Pericardiectomy

Jump to: navigation, search

Pericarditis Microchapters

Home

Patient Information

Overview

Anatomy

Classification

Pathophysiology

Causes

HIV
Post MI
Dressler's syndrome
Post-pericardiotomy
Radiation
Tuberculosis
Uremia
Malignancy

Differentiating Pericarditis from other Diseases

Epidemiology and Demographics

Natural History, Complications and Prognosis

Pericardial Effusion
Cardiac Tamponade
Constrictive Pericarditis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples

Chest X Ray

CT

MRI

Echocardiography

Other Imaging Findings

Treatment

Medical Therapy

Surgery

Pericardiocentesis
Pericardial Window
Pericardial Stripping

Treatment Related Videos

Case Studies

Case #1

Pericardiectomy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Google Images

American Roentgen Ray Society Images of Pericardiectomy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Pericardiectomy

CDC on Pericardiectomy

Pericardiectomy in the news

Blogs on Pericardiectomy

Directions to Hospitals Treating Type page name here

Risk calculators and risk factors for Pericardiectomy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and Keywords: Pericardial stripping; pericardial excision

Overview

Pericardiectomy is the surgical removal of part or most of the pericardium. This operation is performed to relieve constrictive pericarditis or to remove a pericardium that is calcified and fibrous. Constrictive pericarditis is a progressive disease without spontaneous reversal of pericardial thickening. Some patients can be medically managed for several years. Edema can be controlled with diuretics and slowing the heart rate can maximize the diastolic filling time. Many patients eventually develop significant debility from impaired cardiac output and elevated right and left sided filling pressures. The definitive treatment for constrictive pericarditis is pericardiectomy which is also known as pericardial stripping. This is a surgical procedure where the entire pericardium is peeled away from the heart. Due to the significant risks involved with pericardial stripping, many patients are treated medically, with judicious use of diuretics.

Procedure

The procedure begins when the surgeon makes an incision in the skin over the sternum and divides it to expose the pericardium. During the surgery, the surgeon will grasp the pericardium surrounding the heart, and will remove the fibrous, calcified or infected tissue covering of the heart. Once the pericardium is removed, the surgeon will wire the sternum back together, the incision is closed, and the procedure is completed.

Complications

The procedure has significant risks involved,[1] with mortality rates of 6%-12% in major referral centers.[2][3] The procedure can be complicated by perforation or tearing of the heart muscle if the heart muscle is tightly adherent to the pericardium. Stated simply, removal of the pericardium can remove the densely adherent heart muscle itself which is a catastrophic complication.

The high risk of the procedure is attributed to adherence of the thickened pericardium to the myocardium and coronary arteries. In patients who have undergone coronary artery bypass surgery with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium. Given the thin wall of the right ventricle, this can be a dangerous procedure and should only be undertaken if the patient's symptoms are incapacitating.

Prognosis and Long Term Outcomes Following Pericardiectomy

If any pericardium is not removed, it is possible for bands of pericardium to cause localized constriction which may cause symptoms and signs consistent with constriction. Some patients do not have complete relief of symptoms and up to 60% will have at least echocardiographic evidence of a restrictive filling pattern at approximately 2 years. Radiation induced disease seems to have a worse prognosis for improvement in functional class. The 5 and 10-year survival after pericardiectomy is 78% and 57% respectively, but is obviously highly correlated with the underlying illness.

Special Patient Groups

Pericardiectomy in Patients with Tuberculous Pericarditis

Pericardiectomy may be used in treatment of recurrent pericardial efussion due to TB, in tuberculous constrictive pericarditis, or if there is no hemodynamic and general improvement after 4-8 weeks following antituberculosis chemotherapy.[4] If it is performed in the early stages of TB pericardial constriction, pericardiectomy has a low mortality rate when compared to advanced stages of the disease where pericardiectomy is poorly tolerated. Mortality rate secondary to this procedure is 3-16%.[5][6] This surgery should be undertaken under the coverage of antitubercular drugs.

