIONS

This study confirmed the clinical significance of PiCCO monitoring in the enhanced recovery of patients with constrictive pericarditis undergoing pericardiectomy and provided new evidence for applying PiCCO monitoring in these patients.

Multimodality imaging in pericardial diseases

With a rapidly growing spectrum, non-specific symptoms and overlapping etiologies, pericardial diseases can represent a real diagnostic challenge. Consequently, multimodality imaging has taken a front seat in the diagnosis and management of these conditions. Cardiac CT offers an excellent anatomical characterization of pericardial thickening, fat stranding and/or presence of calcifications. and is also the preferred modality to assess extra-cardiac structures. Active pericardial inflammation, edema and fibrosis comprise pericardial characterization using CMR and allows for a precise diagnosis, disease staging and patient specific tailoring of therapies. PET scan still occupies a very modest role in the evaluation of pericardial diseases, but might help discriminating malignant pericardial effusion and extra-pulmonary tuberculous. More than ever, clinicians need to master how these modalities complement each other while avoiding unnecessary cost and to translate this knowledge into a more customized patient's care approach. The aim of this review is to recognize the role of multimodality imaging in the investigation of various pericardial diseases, assess how these modalities can impact the clinical course and treatment of these affections and finally elucidate their role in the patient's prognostication.

Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes

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.

Constrictive Pericarditis after Open Heart Surgery: A 20-Year Case Controlled Study

BACKGROUND

Constrictive pericarditis is a rare complication of open heart surgery (OHS), but little is known regarding the etiologic determinants, and prognostic factors. The purpose of this study was to investigate clinical predictors and long term prognosis of post-operative constrictive pericarditis (CP).

METHODS

Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 142,837 patients who were admitted for OHS in New Jersey hospitals between 1995 and 2015. Ninety-one patients were hospitalized with CP 30 days or longer after discharge from OHS. Differences in proportions were analyzed using Chi square tests. Controls were matched to cases for demographics, surgical procedure type, history of OHS, and propensity score. Cox proportional hazard models were used to evaluate the risk of all-cause death. Log-rank tests and Cox models were used to assess differences in the Kaplan-Meier survival curves with and without adjustments for comorbidities.

RESULTS

Patients with CP were more likely to have history of valve disease (VD, p < 0.001), atrial fibrillation (AF, p = 0.024) renal disease (CKD, p = 0.028), hemodialysis (HD, p = 0.008), previous OHS (p < 0.001). Patients with CP compared to matched controls had a higher 7-year mortality (p < 0.001). This difference became statistically significant at 1-year after surgery.

CONCLUSION

CP is a rare complication of OHS that occurs more frequently in patients with VD, AF, CKD, HD, multiple OHS, and it is associated with an unfavorable long-term prognosis. Given the large number of OHS performed every year, the results highlight the need for clinicians to recognize and properly manage this complication of OHS.

Case Report: Constrictive Pericarditis in a Patient With Isolated Anomalous Right Upper Pulmonary Venous Return

Thirty-eight-year-old male presented for evaluation of abdominal swelling, lower extremity edema and dyspnea on exertion. Extensive work-up in search of the culprit etiology revealed the presence of an Anomalous Right Upper Pulmonary Venous Return (ARUPVR) into the Superior Vena Cava (SVC). During the attempted repair, the pericardium was found to be thickened and constrictive. Only one other case of co-existent partial anomalous pulmonary venous return and constrictive pericarditis (CP) has been reported. The patient underwent a warden procedure with pericardial stripping with good outcomes at 45 days post-operatively. Thus, the presence of severe heart failure symptoms in the setting of ARUPVR should prompt further investigations. Also, further cases are needed to help guide management in these patients.

Idiopathic Constrictive Pericarditis and Eggshell Calcification of the Heart

Extensive pericardial calcification is rare in patients with chronic constrictive pericarditis (CCP). We report the case of a young man who had CCP with "eggshell" calcification of the pericardium and the classic features of CCP on echocardiography and cardiac catheterization. The patient had an uneventful recovery following surgical pericardiectomy. (Level of Difficulty: Intermediate.).