Nicola Vistarini, MD, Christina Chen, BEng, Amine Mazine, MD, Denis Bouchard, MD, Yves Hebert, MD, Michel Carrier, MD, Raymond Cartier, MD, Philippe Demers, MD, Michel Pellerin, MD, and Louis P. Perrault, MD, PhD Department of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, Montreal, Quebec, Canada; and Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Pavia University School of Medicine, Pavia, Italy

Background. The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors. Methods. Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. Results. Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation

were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. Conclusions. The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.

C

pericardiectomy at a single surgical center over a period of 20 years. The main objectives of our analysis were longterm survival, clinical outcome, and identification of risk factors for early and late mortality.

onstrictive pericarditis (CP) is a chronic inflammatory disease involving fibrotic lesions and serous effusions, leading to pericardial thickening, adhesions, and sometimes calcifications, thus causing ventricular compression [1]. The resulting heart failure is the consequence of impaired diastolic ventricular function and may be life-threatening for the patient [2, 3]. Despite the lack of prospective studies comparing the different therapeutic strategies, surgical pericardiectomy is a valuable treatment under most circumstances [4–10]. The main benefits of this operation are the increase in survival, the relief of symptoms, and the prevention of disease worsening [11–14]. Despite a general consensus supporting the procedure, this operation is still associated with significant morbidity. Previous studies have reported different early and long-term survival after pericardiectomy, with a great heterogeneity regarding preoperative and intraoperative risk factors [15–18]. The present study was designed to evaluate early and long-term results after Accepted for publication Feb 18, 2015. Address correspondence to Dr Perrault, Department of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, 5000 B elanger St, Montreal H1T 1C8, Quebec, Canada; e-mail: [email protected].

Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier

(Ann Thorac Surg 2015;100:107–13) Ó 2015 by The Society of Thoracic Surgeons

Patients and Methods Study Population and Study Design From January 1994 through February 2014, 99 consecutive patients underwent total or partial pericardiectomy at the Montreal Heart Institute, and they constitute the subjects of this report. Only the patients in whom the main surgical indication was CP were considered in the study. We also excluded the cases in which the pericardiectomy was an unplanned procedure, performed after an intraoperative finding of CP. The patients’ clinical charts were reviewed, and preoperative, intraoperative, and postoperative data were recorded on a computer-based surgical database. The CP was evaluated preoperatively by echocardiography, computed tomography (CT), angiography, magnetic resonance imaging (MRI), and chest roentgenography (Fig 1). We considered in our analysis relevant clinical information: demographics (age, sex, race), cause of CP (idiopathic, infectious, postsurgical, 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.054

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Fig 1. Preoperative evaluation of a patient with constrictive calcified pericarditis. (A) Chest roentgenogram. (B) Cardiac angiogram. (C) Chest computed tomographic scan.

postirradiation, miscellaneous), clinical signs and symptoms (New York Heart Association [NYHA] class, duration of symptoms, distended jugular veins, hepatomegaly, ascites, pulsus paradoxus, pleural effusion), comorbidities (systemic hypertension, diabetes, atrial fibrillation, renal insufficiency), echocardiographic data (left and right ventricular function, pulmonary hypertension, pericardial calcification), preoperative laboratory test results (creatinine, sodium, bilirubin, albumin), and intraoperative data (surgical approach, total or partial pericardiectomy, associated procedures, need for cardiopulmonary bypass [CPB]). Follow-up of patients was done with telephone calls to the patients or their relatives and through the reports of cardiologic clinical and echocardiographic controls.

Surgical Techniques Median sternotomy has been the preferred surgical approach in the great majority of cases, offering easy access for a complete pericardiectomy. Alternative approaches were left or right anterolateral thoracotomy, performed in the fourth or fifth intercostal space, and subxiphoid approach. In all cases of pericardiectomy, a circuit for extracorporeal circulation was ready to use, and the perfusionist was present in the operating room. External defibrillation pads were always installed before operation. Total pericardiectomy was defined as radical phrenic-to-phrenic excision of the pericardium, from the great arteries superiorly to the diaphragmatic surface inferiorly. Any other type of pericardial resection that did not meet these criteria was classified as a partial pericardiectomy. The key element of this surgical procedure, regardless of the extent of the resection, is the decompression of the right cavities, which are almost always at the center of the symptoms and therefore of the indication. In this sense it is important to remove any constriction from the orifices of the caval veins, and this can be obtained without touching the posterior surface of these vessels, simply breaking sufficiently the “banding effect” to achieve the result.

Definitions The causes of CP were deduced mainly by clinical history. Postsurgical pericarditis was defined when CP developed in patients with previous cardiac operations. Patients with a history of mediastinal irradiation were defined as having postirradiation pericarditis. Additional possible causes included infectious (bacterial or viral) or miscellaneous (posttraumatic, tumor-related, and post– myocardial infarction). Patients who did not fit in any of those groups were classified into the idiopathic group. The diagnosis of CP was mainly established on echocardiographic data: comprehensive evaluation of systolic and diastolic left and right ventricular function, search for abnormal motion of the interventricular septum, inferior venae cava dilatation, pericardial thickening, and variations in mitral and tricuspid inflow velocity and in pulmonary and hepatic vein flow. Other instrumental examinations that were used to complete or refine the diagnosis were invasive hemodynamic measurements, MRI, and high-resolution CT. Pericardial calcification was defined as the presence of calcifications detected preoperatively on chest roentgenogram, angiography, CT, or MRI (Fig 1). Hospital mortality was defined as death occurring in the first 30 days after operation or during the same hospitalization as for operation.