Treatment of effusive constrictive pericarditis is challenging because pericardiocentesis does not relieve the impaired filling of the heart, and surgical removal of the fibrinous exudate coating the visceral pericardium may not be possible. Patients should be started on antitubercular drugs and serial echocardiography should be performed to monitor the changes of pericardium and to make a decision regarding its surgical stripping.[4]

Related Chapters

Sources

Acknowledgements

The content on this page was first contributed by C. Michael Gibson, M.S., M.D.

Additional Resources

  • Adler Y, Finkelstein Y, Guindo J, de la Serna R, Shoenfeld Y, Bayes-Genis A, Sagie A, Bayes de Luna A, Spodick DH. Colchicine treatment for recurrent pericarditis: a decade of experience. Circulation. 1998;97:2183–2185.
  • Applegate RJ, Johnston WE, Vinten-Johansen J, Klopfenstein HS, Little WC. Restraining effect of intact pericardium during acute volume leading. Am J Physiol. 1992;262:H1725–H1733.
  • Artom G, Koren-Morag N, Spodick DH, Brucato A, Guindo J, Bayesde-Luna A, Brambilla G, Finkelstein Y, Granel B, Bayes-Genis A, Schwammenthal E, Adler Y. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multicentre all-case analysis. Eur Heart J. 2005;26:723–727.
  • Arunasalam S, Siegel RJ. Rapid resolution of symptomatic acute pericarditis with ketorolac tromethamine: a parenteral nonsteroidal antiinflammatory agent. Am Heart J. 1993;125(pt 1):1455–1458.
  • Bonnefoy E, Gordon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000;21:832–836.
  • Correale E, Maggioni AP, Romano S, Ricciardiello V, Battista R, Salvarola G, Santoro E, Tognoni G, on behalf of the Gruppo Italiano perlo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI). Comparison of frequency, diagnostic and prognostic significance of pericardial involvement in acute myocardial infarction treated with and without thrombolytics. Am J Cardiol. 1993;71:1377–1381.
  • Fowler NO. Tuberculous pericarditis. JAMA. 1991;266:99 –103.
  • Freeman GL, LeWinter MM. Determinants of the intrapericardial pressure in dogs. J Appl Physiol. 1986;60:758 –764.
  • Freeman GL, LeWinter MM. Pericardial adaptations during chronic cardiac dilation in dogs. Circ Res. 1984;54:294 –300.
  • Freeman GL, Little WC. Comparison of in situ and in vitro studies of pericardial pressure-volume relation in the dog. Am J Physiol. 1986;251: H421–H427.
  • Gunukula SR, Spodick DH. Pericardial disease in renal patients. Semin Nephrol. 2001;21:52–56.
  • Hoit BD, Gabel M, Fowler NO. Cardiac tamponade in left ventricular dysfunction. Circulation. 1990;82:1370–1376.
  • Imazio M, Bobbio M, Cecchi E, Demarie D, Demichellis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghiso A, Belli R, Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) Trial. Circulation. 2005;112:2012–2016.
  • Imazio M, Demichellis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003;42:2144–2148.
  • Imazio M, Demichellis B, Parrini I, Gluggia M, Cecchi E, Gaschino G, Demarie D, Ghislo A, Trinchero R. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43:1042–1046.
  • Jerjes-Sanchez C, Ramirez-Rivera A, Ibarra-Perez C. The Dressler syndrome after pulmonary embolism. Am J Cardiol. 1996;78:343–345.
  • Kansal S, Roitman D, Sheffield LT. Two-dimensional echocardiography of congenital absence of pericardium. Am Heart J. 1985;109:912–915.
  • Klopfenstein HS, Schuchard GH, Wann LS, Palmer TE, Hartz AJ, Gross CM, Singh S, Brooks HL. The relative merits of pulsus paradoxus and right ventricular diastolic collapse in the early detection of cardiac tamponade: an experimental echocardiographic study. Circulation. 1985;71: 829–833.
  • Knopf WD, Talley JD, Murphy DA. An echo-dense mass in the pericardial space as a sign of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol. 1987;59:1202.
  • Lange RA, Hillis D. Acute pericarditis. N Engl J Med. 2004;351: 2195–2202.
