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Home , Electrocardiography, Pericardiectomy

Central Journal of & Clinical Research

Research Article *Corresponding author

Prof. Sushil K Singh, Professor and Head, Department of Cardiovascular and Thoracic surgery, King George’s Constrictive - A Medical University, Lucknow, 226003, India, Tel and Fax: 91-522-2258830; Email: [email protected] Submitted: 30 July 2020 Long Term Surgical Experience Accepted: 14 August 2020 Published: 18 August 2020 Sarvesh Kumar, Vivek Tewarson, Mohammad Zeeshan Hakim, Copyright Shobhit Kumar, and Sushil K Singh* © 2020 Kumar S, et al. OPEN ACCESS Department of Cardiovascular and Thoracic Surgery, King George’s Medical University,

India Keywords • Constrictive Pericarditis; Tuberculosis; ; Surgical technique

Abstract

Introduction: Chronic constrictive pericarditis is a significant cause for diastolic dysfunction of the . Tuberculosis is considered a significant etiology in developing countries, whereas idiopathic cases are most common world-wide. Although pericardiectomy is an established procedure for chronic constrictive pericarditis, the extent of resection and utility of is still debatable. The aim of this study was to study the feasibility and surgical outcomes of pericardiectomy for this disease in a large patient group in today’s scenario.

Materials & methods: We retrospectively analyzed data of all patients who underwent pericardiectomy at our center between 2005 to 2019. We collected data of precise etiopathology of constrictive pericarditis. Analysis of surgical approach and outcomes was done. Inclusion criteria involved all consecutive patients with a diagnosis of constrictive pericarditis.

Results: A total of 311 patients underwent pericardiectomy. Good surgical outcomes were demonstrated. There was a significant improvement in the functional status after surgery. Tuberculosis was the predominant etiology as seen in 48.23% cases, while idiopathic cases constituted 42.12%. Adequate removal of in all cases was possible without resorting to cardiopulmonary bypass and 23.15% patients could be operated through left antero- lateral . In-hospital mortality was 1.6%.

Conclusion: Tubercular pericarditis is still a common etiology of pericardial disease in our set-up and pericardiectomy carried out without use cardiopulmonary bypass can achieve excellent results for such cases.

ABBREVIATIONS etiology in the developing countries and in immunosuppressed CCP: Chronic Constrictive Pericarditis; ECG: ; TTE: Trans-Thoracic ; individuals [2-7]. AF: ; CT: Computed Tomography; CMR: and diminished , and include dyspnea, increased Clinical arise as a result of fluid overload Cardiac Magnetic Resonance; 2D Echo: Two-Dimensional , hypotension, , Echocardiography; CPB: Cardiopulmonary Bypass; LV: Left ascites, or cachexia. Diagnostic modalities ; RV: Right Ventricle; CVP: ; formuffled the heart initial sounds, diagnosis Kussmaul’s include sign, Electrocardiography pericardial knock, edema, (ECG), ICU: Intensive Care Unit; NYHA: New York Heart Association; SD: chest radiograph and trans-thoracic echocardiography (TTE). Standard Deviation; IVC: Inferior Vena Cava While chest radiograph may show only effusion, pericardial INTRODUCTION calcification may also be present. Low complexes are associated with a variety of causes. Chronic Constrictive pericarditis.noted on ECG Otherand atrial modalities fibrillation such (AF) as is computed also seen in tomographic 30% cases. PericarditisInflammation (CCP), of is the the pericardium end result or of pericarditischronic scarring has been and (CT),TTE is or the cardiac first line magnetic investigation resonance for diagnosis (CMR) imaging of constrictive provide additional information when needed such as the extent of inflammation of the pericardium, that leads to eventual pericardiectomy is an established procedure for CCP, the extent whichthickening, leads fibrosisto progressive and calcification diastolic dysfunction of the pericardial and eventually, sac [1]. ofpericardial resection thickening, and utility ofcalcification cardiopulmonary and scarring bypass [8-10]. often Althoughbecomes This inelastic pericardium prevents adequate diastolic filling, debatable. The aim of this study was to study the feasibility and as one of the most common aetiologies of constrictive pericarditis surgical outcomes of pericardiectomy for this disease in a large [2,3]. Idiopathic or viral pericarditis has been cited world-wide. Tuberculosis is considered to be a significant patient group in today’s scenario. Cite this article: Kumar S, Tewarson V, Hakim MZ, Kumar S, Singh SK (2020) Constrictive Pericarditis - A Long Term Surgical Experience. J Cardiol Clin Res 8(2): 1153. Kumar S, et al. (2020)

