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Moreyra AE, Cosgrove NM, Zinonos S, Yang Y, Cabrera J, Pepe RJ, Alam A, Kostis JB, Lee L, Kostis WJ. Constrictive Pericarditis after Open Heart Surgery: A 20-Year Case Controlled Study. Int J Cardiol 2021; 329:63-66. [PMID: 33421450 DOI: 10.1016/j.ijcard.2020.12.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/14/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Abel E Moreyra
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Nora M Cosgrove
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Stavros Zinonos
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yi Yang
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Javier Cabrera
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Russell J Pepe
- Department of Surgery, Hofstra-Northwell, North Shore, NY, USA
| | - Amit Alam
- Baylor University Medical Center, Division of Cardiology, Department of Advanced Heart Failure, Dallas, TX, USA
| | - John B Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Leonard Lee
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - William J Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Ramasamy V, Mayosi BM, Sturrock ED, Ntsekhe M. Established and novel pathophysiological mechanisms of pericardial injury and constrictive pericarditis. World J Cardiol 2018; 10:87-96. [PMID: 30344956 PMCID: PMC6189073 DOI: 10.4330/wjc.v10.i9.87] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/06/2018] [Accepted: 04/22/2018] [Indexed: 02/06/2023] Open
Abstract
This review article aims to: (1) discern from the literature the immune and inflammatory processes occurring in the pericardium following injury; and (2) to delve into the molecular mechanisms which may play a role in the progression to constrictive pericarditis. Pericarditis arises as a result of a wide spectrum of pathologies of both infectious and non-infectious aetiology, which lead to various degrees of fibrogenesis. Current understanding of the sequence of molecular events leading to pathological manifestations of constrictive pericarditis is poor. The identification of key mechanisms and pathways common to most fibrotic events in the pericardium can aid in the design and development of novel interventions for the prevention and management of constriction. We have identified through this review various cellular events and signalling cascades which are likely to contribute to the pathological fibrotic phenotype. An initial classical pattern of inflammation arises as a result of insult to the pericardium and can exacerbate into an exaggerated or prolonged inflammatory state. Whilst the implication of major drivers of inflammation and fibrosis such as tumour necrosis factor and transforming growth factor β were foreseeable, the identification of pericardial deregulation of other mediators (basic fibroblast growth factor, galectin-3 and the tetrapeptide Ac-SDKP) provides important avenues for further research.
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Affiliation(s)
- Vinasha Ramasamy
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of Integrative Biomedical Sciences, University of Cape Town, Observatory 7925, South Africa
| | - Bongani M Mayosi
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
- Division of Cardiology, University of Cape Town, Observatory 7925, South Africa
| | - Edward D Sturrock
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of Integrative Biomedical Sciences, University of Cape Town, Observatory 7925, South Africa
| | - Mpiko Ntsekhe
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
- Division of Cardiology, University of Cape Town, Observatory 7925, South Africa
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Kandachar PS, Kandachar SS, Maddali MM, Thomas E, Zacharias S. Constrictive Pericarditis and Tricuspid Valve Involvement. J Cardiothorac Vasc Anesth 2016; 30:1435-6. [DOI: 10.1053/j.jvca.2016.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Indexed: 11/11/2022]
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Abstract
Pericardial disease commonly occurs in the intensive care setting, but its timely diagnosis may be missed. The normal pericardium serves as a lubricated sac within which the heart may beat with minimal friction. The effect of the pericardium on cardiac filling at normal diastolic pressures is not clear; however, it may limit cardiac dilation in states of acute volume overload such as mitral regurgitation and right ventricular infarction. Pericardial disease may be divided into two catego ries : those cases that result from inflammation of the pericardium (pericarditis), and those cases in which a pericardial effusion or the thickened pericardium itself causes hemodynamic changes (tamponade and constric tion). Simple pericarditis should not lead to any hemo dynamic alteration other than tachycardia. In both tam ponade and constriction, the jugular venous pressure is elevated with low forward cardiac output; tamponade typically shows pulsus paradoxus, whereas constric tion more frequently shows Kussmaul's sign. The electrocardiogram may show diffuse ST segment elevation with PR segment depression in pericarditis; a large pericardial effusion, even with early tamponade, may not by itself cause any changes in the electrocar diogram. The echocardiogram is invaluable in diagnos ing the presence of a pericardial effusion and recogniz ing tamponade physiology (diastolic collapse of the right ventricular outflow tract and invagination of the right atrium). In selected patients, simple pericarditis may be managed outside of the hospital. Anyone suspected of having a hemodynamically significant pericardial effu sion should be hospitalized, usually in an intensive care unit. Pericardiocentesis should be performed under op timal monitoring conditions, although in an emergency, blind pericardiocentesis may be attempted. Recognition of the cause of the pericardial process will guide its treatment. Management of selected pericardial syn dromes is discussed later in this review.