  • LeWinter MM, Kabbani S. Pericardial diseases. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease. 7th ed. Philadelphia, Pa: Elsevier Saunders; 2005:1757–1780.
  • Maisch B, Ristic D, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone. Eur Heart J. 2002;23: 1503–1508.
  • Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH, for the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases: executive summary. Eur Heart J. 2004;25:587– 610.
  • Maisch B. Recurrent pericarditis: mysterious or not so mysterious? Eur Heart J. 2005;26:631– 633.
  • Mandell BF. Cardiovascular involvement in systemic lupus erythematosus. Semin Arthritis Rheum. 1987;17:126 –141.
  • Miyazaki T, Pride HP, Zipes DP. Prostaglandins in the pericardial fluid modulate neural regulation of cardiac electrophysiological properties. Circ Res. 1990;66:163–175.
  • Park JH, Choo SJ, Park SW. Acute pericarditis caused by acrylic bone cement after percutaneous vertebroplasty. Circulation. 2005; 111:e98.
  • Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56:623– 630.
  • Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart. 2004;90:252–254.
  • Reddy PS, Curtiss EI, O’Toole JD, Shaver JA. Cardiac tamponade: hemodynamic observations in man. Circulation. 1978;58:265–272.
  • Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. 1990;66:1487–1491.
  • Shabetai R, Fowler NO, Guntheroth WG. The hemodynamics of cardiac tamponade and constrictive pericarditis. Am J Cardiol. 1970;26: 480–489.
  • Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart. 2004; 90:255–256.
  • Shabetai R. Recurrent pericarditis: recent advances and remaining questions. Circulation. 2005;112:1921–1923.
  • Singh S, Wann S, Schuchard GH, Klopfenstein HS, Leimgruber PP, Keelan MH, Brooks HL. Right ventricular and right atrial collapse in patients with cardiac tamponade: a combined echocardiographic and hemodynamic study. Circulation. 1984;70:966–971.
  • Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349: 684–690.
  • Spodick DH. Acute pericarditis: current concepts and practice. JAMA. 2003;289:1150 –1153.
  • Spodick DH. Intrapericardial treatment of persistent autoreactive pericarditis / myopericarditis and pericardial effusion. Eur Heart J. 2002;23: 1481–1482.
  • Spodick DH. Macrophysiology, microphysiology, and anatomy of the pericardium: a synopsis. Am Heart J. 1992;124:1046 –1051.
  • Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004;363: 717–727.
  • Tsang TS, Barnes ME, Hayes SN, Freeman WK, Dearani JA, Butler SL, Seward JB. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979–1998. Chest. 1999;116:322–331.
  • Tsang TS, Oh JK, Seward JB, Tajik AJ. Diagnostic value of echocardiography in cardiac tamponade. Herz. 2000;25:734–740.
  • Zayas R, Anguita M, Torres F, Gimenez D, Bergillos F, Ruiz M, Ciudad M, Gallardo A, Valles F. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol. 1995;75:378 –382.

References

  1. Cinar B, Enc Y, Goksel O, Cimen S, Ketenci B, Teskin O, Kutlu H, Eren E. (2006). "Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy". Int J Tuberc Lung Dis. 10 (6): 701–6. PMID 16776460.
  2. Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, Seth S, Mishra PK, Pradeep KK, Sathia S, Venugopal P (2006). "Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques". Ann Thorac Surg. 81 (2): 522–9. PMID 16427843.
  3. Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB, Tajik AJ (1999). "Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy". Circulation. 100 (13): 1380–6. PMID 10500037.
  4. 4.0 4.1 Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
  5. Fennell WM (1982). "Surgical treatment of constrictive tuberculous pericarditis". S Afr Med J. 62 (11): 353–5. PMID 7112301.
  6. Bashi VV, John S, Ravikumar E, Jairaj PS, Shyamsunder K, Krishnaswami S (1988). "Early and late results of pericardiectomy in 118 cases of constrictive pericarditis". Thorax. 43 (8): 637–41. PMC 461401. PMID 3175976.

de:Perikarditis nl:Pericarditis sv:Hjärtsäcksinflammation



Linked-in.jpg