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MATERIALS AND METHODS Post-operative management- The patients were shifted un-reversed from general to the cardiac surgical This was a retrospective study of patients and their surgical Intensive Care Unit (ICU), where invasive was continued, and ionotropic and ventilator support was carried on. our institution. Weaning off ventilatory support and subsequent extubation was outcome for pericardiectomy from 2004 to 2019 (15 years), at Inclusion criteria involved all consecutive patients with a done according to protocol. Routine histopathology and tissue / diagnosis of constrictive pericarditis. Preoperative Evaluation-All patients underwent preoperative fluidIn cultures known werecases sent. of tubercular pericarditis, if the patient had evaluation with two-dimensional echocardiography (2D Echo), already completed a course of anti-tubercular therapy, new course was not started. In others, anti-tubercular therapy was and chest X-ray. Routine pre-operative blood work-up, evaluation started only when the pericardial biopsy was positive or there for tuberculosis and electrocardiography (ECG), was done. was strong clinical evidence of active tuberculosis. These patients Surgical technique -A full informed consent was taken from received 6 months of antitubercular therapy as per Revised each patient prior to surgery. Part preparation and draping National Tuberculosis Programme guidelines. Follow up was was done in the standard manner for , with the groins available if emergency cardiopulmonary bypass scheduled for 10 days and 1, 6 and 12-months and then yearly for 5 yearsStatistical respectively Analysis- to assess The statistical the outcomes analysis of patients. was done using of our case. Pericardiectomy was performed through either statistical software -Statistical Product and Service Solutions (CPB), should become necessary, which wasn’t required in any a or a left anterolateral thoracotomy. (IBM SPSS®) for Windows® Median sternotomy provided good access to the right ventricle, right , and great vessels, including the caval–right atrial Version 19.0. Paired t-test and Chi junctions and thus enabled a good clearance of the diseased patients.square Test There were was used no controlto assess group data in(p this value study of less as thisthan was 0.05 a pericardium from to phrenic nerve. The left retrospectivehas been considered observational significant) study. for our sample size of 311 anterolateral thoracotomy was employed for infected-purulent cases as in effusive constrictive pericarditis, in order to avoid RESULTS sternal postoperatively.