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Affiliation(s)
- James D. Thomas
- Cardiology Unit, Medical Center Hospital of Vermont, Burlington, VT 05401
| | - Martin M. LeWinter
- Cardiology Unit, Medical Center Hospital of Vermont, Burlington, VT 05401
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5
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Deepti S, Gupta SK, Ramakrishnan S, Talwar S, Kothari SS. Constrictive pericarditis following open-heart surgery in a child. Ann Pediatr Cardiol 2016; 9:68-71. [PMID: 27011697 PMCID: PMC4782473 DOI: 10.4103/0974-2069.171402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
A 6-year- old child developed constrictive pericarditis 2 years after undergoing an open-heart surgery for a congenital cardiac disorder. No other cause of pericarditis was identified. The clinical condition improved after pericardiectomy. The case is reported for its rarity.
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Affiliation(s)
- Siddharthan Deepti
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Saurabh Kumar Gupta
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sivasubramanian Ramakrishnan
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Shyam Sunder Kothari
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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6
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Kim JH, Hwang YH, Youn YN, Yoo KJ. Effect of postoperative constrictive physiology on early outcomes after off-pump coronary artery bypass grafting. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:22-6. [PMID: 23422841 PMCID: PMC3573161 DOI: 10.5090/kjtcs.2013.46.1.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/22/2012] [Accepted: 10/09/2012] [Indexed: 11/25/2022]
Abstract
Background Constrictive pericarditis after coronary artery bypass surgery has been known to affect cardiac output by limiting diastolic ventricular filling. We aimed to assess the influence of postoperative constrictive physiology on the early outcomes of patients undergoing off-pump coronary artery bypass grafting (OPCAB). Materials and Methods Between January 2008 and July 2011, 903 patients underwent an isolated OPCAB and postoperative transthoracic-echocardiography. The patient cohort was classified into two groups: group A, constrictive physiology and group B, control group without constrictive physiology. Early outcomes were analyzed between the two groups. Results Of the total 903 patients, group A consisted of 153 patients (16.9%). The amount of blood loss in group A during the postoperative 24 hours was greater than that of group B, but this was not statistically significant (p=0.20). No significant differences were found in the mortality rates (group A, 0.6%; group B, 1.4%; p=0.40) and 30-day major adverse cardiac and cerebrovascular events (MACCEs; group A, 3.3%; group B, 6.1%; p=0.42). Conclusion Postoperative constrictive physiology does not affect 30-day MACCEs or other major complications after OPCAB. The results of this study suggest that patients with early postoperative constrictive physiology do not need medical or surgical treatment, and that conservative care is sufficient.
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Affiliation(s)
- Jung-Hwan Kim
- Division of Cardiovascular Surgery, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Korea
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7
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Al Soub H, Ahmedulla HS. Large Organized Intrapericardial Hematoma Presenting as a Case of Constrictive Pericarditis and Superior Vena Cava Syndrome. Qatar Med J 2012. [DOI: 10.5339/qmj.2012.1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Superior vena cava syndrome and constrictive pericarditis are rare complications of intrapericardial hematoma. We herein report a young patient presenting with a mass attached to the heart causing pressure on the right atrium and superior vena cava, and leading to superior vena cava syndrome and constrictive pericarditis. The exact pathogenesis was not determined but possibly was related to pericardiocentesis 29 years prior to presentation. Diagnosis was established at surgery and confirmed by histopathology. Resolution was partial because complete resection was not possible due to adherence of the mass to the right ventricular wall.