Statistical Analysis Statistical analyses were performed with the Statistical Package for Social Sciences (SPSS) version 20 (Chicago, IL). Continuous variables are presented as mean  standard deviation, and categoric variables are reported as frequency (percentage). Predictors of hospital mortality were assessed by a multivariable logistic regression model. Variables screened as potential confounders were the preoperative baseline characteristics. All variables with p < 0.20 on univariate analysis were considered as having a potential confounding effect. Variables with p < 0.05 were retained in the final model. Long-term survival was assessed by Kaplan-Meier actuarial methods. Risk factors for late mortality were evaluated with a multivariable Cox proportional hazards model. The variables

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assessed as potential risk factors were the same as for hospital mortality, and variable selection was carried out in the same manner.

Results Preoperative Characteristics Table 1 shows the preoperative characteristics of patients. In two thirds of cases, CP was idiopathic. The miscellaneous causes of CP were prior chest trauma in 2 patients, malignancy in 1 patient, and myocardial infarction in 6 patients. The duration of symptoms was less than 6 months only in 47% of patients, and the remaining patients had symptoms for longer than 6 months, in some cases years. Two thirds of patients were in NYHA functional class III or IV.

Intraoperative Findings The patients’ intraoperative characteristics are reported in Table 2. The operation was performed through a standard sternotomy in the great majority of cases (97 patients). Left thoracotomy was performed in 1 patient, right thoracotomy in 1 patient, and a subxiphoid Table 1. Preoperative Characteristics Characteristic Age (y) Male gender Cause Idiopathic Infectious Postsurgical Postirradiation Miscellaneous NYHA preoperative class I II III IV NA LVEF (%) Distended jugular veins Hepatomegaly Ascites Pleural effusion Pericardial calcification Atrial fibrillation Diabetes mellitus Systemic arterial hypertension Renal failure (serum creatinine 120 mmol/L) Pulmonary hypertension (PAPs 60 mm Hg)

Median (Range)

n

%

60 (24–79) . . . . . . . . . . . . . 55 (14–70) . . . . . . . . .

. 85

. 86

60 15 13 2 9

61 15 13 2 9

7 23 61 7 1 . 51 29 22 41 62 34 16 47 20

7 23 62 7 1 . 52 29 22 41 63 34 16 47 20

.

5

5

LVEF ¼ left ventricular ejection fraction; NA ¼ not available; NYHA ¼ New York Heart Association; PAPs ¼ systolic pulmonary arterial pressure.

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Table 2. Intraoperative Characteristics Characteristic

n

%

Sternotomy Thoracotomy þ sternotomy Subxiphoid Thoracotomy Need for CPB Associated procedures Coronary artery bypass Valvular operation Miscellaneous Complete pericardiectomy

93 3 1 2 37 36 20 13 8 60

94 3 1 2 37 36 20 13 8 61

CPB ¼ cardiopulmonary bypass.

approach in another patient. In 3 patients a thoracotomy was initially performed, but then it was extended into a median sternotomy. Complete pericardiectomy was performed in 61% of patients. Associated procedures were performed in 36% of patients. Miscellaneous procedures included thymectomy (n ¼ 2), resection of epicardial pacemaker electrode (n ¼ 1), Maze procedure (n ¼ 1), Maze procedure and septal myomectomy (n ¼ 2), resection of lung cancer (n ¼ 1), and decortication of the lung (n ¼ 1). CPB was used in 37% of patients, but only 8 of them underwent isolated pericardiectomy.

Postoperative Findings Regarding the postoperative course, complications included renal failure (n ¼ 16), atrial fibrillation (n ¼ 16), pleural effusion (n ¼ 11), postoperative bleeding (n ¼ 9), respiratory failure (n ¼ 3), paralytic ileus (n ¼ 2), and hepatic failure (n ¼ 1). Hospital mortality was 9%, and the causes of death were multiorgan failure (n ¼ 4), heart failure (n ¼ 3), and respiratory failure (n ¼ 2). Among these 9 patients, pericardiectomy was incomplete in only 2 patients, CPB was required in 4 patients for associated cardiac procedures and in 2 patients for hemodynamic instability. Several preoperative variables (age, sex, race, cause of CP, NYHA functional class, duration of symptoms, distended jugular veins, hepatomegaly, ascites, pulsus paradoxus, pleural effusion, systemic hypertension, diabetes, atrial fibrillation, renal insufficiency, creatinine, sodium, bilirubin, albumin, left and right ventricular function, pulmonary hypertension, pericardial calcification) and intraoperative variables (surgical approach, total or partial pericardiectomy, associated procedures, need for CPB) were tested in the statistical analysis of the risk factors affecting hospital mortality after operations for CP. Table 3 shows the variables that were statistically significant at univariate and multivariate analysis. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality (odds ratio [OR] 0.11) compared with those who were symptomatic for longer times. Preoperative hepatomegaly was associated with significantly higher mortality on both univariate and multivariate analysis. No significant difference was found in mortality according to the cause

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Table 3. Univariate and Multivariate Analysis for Predictors of Hospital Mortality (entire cohort, n ¼ 99) Univariate Analysis

p Value

OR

0.075 0.045 0.020 0.009

1.071 0.114 5.368 7.200

Age Symptoms

Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute.

The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our anal...
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