The conventional approach was to decorticate the Left As depicted in Table 1, a total of 311 patients underwent Ventricle (LV), before the Right Ventricle (RV), to avoid andpericardiectomy the majority at were our center male. overProgressive 15 years. dyspnea The mean was agethe pulmonary edema but this was not always easy to perform on commonestof patients undergoing presentation. the Almostprocedure all patientswas 26.53 had ± 18.23 raised years CVP, a beating heart. After freeing the mid-anterior part using sharp and blunt dissection techniques, dissection proceeded laterally on both right and left sides. During this stage, the aim was to while pulsus paradoxus was present in 32.15% cases. Chest X-ray offindings cases respectively.included congestion 2D-Echo in revealed 21.86% pericardialcases, while thickening presence inof calcification (Figure 1), and effusion were seen in 4.5% and 3.54% attentioncautiously to find the a coronary dissection arteries plane whose between visibility the epicardium during the procedureand the fibrotic-constricted was ensured throughout parietal by pericardium ensuring correct by paying depth 95% cases while 23.15% cases had . Septal of the dissection plane. When access to the correct dissection bounce was noted in 95.18% cases and 88.10% had ventricular plane was attained, better diastolic relaxation of the heart was septal shift. A large number of patients (96.46%), had diastolic reversalPerioperative in hepatic data vein isflow. depicted in Table 2 where it is seen there was hemodynamic relief. The lateral extent of dissection observed after removal of the fibrotic parietal pericardium & thoracotomy approach, while the rest were operated through conventionalthat 23.15% patients median were sternotomy operated forthrough pericardiectomy. a left antero-lateral While dissection lateral to the main was avoided. This was about done to1 cm prevent anterior to the to right the phrenic and left nervesphrenic at nerves this level. and During continuous intraoperative monitoring, evaluation of the conventional pericardiectomy could be performed in 90.03% hemodynamic impact of the pericardiectomy intraoperatively cases, 9.97% underwent procedure. There was achieved by measuring fall in central venous pressure (CVP). was a significant (p<0.001) drop in CVP seen on table after respectively).stripping of the Iatrogenic diseased pericardium were mostly (26.36 encountered ± 5.69 mm onHg the vs 8.33 ± 2.13 mm Hg mean at the beginning vs after procedure to prevent inadvertent injury to the underlying cardiac chambers. Thick or fibrotic tissue that was hard to peel off was left alone RV. Mean blood loss encountered during surgeries was 271.22 ± 241.80 ml and 180 patients required blood transfusions. While incisionsSmall bleeding are made spots in the were epicardial dealt with layer as was required. also employed The waffle at procedure [11], in which multiple transverse and longitudinal the mean ICU stay was 1.57 ± 0.692 days, the post-operative recovery was smooth for a majority of patients and only 13 to be removed. After completion of pericardiectomy, hemostasis times in areas where the pericardium was fibrotic and not able patients stayed longer than 5 days after surgery. Surgical site was noted in 3.22% cases. In-hospital mortality was improvement of the echocardiographic and hemodynamic values 1.6%In (5 our patients). series tuberculosis was the most common etiology thewas surgery confirmed, was andconcluded drains and were the inserted. Afterclosed checking in standard for fashion. (48.23%), followed closely by idiopathic (42.12 %), cases. Non tuberculosis infections accounted for 8.68 % of the cases as J Cardiol Clin Res 8(2): 1153 (2020) 2/7 Kumar S, et al. (2020)

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Figure 1 same case. (a) – Chest X-ray in a case of constrictive pericarditis showing extensive pericardial calcification (b) - Intra-operative photograph of the

Table 1:

Patient variables Pre-operative Patient Profile (n=311). Mean ± SD Number (%) Age (years) Age Distribution 26.53 ± 18.23

<20 142 (45.66) Sex21-50 128 (41.16) Male>50 41(13.18) Female 228 (73.31) Clinical Features NYHA Class 83 (26.69) I II III 0 (0) IV 104 (33.44) Raised CVP 38 (12.22) Ascites 169 (54.34) Hepatomegaly 288 (92.60) Pulsus Paradoxus 87 (27.97) 246 (79.09) Chest X-Ray Findings Increased cardio-thoracic ratio 100 (32.15) Pulmonary Congestion Pleural Effusion 32 (10.29) 11 (3.54) 68 (21.86) 2D- Echocardiographic Findings Pericardial Calcification 14 (4.50) Pericardial thickening VentricularEjection Fraction Septal (%) Shift 58.3±8.5 Septal Bounce 295 (94.85) Pericardial Effusion 299 (96.17) IVC Maximum diameter (cm) 296 (95.18) IVC Minimum diameter (cm) 72 (23.15) 2.7 ± 0.6 2.3 ± 0.5 Abbreviations: IVC-Hepatic inferior vein venadiastolic cava, flow cm- reversal centimetre. 300 (96.46) n- number of patients, %- percentage, SD- standard deviation, NYHA-New York Health Association, CVP- central venous pressure, evident histologically and on cultures. Out of the total number mesothelioma and one case of breast carcinoma respectively IV (87.58%), to NYHA class I and II (99.53%), over a 5-year of neoplastic cases accounting for 0.96%, there were 2 cases of beginningfollow-up. 6 Even months those after patients the procedure, who hadn’t this change completed was found their 5- year follow-up showed signs of functional improvement (Table 3). radiological signs of pleural effusion and pulmonary congestion to be statistically significant based on Chi square analysis. The Follow-up data is illustrated in Table 4. There was a in follow-up. The patients de-escalated from NYHA class III and respectively. significant improvement trend among all patients that presented improved significantly after 1 and 2 years of follow-up period

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Table 2: .