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Affiliation(s)
| | - HS Ahmedulla
- 2**lnternal Medicine Sections, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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8
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Ramana RK, Gudmundsson GS, Maszak GJ, Cho L, Lichtenberg R. Noninfectious constrictive pericarditis in a heart transplant recipient. J Heart Lung Transplant 2005; 24:95-8. [PMID: 15653387 DOI: 10.1016/j.healun.2003.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2003] [Revised: 10/15/2003] [Accepted: 10/15/2003] [Indexed: 01/24/2023] Open
Abstract
Acute rejection, infection, and allograft coronary artery disease have been recognized as the major causes of postoperative morbidity and mortality in cardiac transplant patients. More recently, pericardial and mediastinal complications have been recognized as a more common complication than previously believed. We describe a case of a heart transplant recipient admitted for apparent congestive heart failure exacerbation who was unresponsive to standard medical management of congestive heart failure and rejection. After further invasive evaluation, it was discovered the patient's condition was attributable to posttransplantation constrictive pericarditis. It is appropriate to consider this diagnosis in any postcardiac surgery (especially heart transplant recipients) in patients presenting with congestive heart failure exacerbations refractory to usual medical management.
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Affiliation(s)
- Ravi K Ramana
- Loyola University Medical Center, Maywood, IL 60153, USA
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9
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Ito M, Tanabe Y, Suzuki K, Kumakura M, Nakayama K, Kanazawa H, Yamazaki Y, Aizawa Y. A case of effusive-constrictive pericarditis after cardiac surgery. Mayo Clin Proc 2001; 76:555-8. [PMID: 11357803 DOI: 10.4065/76.5.555] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 60-year-old woman who had undergone repair of an atrial septal defect was readmitted to the hospital with dyspnea, abdominal distention, and leg edema 31 months after surgery. An echocardiogram demonstrated massive pericardial effusion. Cardiac catheterization revealed elevation and equilibrium of the 4-chamber diastolic pressure and a dip-and-plateau pattern in the right and the left ventricular pressures. Despite removal of pericardial fluid by pericardiocentesis, the findings and symptoms did not improve. The patient underwent both parietal and visceral pericardiectomy after which striking hemodynamic and symptomatic improvement occurred. Effusive-constrictive pericarditis is uncommon but should be considered in patients with refractory heart failure and massive pericardial effusion showing no improvement after removal of pericardial fluid.
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Affiliation(s)
- M Ito
- First Department of Internal Medicine, Niigata University School of Medicine, 1-757 Asahimachi-dori, Niigata 951-8517, Niigata, Japan.
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10
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Hinkamp TJ, Sullivan HJ, Montoya A, Park S, Bartlett L, Pifarre R. Chronic cardiac rejection masking as constrictive pericarditis. Ann Thorac Surg 1994; 57:1579-83. [PMID: 8010805 DOI: 10.1016/0003-4975(94)90127-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The hemodynamic changes consistent with constrictive pericarditis are often encountered in patients who have undergone cardiac transplantation. We describe here 4 patients who underwent pericardiectomy after cardiac transplantation. All were found to have evidence of a thickened and constricting peel of pericardium at surgical exploration. Their postoperative clinical courses were variable. One patient with primarily effusive constriction experienced marked improvement. Three patients failed to show clinical improvement and had persistently elevated atrial and ventricular end-diastolic pressures. A coexisting restrictive cardiomyopathy secondary to chronic rejection, coronary arteriopathy, or long-standing constriction may have been the cause of this poor outcome. Many patients with transplanted hearts exhibit evidence of poor diastolic ventricular compliance without evidence of classic constriction; some manifest both the restrictive and constrictive components. The careful selection of patients with constrictive pericarditis can optimize the outcome.
