Asian Cardiovascular and Thoracic Annals http://aan.sagepub.com/
Subtotal Pericardiectomy via Sternotomy for Constrictive Pericarditis Ashok K Srivastava, Anoop K Ganjoo, Bashist Misra, Tapas Chaterjee, Aditya Kapoor and Chandra Mani Pandey Asian Cardiovascular and Thoracic Annals 2000 8: 134 DOI: 10.1177/021849230000800210 The online version of this article can be found at: http://aan.sagepub.com/content/8/2/134
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SUBTOTAL PERICARDIECTOMY VIA STERNOTOMY FOR CONSTRICTIVE PERICARDITISORIGINAL CONTRIBUTION Srivastava
SUBTOTAL PERICARDIECTOMY VIA STERNOTOMY FOR CONSTRICTIVE PERICARDITIS Ashok K Srivastava, MCh, Anoop K Ganjoo, MCh, Bashist Misra, MS, Tapas Chaterjee, MS, Aditya Kapoor, DM1, Chandra Mani Pandey, PhD2 Department of Cardiac Surgery 1Department of Cardiology 2Department of Biostatistics Sanjay Gandhi Post-Graduate Institute of Medical Sciences Lucknow, India
ABSTRACT Records of 103 patients with constrictive pericarditis who underwent subtotal pericardiectomy from January 1990 to December 1997 were retrospectively analyzed. The etiology of pericardial constriction was unknown in 63, tuberculous in 30, pyogenic in 7, and miscellaneous in 3 patients. Adequate pericardiectomy could be accomplished in 85 (82.5%) patients. Eleven patients (10.68%) died within 30 days of surgery. The 92 survivors were followed up for 47.21 ± 30.7 months; functional status improved in all cases. Of 15 variables examined by univariate logistic regression analysis, preoperative New York Heart Association functional class IV, atrial fibrillation, left atrial size > 40 mm·m–2, mild to moderate mitral regurgitation, tricuspid regurgitation, pericardial calcification, and inadequate pericardiectomy were found to be significant predictors of poor outcome. Adequate pericardiectomy via sternotomy was considered to carry low operative risk and provide excellent improvement in functional capacity. (Asian Cardiovasc Thorac Ann 2000;8:134–6)
INTRODUCTION Constrictive pericarditis (CP) is a chronic inflammatory process that produces pericardial fibrosis and constriction around the heart. This prevents normal diastolic filling and function of the ventricles, leading to systemic venous congestion and reduced cardiac output. Surgery is the only effective treatment for this potentially curable disorder. Several surgical approaches and various degrees of pericardial resection have been recommended since the procedure was originally performed by Churchill1 in 1929. Several factors including preoperative advanced New York Heart Association functional class, left atrial size > 40 mm·m–2, elevated right ventricular end-diastolic pressure, and inadequate pericardiectomy have been implicated as responsible for poor outcome following pericardiectomy.2–8 This retrospective study was under-
taken to determine the effectiveness of subtotal pericardiectomy through the median sternotomy approach and the impact of various risk factors on the outcome.
PATIENTS AND METHODS The medical records of 103 patients with constrictive pericarditis who underwent subtotal pericardiectomy in this institute from January 1990 to December 1997 were retrospectively analyzed. Patients with clinical, operative, and pathological findings of constrictive pericarditis were included in this study. Details were noted of New York Heart Association (NYHA) functional class, atrial fibrillation, etiology, presence of mitral or tricuspid regurgitation as assessed by 2-dimensional and color Doppler echocardiography, adequacy of operation, and postoperative outcome.