OperativePeri-Operative variables details (n=311) Mean ± SD Number (%) Approaches (n) Median Sternotomy Antero-Lateral Thoracotomy 239 (76.85) Procedures (n) Pericardiectomy 72 (23.15) Pericardial Window 280 (90.03) Blood loss (ml) 31 (9.97) 271.22 ± 241.80 0-200 167 (53.70) Packed201- 400 red cell transfusion requirement (n) 106 (34.08) >400 38 (12.22) Post-Operative Ventilatory requirement (hours) 180 (57.88) 5.21 ± 3.64 <6 218 (70.09) Post-Operative6 – 12 Inotropic support duration (hours) 91 (29.26) >12 2 (0.64) 6.13 ± 3.31 <6 144 (46.3) ICU6-12 Stay (days) 165 (53.05) >12 2 (0.60) 1.57 ± 0.692 1 170 (54.66) Hospital1-2 Stay (days) 105 (33.76) >3 36 (11.58)

Complications≤ 5 (n) 298 (95.82) Wound>5 Infection 13 (4.18) Iatrogenic Injuries Mortality 3 (0.96) 17 (5.46) Abbreviations: 5 (1.61) n- number of patients, %- percentage, SD- standard deviation, ml= millilitres, ICU- Intensive Care Unit Table 3:

AetiologyPost-operative Histopathological Diagnosis (n=311). Number (%) Idiopathic

Tubercular 131 (42.12) Other Infectious causes 150 (48.23) Streptococcus pneumoniae Staphylococcus aureus 27 (8.68) Others 18 (5.79) 6 (1.93) Neoplastic Breast cancer 3 (0.96) Mesothelioma 3 (0.96) 1 (0.32) Abbreviations: 2 (0.64) n- number of patients, %- percentage DISCUSSION which demonstrate thickened pericardium and diastolic septal The incidence of idiopathic constrictive pericarditis is septal motion along with a constrained total cardiac volume. highest in the world; however, the trends are not similar among bounce with inspiration, rapid diastolic filling and paradoxical developing and developed countries and our series showed a Inspiratory ventricular septal shift reduced mitral annular high incidence of tuberculosis associated pericarditis, which is velocity and hepatic vein diastolic flow reversal ratio >0.79 are There has also been an increase in the incidence of pericarditis considered specific findings [15,16]. We noted that reversal similar to those reported in Asian and African studies [6,12,13]. frequently present among our patients. Septal bounce and in diastolic hepatic vein flow and pericardial thickening were in post-operative and post-irradiation cases [14]. The prevalence progress to chronic constrictive pericarditis. Presentation as respectively, demonstrating these to be important signs to look of CCP is less than 1 in 10000 and only 9% of ventricular septal shift were also noted in 95.18% and 88.10% for in 2D-echocardiography. cardiac failure is common and diagnosis is chiefly by 2D Echo, J Cardiol Clin Res 8(2): 1153 (2020) 4/7 Kumar S, et al. (2020)

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Table 4: Follow-up data. Chest X-ray Findings Follow up Number of NYHA Status of Pulmonary period patients on patients Pleural Effusion Congestion follow up (n, % per class) p-value (n, %) p-value p-value (n, %)