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Affiliation(s)
- T J Hinkamp
- Loyala University Medical Center, Maywood, Illinois 60153
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11
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12
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Cimino JJ, Kogan AD. Constrictive pericarditis after cardiac surgery: report of three cases and review of the literature. Am Heart J 1989; 118:1292-301. [PMID: 2686382 DOI: 10.1016/0002-8703(89)90021-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Constrictive pericarditis after cardiac surgery is a rare phenomenon occurring with an incidence of 0.2% to 0.3%. To date only 158 cases have been reported in the world literature. Symptoms include dyspnea (81%), chest pain (34%), and fatigue (29%). Peripheral edema (90%) and an elevated jugular venous pressure (86%) were the most common abnormal signs found during physical examination. Chest x-ray and ECG abnormalities were not helpful in making the diagnosis, and abnormal echocardiographic findings were reported in less than half of the cases. Computerized tomography and magnetic resonance imaging scans of the heart were usually of great diagnostic benefit. Diastolic equalization of cardiac pressures remains the sine que non for diagnosis. Oral steroids have been reported to favorably alter the course early in the disease, but pericardial stripping remains the definitive form of therapy. Operative mortality rates vary from 5.5% to 14.5%.
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13
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Abstract
Forty-five patients were identified as having constrictive pericarditis after cardiac surgery. The mean patient age was 61 years (range, 40 to 77 years). Twenty-three of 37 patients with adequate clinical information were reported to have had a diagnosis of postpericardiotomy syndrome after the original surgery. The mean interval from original surgery to presentation with constriction was 23.4 months (range, 1 to 204 months). Computerized tomography was helpful in establishing a diagnosis of constriction in 23 of 29 patients (79%). Bypass graft patency was 93% (85 of 91 grafts). Severe pulmonary hypertension (pulmonary artery systolic pressure greater than or equal to 60 mm Hg) was present in nine patients; 8 had coexistent valvular disease (seven cases of mitral valve disease, and aortic valve disease in one). Thirty-seven of the 45 patients underwent pericardial stripping, 28 of whom experienced marked symptomatic improvement. One patient had persistent right heart failure, which was not documented to be secondary to constriction. Four patients had persistent constrictive physiologic conditions. Three of these patients had more extensive pericardial stripping and showed clinical improvement. Four patients (11%) died within 30 days of stripping. Eight patients received medical therapy alone. The decision to treat patients medically was based either on favorable response to medical therapy (five patients), or poor general clinical status.
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Affiliation(s)
- D M Killian
- Department of Medicine, Loyola University Medical Center, Maywood, IL 60153
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HIMELMAN RONALDB, LEE EDMOND, KIRCHER BARBARA, SCHILLER NELSONB. Plethora of the Inferior Vena Cava with Blunted Respiratory Response: A Useful Echocardiographic Sign of Pericardial Disease. Echocardiography 1989. [DOI: 10.1111/j.1540-8175.1989.tb00298.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Himelman RB, Kircher B, Rockey DC, Schiller NB. Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol 1988; 12:1470-7. [PMID: 3192844 DOI: 10.1016/s0735-1097(88)80011-1] [Citation(s) in RCA: 117] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
To assess the diagnostic and prognostic value of the respiratory behavior of the inferior vena cava in pericardial effusions, clinical and two-dimensional echocardiographic data of 115 consecutive patients with a moderate or large effusion, including 33 who had cardiac tamponade, were reviewed. Echocardiograms were reviewed for effusion size, inferior vena cava diameter before and after deep inspiration and presence of right atrial and ventricular collapse. For the 83 patients (72%) with less than 50% decrease in inferior vena cava diameter after deep inspiration ("plethora"), inferior vena cava diameter decreased from 2.0 +/- 0.3 to 1.6 +/- 0.4 cm after inspiration (mean +/- SD) (mean decrease 18%). For the 32 patients (28%) without plethora, the diameter decreased from 1.6 +/- 0.5 to 0.6 +/- 0.3 cm (mean decrease 63%). Patients with plethora had significantly higher values for heart rate (111 +/- 21 versus 98 +/- 20 beats/min), pulsus paradoxus (24 +/- 15 versus 12 +/- 4 mm Hg), jugular venous distension (14 +/- 5 versus 8 +/- 3 cm H2O) and right atrial pressure (17 +/- 6 versus 12 +/- 6 mm Hg) and lower values for systolic blood pressure (109 +/- 22 versus 132 +/- 27 mm Hg) (all p less than 0.05) than did patients without plethora. Plethora was present in 58 (92%) of 63 patients who underwent a pericardial drainage procedure, 14 (88%) of 16 who developed constrictive physiology and 11 (92%) of 12 of those whose hospital death was related to pericardial effusion.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R B Himelman