For reprint information contact: Ashok K Srivastava, MCh Tel: 91 522 44 0900 Ext. 2204 Fax: 91 522 44 0017 email:
[email protected] Department of Cardiac Surgery, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow 226014, India. A SIAN CARDIOVASCULAR & T HORACIC ANNALS
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SUBTOTAL PERICARDIECTOMY VIA STERNOTOMY FOR CONSTRICTIVE PERICARDITIS
There were 76 (74%) males and 27 (26%) females. The mean age was 32.22 ± 17.08 years (range, 3 to 70 years). Seventeen patients were below 14 years of age and 13 were more than 55 years of age. Preoperatively, 14 patients were in NYHA functional class II, 71 were in class III, and 18 were in class IV. The mean duration of symptoms was 19.07 ± 17.43 months (range, 2 to 96 months). Atrial fibrillation was present in 12 patients. Among specific causes of CP, tuberculosis was the most common (30 patients), the etiology was unknown in 63 (61%), pyogenic in 7, and miscellaneous in 3 patients. Two-dimensional echocardiographic assessment revealed effusive CP in 55 patients and fibrinous CP in 48. Mean left atrial size was 41.38 ± 8.18 mm·m–2. Left ventricular function was normal in 97 patients and 6 had left ventricular dysfunction (ejection fraction < 50%). Mild to moderate mitral regurgitation was found in 25 (24%) cases and tricuspid regurgitation was noted in 23 (22%). All patients underwent surgery through a median sternotomy after placing radial artery and central venous pressure lines and an indwelling urinary catheter. The cleavage plane between the pericardium and myocardium was established and thickened pericardium was removed from the anterior, lateral, and diaphragmatic surface of both ventricles. The extent of pericardial resection was
limited on the lateral aspect between the two phrenic nerves. We defined an adequate pericardiectomy as one in which there was complete removal of thickened pericardium from the anterolateral surface of both ventricles, right atrium, both venae cavae, great vessels, and from one phrenic nerve to the other. At the completion of decortication, hemostasis was carefully achieved and the chest was closed after insertion of drainage tubes. Cardiopulmonary bypass was used in a patient who underwent concomitant closure of a ventricular septal defect and in another who had mitral valve replacement. Univariate logistic regression analysis was used to determine the impact of various factors on outcome. A p value < 0.05 was considered significant. The data were analyzed using SPSS-PC software (SPSS, Inc., Chicago, IL, USA).
RESULTS Eleven patients (10.68%) died within 30 days of surgery. The major cause of death was low output syndrome secondary to inadequate pericardiectomy in 7 patients. Two patients died during surgery due to accidental tear in the right atrium leading to uncontrolled bleeding. One patient died from refractory ventricular fibrillation and another because of respiratory failure secondary to preoperative chronic obstructive airway disease. Adequate
Table 1. Transition in New York Heart Association Functional Class After Surgery in 103 Cases of Constrictive Pericarditis Preoperative Functional Class II III IV Total
No. of Patients
Class I Postoperative (n)
Class II Postoperative (n)
No. of Deaths
14 54 12 80
0 11 1 12
0 6 5 11
14 71 18 103
Table 2. Univariate Logistic Regression Analysis of Predictors of Outcome After Subtotal Pericardiectomy Predictor Age Gender Duration of symptoms NYHA functional class Atrial fibrillation Tubercular etiology Left atrial dimension Mitral regurgitation Tricuspid regurgitation Left ventricular end-diastolic pressure Right ventricular end-diastolic pressure Pulmonary arterial pressure Effusive constrictive pericarditis Pericardial calcification Adequacy of pericardiectomy
Regression Coefficient (ß)
Odds Ratio (eß)
Overall Prediction (%)
p
0.01 1.04 0.02 4.45 4.37 –1.50 0.63 3.84 3.14 –0.03 0.08 –0.11 0.37 –2.43 4.52
1.01 2.82 1.02 85.70 79.11 0.22 1.88 46.76 23.32 0.97 1.08 0.89 0.69 0.09 92.22
89.32 89.32 89.32 95.15 94.17 89.32 94.17 96.12 93.20 86.67 79.59 86.67 89.32 89.32 90.29
0.7506 0.1135 0.3204 0.0000* 0.0000* 0.063 0.0016* 0.0002* 0.0000* 0.7756 0.2996 0.2939 0.5778 0.0229* 0.0000*
*Statistically significant. NYHA = New York Heart Association.
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SUBTOTAL PERICARDIECTOMY VIA STERNOTOMY FOR CONSTRICTIVE PERICARDITIS
Srivastava
pericardiectomy was accomplished in 85 (82.5%) patients. Extensive calcification in 12, accidental right atrial tear in 4, and right ventricular tear in 2 patients were the main reasons for inadequate pericardiectomy in this series. Mortality was significantly higher among patients who were in preoperative NYHA functional class IV (5/18; 27.8%) compared to class III (6/71; 8.5%). None of the patients in preoperative NYHA functional class II died following surgery. The 92 survivors were followed up for 47.21 ± 30.7 months (range, 6 to 102 months); 80 improved to NYHA functional class I and 12 to class II. Improvement by at least one NYHA functional class was observed in all survivors; 67 patients improved by more than one NYHA functional class. The transition in NYHA functional class is depicted in Table 1.