10 days I -0 (0.00) - - - II -38 (12.42) 306 9 (2.94) 43 (14.05) III -102 (33.33) IV -166 (54.25) 6 months I -30 (9.90) II -27 (8.91) 303 0.001 6 (1.98) 0.61 31 (10.23) 0.18 III -100 (33.00) IV -146 (48.19) 1 year I -75 (26.79) II -30 (10.71) 280 0.000 3 (1.07) 0.15 20 (7.14) 0.01 III -75 (26.79) IV -100 (35.71) 2 year I - 80 (30.77) II -32 (12.31) 260 0.000 1 (0.38) 0.047 12 (4.62) 0.000 III -55 (21.15) IV -93 (35.77) 3 year I -102 (43.59) II -28 (11.96) 234 0.000 0 (0) 0.021 3 (1.28) 0.000 III -38 (16.24) IV -66 (28.21) 4 year 222 I -140 (63.06) II -26 (11.71) 0.000 0 (0) 0.025 0 (0) 0.000 III -28 (12.61) IV -28 (12.61) 5 year I -211 (98.14) II -3 (1.39) 215 0.000 0 (0) 0.028 0 (0) 0.000 III -1 (0.46) Abbreviations: IV -0(0.00) NYHA- New York Heart Association (functional status), %- percentage, n- number of patients Another important investigation that aids diagnosis is the chest radiograph. Various signs such as presence of pulmonary on the other hand has displayed a trend towards surgeries being congestion, effusion, presence and extent of pericardial carrieduse of CPB out inin thesean older cases and [21]. functionally The Mayo poor clinic population 8-decade overanalysis the years. Regardless of the pre-operative picture, the post-operative outcome in terms of mortality and functional status of patients calcification and increased cardio-thoracic ratio can be noted. withPresence tubercular of calcification pericarditis. in chest However, radiographs even withas was idiopathic seen in relatively young population undergoing pericardiectomy with a cases during our study (Figure 1), have been frequently noted predominanthas improved male over fraction. time [14,22]. This demographic Our study trend also is described also noted a pericarditis, about 30 to 50% cases have been reported having disease is more prevalent among young men. pericardial calcification in various series and this is also among recent long-term studies [14,21,22] suggesting that the Pericardiectomy is considered therapeutic for both andconsidered idiopathic a poor pericarditis prognostic factor with signsin outcome of right [17,18]. sided Our cardiac study chronic constrictive and effusive constrictive pericarditis. failuredemonstrated such as a significant raised CVP, number hepatomegaly, of patients pedal with edema tubercular and Approach through median sternotomy has been advocated poor functional class. 2D-Echo in these patients demonstrated for ease in employing cardiopulmonary bypass when needed. thickened pericardium and ventricular septal shift in a large Use of alternate approaches including the left antero-lateral number of cases. While 2D Echo is the backbone of diagnosis, especially in re-do cases and those that carry a higher risk of thoracotomy have been frequent and have proven beneficial scansinvestigations can provide must a good be individualizedanatomical outline and before appropriate embarking use on of chest x-ray, computerized tomographic and magnetic resonance antero-lateral thoracotomy in patients for pericardiectomy as wellsternotomy as pericardial wound window. infection [23,24]. In our series, we used left In the US nationwide study for conducted the surgical procedure [19,20]. The extent of pericardial resection has been a topic of debate, with proponents of complete or a more radical pericardial excision being increasingly reported in a younger population presenting have carried out complete stripping of pericardium posterior withover past disease 15years, symptoms. it was noted There that has early also surgical been a intervention decline in the is to the phrenic nerves to the coronary sinus and pulmonary veins, thereby completely removing the parietal pericardium. number of surgeries with a slight but significant increase in the J Cardiol Clin Res 8(2): 1153 (2020) 5/7 Kumar S, et al. (2020)

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The impact of such has been seen in a few studies and has been approach is valuable in selected patients. Good functional status found to provide good short- and long-term results in these should be the aim of the surgeon and with proper and meticulous technique, this can be achieved consistently. there is a constant need for cardiopulmonary bypass in radical patients in experienced centers [6]. It has also been shown that REFERENCES Shabetai R. Constricitve Pericarditis. The Pericardium. Springer US. completepericardiectomy excision and in some as such areas it isof notthe widelypericardium practiced by providing [25-27]. 1. extensiveThe waffle anterior technique release can provide providing an good alternative functional substitute recovery to 2. 2003: 191-252. Guidelines on the diagnosis and management of pericardial diseases executiveMaisch B, Seferovićsummary; PM, The Ristić Task AD,force Erbel on the R, Rienmüllerdiagnosis and R, managementAdler Y, et al. 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Cite this article Kumar S, Tewarson V, Hakim MZ, Kumar S, Singh SK (2020) Constrictive Pericarditis - A Long Term Surgical Experience. J Cardiol Clin Res 8(2): 1153.

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