- Department of Medicine, University of California, San Francisco 94143
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16
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Bazaral MG, Ellis JE, Kaplan JA, Stewart RW. A 66-year-old man has an unexpected low cardiac output syndrome during repeat myocardial revascularization. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1988; 2:375-384. [PMID: 17171876 DOI: 10.1016/0888-6296(88)90321-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Pflugfelder PW, McKenzie FN, Kostuk WJ. Hemodynamic profiles at rest and during supine exercise after orthotopic cardiac transplantation. Am J Cardiol 1988; 61:1328-33. [PMID: 3287883 DOI: 10.1016/0002-9149(88)91178-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
To characterize the spectrum of hemodynamic findings after orthotopic cardiac transplantation, 20 healthy heart transplant recipients with no evidence of cardiac dysfunction by noninvasive testing were studied for 1 to 51 months (mean 15) following surgery. After routine endomyocardial biopsy, right-sided heart pressures and thermodilution cardiac outputs were measured at rest (supine) and during symptom-limited, graded supine exercise. In addition, the effect of respiration on right atrial pressures and waveforms was determined at rest (supine, legs down), and after passive leg raising (volume loading). During exercise, striking increases of pulmonary artery, pulmonary artery wedge and right atrial pressures were seen. The mean pulmonary artery pressure rose 45% during the first stage of exercise (p less than 0.001) and by peak exercise it had increased 87% above resting values. The pulmonary artery wedge pressure increased significantly with passive leg elevation (p less than 0.001) and during the first stage of exercise rose 61% above baseline values. By peak exercise the mean pulmonary artery wedge pressure was more than double the resting value. Similarly, the right atrial mean pressure increased significantly (p less than 0.001) with passive leg elevation and nearly tripled at peak exercise. All values promptly returned to near baseline after exercise. The cardiac output increased 98% during exercise. During early exercise, the rise in cardiac output was mediated primarily by an increase in stroke volume. At rest, there was an abnormal response in right atrial mean pressure during slow deep inspiration in 7 individuals with legs down and in 12 after passive leg elevation (volume loading), including 4 of 10 patients studied beyond 1 year.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P W Pflugfelder
- Department of Medicine, University Hospital, University of Western Ontario, London, Canada
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18
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Abstract
Ninety-five consecutive patients with constrictive pericarditis that was documented at the time of surgery during 1970 to 1985 were reviewed. The etiologies included idiopathic (42%), postradiotherapy (31%), post-cardiac surgery (11%), postinfective (6%), connective tissue disease-related (4%), neoplastic (3%) uremic (2%), and sarcoidosis (1%). Post-cardiac surgery etiology was seen only after 1980, but constituted 29% of cases during 1980-1985. Postradiotherapy etiology occurred with equal incidence in 1980-1985 and in 1970-1980, but the interval from radiotherapy to presentation with constrictive pericarditis was longer in the more recent period (11 vs 4.75 years). Effusive constrictive pericarditis occurred in 24% overall with similar prevalence in all of the etiologic groups except the postsurgical cases, which were caused by noneffusive fibrous constrictive pericarditis in all instances. Operative mortality was 12% overall: It was lower in the idiopathic group (8%) and higher in the postradiotherapy group (21%). Thus postradiotherapy constrictive pericarditis continues to occur despite technical changes aimed at reducing its likelihood, but recent cases have a longer latent period: and postsurgical constrictive pericarditis has emerged as an important etiology.