In agreement with earlier studies, preoperative NYHA functional class IV, left atrial size > 40 mm·m–2, and inadequate pericardiectomy adversely affected the outcome.2–8 In addition, atrial fibrillation, preoperative mild to moderate mitral regurgitation, and tricuspid regurgitation were identified as predictors of adverse outcome, which have not been reported previously.12 Among the factors identified by univariate analysis, pericardial calcification and left atrial size > 40 mm·m–2 had smaller odds ratios and seemed to play less dominant roles compared to the other predictors. This study demonstrated that adequate pericardiectomy via sternotomy carried low operative risk and provided excellent improvements in functional capacity.
Univariate logistic regression analysis was carried out for prediction of outcome. The regression coefficient (ß), odds ratio (eß) and overall prediction of the model, including the constant term and significance of regression coefficient for each predictor, are presented in Table 2. The odds ratios of these factors were between 23.3231 and 92.2153, except for left atrial size > 40 mm·m–2 and pericardial calcification, which were close to 1. The overall prediction of the model lay between 89.32% and 96.12%, which appears reasonable and explains the majority of cases.
1.
Churchill ED. Decortication of the heart (Delorme) for adhesive pericarditis. Arch Surg 1929;19:1457–67.
2.
Culliford AT, Lipton M, Spencer FC. Operation for chronic constrictive pericarditis: do the surgical approach and degree of pericardial resection influence the outcome significantly? Ann Thorac Surg 1980;29:146–52.
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McCaughan BC, Schaff HV, Piehler JM, Danielson GK, Orszulak TA, Puga FJ, et al. Early and late results of pericardiectomy for constrictive pericarditis. J Thorac Cardiovasc Surg 1985;89:340–50.
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Bashi VV, Johh S, Ravikumar E. Early and late results of pericardiectomy in 118 cases of constrictive pericarditis. Thorax 1988;43:637–41.
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Seifert FC, Miller DC, Oesterle SN, Oyer PE, Stinson EB, Shumway NE. Surgical treatment of constrictive pericarditis analysis of outcome and diagnostic error. Circulation 1985;72:264–73.
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Matsubara H, Beppu S, Koyama J. Predictors of ineffective outcome of surgical treatment for constrictive pericarditis. J Cardiol 1995;25:89–94.
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Miller JI, Mansour KA, Hatcher CR Jr. Pericardiectomy: current indications, concepts, and results in a university center. Ann Thorac Surg 1982;34:40–5.
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Auslidillo R, Ivert T. Late results after pericardiectomy for constrictive pericarditis via left thoracotomy. Scand J Thorac Cardiovasc Surg 1989;23:115–9.
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Levine HD. Myocardial fibrosis in constrictive pericarditis: electrocardiographic and pathologic observations. Circulation 1973;48:1268–70.
DISCUSSION Being a major cardiac referral center, chronic CP is commonly seen at our institute. Over the span of 8 years, 103 proven cases of CP underwent subtotal pericardiectomy through a median sternotomy approach. This series comprised relatively young patients (mean age, 32 years) compared to series from Western centers where the mean ages were between 45 and 55 years.5,8,9 This supports a previous finding that CP occurs at a much younger age in developing countries.4 The male to female ratio of 3:1 in this series agrees with an earlier report from India.4 Among the specific causes of CP reported in Western literature, malignancy and radiation therapy were the most common.1,5,8,9 With the advent of effective microbial therapy, the incidence of tuberculous CP has significantly declined.5 However, in this series, tuberculosis was a major cause of pericardial constriction, as in earlier reports.3,4 The optimal surgical approach and extent of pericardiectomy have long been debated.1,2 Median sternotomy was the preferred approach in this series to accomplish adequate pericardiectomy.2,5 Acceptable safety, low mortality, and short hospital stay have been demonstrated using this approach.2,8 We do not have experience of anterolateral thoracotomy as an approach for subtotal pericardiectomy.4,8 The operative mortality of 10.68% was comparable with other reports in the range of 4% to 18%.2,3,7,10,11 The majority of patients improved by one or more functional classes, which compares favorably with the results of other investigators.3–5
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REFERENCES
10. Stalpaert G, Suy T, Daenen W, Nevelsteen A. Total pericardiectomy for chronic constrictive pericarditis. Acta Chir Belg 1981;5:277–82. 11.
Mantri RR, Radhakrishnan S, Sinha N, Goel PK, Bajaj R, Bidwai PS. Atrio-ventricular regurgitations in chronic constrictive pericarditis: incidence and post-operative outcome. Int J Cardiol 1993;39:273–9.
12. DeValeria PA, Baumgartner WA, Casale AS, Greene PS, Cameron DE, Gardner TJ, et al. Current indications, risks and outcome after pericardiectomy. Ann Thorac Surg 1991;52:219–24.
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