Pericardial Diseases

Pericardium

The pericardium is a thin sac that surrounds, protects and lubricates your heart, allowing it to move and work efficiently. Problems can occur when the pericardium becomes inflamed or fills with fluid.

Pericardial diseases include pericarditis, pericardial effusion, cardiac tamponade and constrictive pericarditis. Although pericarditis is a disease primarily treated medically, pericardial effusion, pericardial tamponade and constrictive pericarditis can be treated surgically

Surgeons are asked to treat a patient when, there is collection of fluid within the pericardial cavity (the space between the pericardium and the heart) which may be causing the heart not to work well (tamponade) or to treat a thickening of the pericardium itself that causes an the heart not to be able to fill with blood and not to work well (constrictive pericarditis). 

Surgical therapies for pericardial collection (effusion)

In the event of re-occuring or very big pericardial collection of fluid he patient will need to have the fluid removed to allow the heart to work efficiently.

first attempt in treating pericardial collection should be by percutaneous aspiration of the fluid (pericardiocentesis) and possibly by the insertion of a drain, under local anaesthetic. This procedure should be performed by appropriately trained and experienced operators, at a tertiary hospital with cardiac surgery available on site. It is essential that the drain remains in-situ for a long period of time and until minimum drainage is recorded for over 24 hours. This allows adhesions to form and obliterate the pericardial cavity.

A more invasive approach to drain a pericardial collection is by performing a pericardial “window” using video assisted thoracoscopy (VATS) in theaters and under general anaesthetic. Other options include a sub-xiphoid incision or the construction of pericardial-peritoneal window. VATS pericardial window is the more effective technique to excise a larger usually “circular” part of the pericardium. The presence of the “window” will help to continuously drain subsequent pericardial fluid into the pleural cavity, which due to a much larger surface area, is capable to cope with increased amounts of fluid drained, without the threat of pleural collections. Frequently, the surgeon will also leave in situ a pericardial drain inside the pericardial cavity. The drain is facilitating the continues drainage of areas located further away from the excised pericardium and it is essential that it remains in-situ for a long period of time and until minimum drainage is recorded for over 24 hours, allowing sufficient time for adhesions to form and obliterate the pericardial cavity. This procedure can be done as a day case by experienced team of cardiothoracic anaesthetist and surgeon, it is more effective than percutaneous pericardial drain insertion and its therapeutic effect can last for a much longer period.

Surgical therapies for constrictive pericarditis

Constrictive pericarditis can occur after any pericardial disease process, with tuberculosis (TB) being the major cause of constrictive pericarditis in developing world. Idiopathic (unknown cause), post-cardiac surgery and bacterial infection pericarditis are the three major risk factors in the West. In patients with chronic relapsing pericarditis in whom medical management has failed, surgical pericardiectomy is a safe and effective method of relieving symptoms.

Appropriate, thorough clinical evaluation and assessment is of paramount importance. It is important to understand that patients with surgically proven constrictive pericarditis may have a normal pericardium on imaging studies. Alternatively patients with abnormal pericardial thickness may not clinically demonstrate signs or symptoms of constriction, especially after radiation therapy or prior cardiac surgery.

Pericardiectomy consists of subtotal excision of the parietal pericardium and it requires general anaesthesia, full sternotomy (or less commonly left thoracotomy and is usually performed with a beating heart, if possible.

The recent years success in offering pericardiectomy procedures with acceptable mortality and morbidity is directly related to the better understanding of the disease, the contribution of team approach in selecting and treating patients at sub-specialist centers and our higher capacity to rescue patients with aggressive intensive care management.

Pericardiectomy in experienced centers with complete decortication (when technically feasible) is the treatment of choice for constrictive pericarditis and it results in sustainable, medication free, symptomatic relief in most patients, with acceptable mortality and morbidity (Class I recommendation; Level of evidence C). Confronted with medically refractory pericarditis, earlier consideration for pericardiectomy may be warranted.

Medical therapy is essential in treating the underlying cause of infection or autoimmune disease; supportive in optimizing the patient prior to pericardiectomy or palliative, helping to control symptoms in advanced cases where surgery is unsuitable or has failed to relieve the symptoms.

Prevention of post-cardiotomy constrictive pericarditis

Post-cardiotomy constrictive pericarditis is the second most common indication for pericardiectomy in the developed world countries. It is essential that all necessary steps be followed to prevent the development of post-cardiotomy constrictive pericarditis. The current guidelines, based on data from available randomized control trials, support the use of low dose Colchicine for a period of one month after cardiac surgery, as the best available prevention therapy.

 

Relevant literature

Langdon SE, Seery K, Kulik A. Contemporary outcomes after pericardial window surgery: impact of operative technique. J Cardiothorac Surg. 2016;11(1):73. PubMed PMID: 27118051. Pubmed Central PMCID: PMC4847179.

Porta-Sanchez A, Sagrista-Sauleda J, Ferreira-Gonzalez I, Torrents-Fernandez A, Roca-Luque I, Garcia-Dorado D. Constrictive Pericarditis: Etiologic Spectrum, Patterns of Clinical Presentation, Prognostic Factors, and Long-term Follow-up. Rev Esp Cardiol (Engl Ed). 2015 Dec;68(12):1092-100. PubMed PMID: 25936614. English.

Szabo G, Schmack B, Bulut C, Soos P, Weymann A, Stadtfeld S, et al. Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy: 24 years of experience. Eur J Cardiothorac Surg. 2013 Dec;44(6):1023-8; discussion 8. PubMed PMID: 23761416.

Vistarini N CC, Mazine A, Bouchard D, Hebert Y, Carrier M, Cartier R, Demers P, Pellerin M, Perrault LP. Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute. Annals of Thoracic Surgery. 2015;100(1).

Busch C PK, Amorim PA, Gerbade J, Davierwala P, Schuler GC et al. Risk factors for mortality after pericardiectomy for constructive pericarditis in a large single-centre cohort. . European Journal of Cardiothoracic Surgery. 2015;48.
Gillaspie EA, Stulak JM, Daly RC, Greason KL, Joyce LD, Oh J, et al. A 20-year experience with isolated pericardiectomy: Analysis of indications and outcomes. J Thorac Cardiovasc Surg. 2016 Apr 29. PubMed PMID: 27210468. Pubmed Central PMCID: 27210468.

Kang SH, Song JM, Kim M, Choo SJ, Chung CH, Kang DH, et al. Prognostic predictors in pericardiectomy for chronic constrictive pericarditis. J Thorac Cardiovasc Surg. 2014 Feb;147(2):598-605. PubMed PMID: 23380514.

Ak K, Demirbas E, Atas H, Birkan Y, Akalin F, Cobanoglu A, et al. Results of pericardiectomy for constrictive pericarditis : Single-center experience. Herz. 2016 Jun 2. PubMed PMID: 27255116. Ergebnisse nach Perikardektomie bei Pericarditis constrictiva : Erfahrungen eines einzelnen Zentrums.

Bicer M, Ozdemir B, Kan I, Yuksel A, Tok M, Senkaya I. Long-term outcomes of pericardiectomy for constrictive pericarditis. J Cardiothorac Surg. 2015;10:177. PubMed PMID: 26613929. Pubmed Central PMCID: PMC4662820.

Landex NL, Ihlemann N, Olsen PS, Gustafsson F. Constrictive pericarditis in a contemporary Danish cohort: aetiology and outcome. Scand Cardiovasc J. 2015 Apr;49(2):101-8. PubMed PMID: 25658593.
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