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Kabbani SS, Bashour T, Ellertson DG, Geiger J, Hanna ES, Cheng TO. Constrictive pericarditis following myocardial revascularization: a possible cause of graft occlusion. Am Heart J 1985; 110:493-5. [PMID: 3875276 DOI: 10.1016/0002-8703(85)90179-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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20
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Ruder MA, Flaker GC, Alpert MA, Selmon MR. Right ventricular myocardial contusion simulating constrictive pericardial disease. Am Heart J 1984; 108:1353-1354. [PMID: 6496292 DOI: 10.1016/0002-8703(84)90764-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Ribeiro P, Sapsford R, Evans T, Parcharidis G, Oakley C. Constrictive pericarditis as a complication of coronary artery bypass surgery. Heart 1984; 51:205-10. [PMID: 6607061 PMCID: PMC481485 DOI: 10.1136/hrt.51.2.205] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Although it is now recognised as a rare complication of cardiac surgery, constrictive pericarditis was diagnosed in three patients after coronary artery bypass surgery. The time interval between cardiac surgery and the development of constrictive features varied from two to six weeks. All three patients presented with severe congestive heart failure. Haemodynamic findings were characteristic of constrictive pericarditis. Pericardial thickening detected by computed tomography in one patient was useful in establishing a definite diagnosis. One of the patients had a serous constrictive effusive pericarditis, and surgical pericardial drainage was needed. The other patient underwent pericardiectomy with preservation of the grafts. The diagnosis of constrictive pericarditis should be considered in patients presenting with unexplained right sided heart failure after cardiac surgery.
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Abstract
Constrictive pericarditis as a complication of cardiac surgery does exist. Although the problem is somewhat uncommon, it should be suspected in patients following cardiac surgery who present with deteriorating cardiac function. The clinical spectrum of the disease is wide and may present as true rigid shell constriction or a more subtle form of elastic sero-effusive construction. It is imperative for the physician to consider this entity in the differential of complications following cardiac surgery.
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Anderson PA. Diagnostic problem: constrictive pericarditis or restrictive cardiomyopathy? CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1983; 9:1-7. [PMID: 6339069 DOI: 10.1002/ccd.1810090102] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
The current status of constrictive pericarditis is reviewed with regard to its etiology, physical signs, electrocardiographic findings, and hemodynamic features. Angiographic aspects are also presented. The role and limitations of M-mode echocardiography in this disease are emphasized. The value of other noninvasive studies such as measurement of systolic time intervals, myocardial scanning, and high-speed echocardiography is described. Emphasis is placed on the invasive and noninvasive methods that may be useful in separating restrictive cardiomyopathy from constrictive pericarditis. Methods of treatment, indications for pericardial resection, and the current operative results are commented on briefly.
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Kutcher MA, King SB, Alimurung BN, Craver JM, Logue RB. Constrictive pericarditis as a complication of cardiac surgery: recognition of an entity. Am J Cardiol 1982; 50:742-8. [PMID: 6981995 DOI: 10.1016/0002-9149(82)91228-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Among 5,207 adult patients who underwent cardiac surgery, postoperative constrictive pericarditis was recognized in 11 patients (0.2% incidence rate). Seven patients had coronary arterial bypass grafting and 4 had valve replacement; the pericardium was left open in all cases. The average interval between surgery and presentation of pericardial constriction was 82 days (range 14 to 186). M mode echocardiography revealed epicardial and pericardial thickening in 7 cases and variable degrees of posterior pericardial effusion in 5 cases. Cardiac catheterization demonstrated uniformity of diastolic pressures with a characteristic early diastolic dip and late plateau pattern. Two patients responded to medical therapy for chronic pericarditis. One patient had a limited parietal pericardiectomy followed by recurrent constrictive pericarditis that eventually stabilized with medical therapy. The other 8 patients required radical pericardiectomy. The pathophysiology of constriction after surgery is unclear. Its clinical expression involves a wide spectrum of presentation and therapeutic response. Constrictive pericarditis may be a complication of cardiac surgery in spite of an open pericardium and should be considered in postoperative patients who present with deteriorating cardiac function.
