Central Journal of Cardiology & Clinical Research Research Article *Corresponding author Prof. Sushil K Singh, Professor and Head, Department of Cardiovascular and Thoracic surgery, King George’s Constrictive Pericarditis - 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; Pericardiectomy; Surgical technique Abstract Introduction: Chronic constrictive pericarditis is a significant cause for diastolic dysfunction of the heart. 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 cardiopulmonary bypass 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 pericardium in all cases was possible without resorting to cardiopulmonary bypass and 23.15% patients could be operated through left antero- lateral thoracotomy. 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: Electrocardiography; TTE: Trans-Thoracic Echocardiography; individuals [2-7]. AF: Atrial Fibrillation; CT: Computed Tomography; CMR: and diminished cardiac output, and include dyspnea, increased Clinical signs and symptoms arise as a result of fluid overload Cardiac Magnetic Resonance; 2D Echo: Two-Dimensional jugular venous pressure, hypotension, pulsus paradoxus, Echocardiography; CPB: Cardiopulmonary Bypass; LV: Left ascites, pleural effusion or cachexia. Diagnostic modalities Ventricle; RV: Right Ventricle; CVP: Central Venous Pressure; formuffled the heartinitial 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 voltage complexes are associated with a variety of causes. Chronic Constrictive pericarditis.noted on ECG Other and atrial modalities fibrillation such (AF) as iscomputed also seen intomographic 30% cases. PericarditisInflammation (CCP), of is the the pericardium end result orof pericarditischronic scarring has beenand (CT),TTE isor the cardiac first linemagnetic 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 heart failure [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) Central MATERIALS AND METHODS Post-operative management- The patients were shifted un-reversed from general anesthesia to the cardiac surgical This was a retrospective study of patients and their surgical Intensive Care Unit (ICU), where invasive monitoring 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 cardiac surgery, 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 median sternotomy or a left anterolateral thoracotomy. (IBM SPSS®) for Windows® Median sternotomy provided good access to the right ventricle, right atrium, 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 phrenic nerve 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 infections 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 wereour centermale. overProgressive 15 years. dyspnea The mean was agethe pulmonary edema but this was not always easy to perform on commonestof patients undergoingpresentation. the Almost procedure all patientswas 26.53 had ± 18.23raised yearsCVP, 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 acoronary dissection arteries plane whose between visibility the epicardiumduring the procedureand the fibrotic-constricted was ensured throughout parietal by pericardiumensuring correct by paying depth 95% cases while 23.15% cases had pericardial effusion. 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 for through pericardiectomy. a left antero-lateral While dissection lateral to the main pulmonary artery was avoided. This was aboutdone to1 cmprevent anterior