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Dillon JC, Vasu CM, Berman DS, DeMaria AN, Goldstein S, Mandel WJ, Warren JV. Task force III: diagnostic procedures. Emergency cardiac care. Am J Cardiol 1982; 50:382-92. [PMID: 7048889 DOI: 10.1016/0002-9149(82)90195-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Miller JI, Mansour KA, Hatcher CR. Pericardiectomy: current indications, concepts, and results in a university center. Ann Thorac Surg 1982; 34:40-5. [PMID: 7092398 DOI: 10.1016/s0003-4975(10)60850-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
During a 7 1/2-year period, 102 patients underwent pericardiectomy in the Emory University Affiliated Hospitals for a wide variety of pericardial disease. Seventy-six patients had predominantly effusive pericardial disease, and 26 patients had constrictive pericarditis. Nineteen cases of constrictive pericarditis developed in patients who had undergone previous open-heart operations. Hospital mortality at six weeks was 8.8%. The surgical approach was a left anterior thoracotomy in 72 patients; median sternotomy in 26 patients; and a subxiphoid approach in 4 patients. Only 2 patients required cardiopulmonary bypass. A detailed discussion of each subgroup of patients with pericardial disease requiring pericardiectomy is given.
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Abstract
Five patients with constriction secondary to pericarditis or membrane formation following cardiac surgical procedures are reported. In 4 of the 5 patients, a postpericardiotomy syndrome developed after the original procedure. Constriction occurred from ten weeks to almost 6 years after the cardiac operation. Clinicians should watch carefully for the delayed onset of constriction in patients with a postpericardiotomy syndrome after cardiac operation.
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Kanakis C, Sheikh AI, Rosen KM. Constrictive pericardial disease following mitral valve replacement. Chest 1981; 79:593-4. [PMID: 7226939 DOI: 10.1378/chest.79.5.593] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Constrictive pericardial disease developing after open heart surgery is not a well-recognized complication of this procedure. It has been reported only a few times and usually not with good hemodynamic data before and after the subsequent pericardiectomy. We presently report a patient who developed constrictive pericardial disease five years after mitral valve replacement. This was documented with left- and right-sided heart catheterization. The patient underwent pericardiectomy with remarkable clinical improvement. Repeat right- and left-sided heart catheterization done three months postoperatively documented the resolution of the constrictive hemodynamic pattern present before pericardiectomy.
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Abstract
In valvular heart disease, there is a different radionuclide angiographic pattern in each of three left-sided valve abnormalities: pressure overload (aortic stenosis), volume overload (aortic or mitral regurgitation) and inflow obstruction (mitral stenosis). In pressure overload, the left ventricle is usually normal in size or minimally dilated. The ejection fraction may be normal, increased or decreased. In volume overload, there is left ventricular dilatation with a normal or reduced ejection fraction at rest. Scans may be performed during exercise to unmask abnormalities of ventricular function not evident at rest. In inflow obstruction, left ventricular function is usually normal but may be depressed. Right ventricular function may be abnormal secondary to pulmonary hypertension. Radionuclide angiography in valvular heart disease evaluates the impact of the valve abnormality on cardiac chamber size and function, which is useful in managing the patient, in determining the prognosis and in evaluating the success of valve surgery. Thallium-2-1 imaging evaluates regional myocardial blood flow and cell integrity and can be used to assess associated coronary artery disease.
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Little WC, Primm RK, Karp RB, Hood WP. Clotted hemopericardium with the hemodynamic characteristics of constrictive pericarditis. Am J Cardiol 1980; 45:386-8. [PMID: 7355745 DOI: 10.1016/0002-9149(80)90664-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiac catheterization in a patient 4 weeks after coronary arterial bypass surgery demonstrated the typical hemodynamic findings of constrictive pericarditis, which completely resolved after removal of 500 ml of clotted pericardial blood. The pericardium was not responsible for the findings because it was left in place. This case demonstrates that clotted hemopericardium may mimic constrictive pericarditis.
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