Constrictive Pericarditis After Cardiac Transplantation: A Case Report and Literature Review

Constrictive pericarditis following cardiac transplantation: a report of two cases and a literature review

The data on constrictive pericarditis following heart transplantation are scarce. Herein, the authors present 2 patients who developed a constrictive pericarditis 19, and 55 months after heart transplantation. They underwent several diagnostic procedures and successfully recovered after a radical pericardiectomy. In addition, the authors review the literature and report the incidence, aetiology, diagnostic features, and management of this rare and challenging condition.

Indications, Complications, and Outcomes of Cardiac Surgery After Heart Transplantation: Results From the Cash Study

Background

Allograft pathologies, such as valvular, coronary artery, or aortic disease, may occur early and late after cardiac transplantation. Cardiac surgery after heart transplantation (CASH) may be an option to improve quality of life and allograft function and prolong survival. Experience with CASH, however, has been limited to single-center reports.

Methods

We performed a retrospective, multicenter study of heart transplant recipients with CASH between January 1984 and December 2020. In this study, 60 high-volume cardiac transplant centers were invited to participate.

Results

Data were available from 19 centers in North America (n = 7), South America (n = 1), and Europe (n = 11), with a total of 110 patients. A median of 3 (IQR 2–8.5) operations was reported by each center; five centers included ≥ 10 patients. Indications for CASH were valvular disease (n = 62), coronary artery disease (CAD) (n = 16), constrictive pericarditis (n = 17), aortic pathology (n = 13), and myxoma (n = 2). The median age at CASH was 57.7 (47.8–63.1) years, with a median time from transplant to CASH of 4.4 (1–9.6) years. Reoperation within the first year after transplantation was performed in 24.5%. In-hospital mortality was 9.1% (n = 10). 1-year survival was 86.2% and median follow-up was 8.2 (3.8–14.6) years. The most frequent perioperative complications were acute kidney injury and bleeding revision in 18 and 9.1%, respectively.

Conclusion

Cardiac surgery after heart transplantation has low in-hospital mortality and postoperative complications in carefully selected patients. The incidence and type of CASH vary between international centers. Risk factors for the worse outcome are higher European System for Cardiac Operative Risk Evaluation (EuroSCORE II) and postoperative renal failure.

Constrictive pericarditis following heart transplantation: Reality or fiction?

Constrictive pericarditis (CP) is a curable cause of diastolic heart failure with prior cardiac surgery being a recognizable etiology. We report a patient who developed CP one year following heart transplantation. Several clinical and imaging related factors may lead to diagnostic delays in similar patients, including the mistaken belief that transplanted hearts are devoid of pericardium and thus do not develop constriction. Post-transplantation pericardial effusion, mediastinitis, and cardiac rejection predispose to future CP. Caretakers should consider this entity in allograft recipients who develop heart failure symptoms of unclear etiology.

Clinical features and prognosis of surgically proven constrictive pericarditis after orthotopic heart transplantation

Constrictive pericarditis (CP) results in pericardial non-compliance and diastolic dysfunction. Definitive treatment is pericardiectomy, but data on CP after orthotopic heart transplantation (OHT) are limited. Accordingly, a retrospective review of 8 cases of surgically proven CP after OHT undergoing pericardiectomy was conducted. In this series, all patients were male. The median time to symptomatic CP after OHT was 1.7 years (range: 0.8-18.1 years). The echocardiographic assessment was diagnostic for CP in 3 cases (38%). Cross-sectional imaging was performed in 6 cases, revealing ≥ mild pericardial thickening in all. A total of 6 patients (75%) underwent cardiac catheterization, which revealed CP in 5 (83%). Post-pericardiectomy 30-day mortality was 13% (1 patient). The median survival after pericardiectomy was 2.3 years (range: 18 days-14.6 years) and 5-year survival was 29%. Overall, CP after OHT represents a subset of patients with CP with high morbidity and mortality, and multimodality assessment is essential for its diagnosis. Despite a relatively low surgical mortality, long-term survival is poor.

Constrictive Pericarditis After Lung Transplantation

BACKGROUND

Constrictive pericarditis is a rare, but increasingly recognized long-term postoperative complication of lung transplantation. Heightened clinical suspicion, improved diagnostic imaging, and effective surgical treatment of the disease have led to progressive awareness of the pathology. We present our institutional experience with constrictive pericarditis after lung transplant in an effort to investigate the cause and natural history of the disease.

METHODS

From October 2005 to October 2018, 1234 patients underwent orthotopic lung transplantation at Duke University Hospital. An institutional database was queried to identify incident patients and determine baseline clinical data. At a median of 11.2 months (interquartile range = 4.6-28.6 mo), 10 patients (0.8%) developed constrictive pericarditis. Simple descriptive statistics were used to describe cohort characteristics and identify variables associated with constrictive pericarditis after lung transplantation.

RESULTS

The indication for transplantation at index operation was idiopathic pulmonary fibrosis in 8 of 10 patients (1.2% of the 760 restrictive lung disease patients transplanted in the same time period). All 10 patients presented with worsening dyspnea and pleural effusions. Right heart catheterization confirmed constrictive physiology in all cases. Eight patients underwent pericardiectomy with improvement in cardiovascular hemodynamics and resolution of symptoms with no 30-day mortality.

CONCLUSIONS

Diagnosis of constrictive pericarditis should be considered in patients with new-onset heart failure symptoms or recurrent pleural effusions within 2 years of lung transplantation. Idiopathic pulmonary fibrosis may be associated with increased risk for constrictive pericarditis. Pericardiectomy is a safe and effective treatment for posttransplant constrictive pericarditis.

Constrictive pericarditis after heart transplantation: a case report

Background

Constrictive pericarditis (CP) is a disease characterized by inflammation, progressive fibrosis, and thickening of the pericardium. Constrictive pericarditis after heart transplantation (HT) is a rare phenomenon, with a reported incidence of 1.4-3.9%. It is an important clinical problem which shares similar clinical features with entities such as restrictive cardiomyopathy. Therefore, it poses diagnostic challenges and therapeutic dilemmas even for experienced clinicians.

Case summary

A 53-year-old patient developed a zoster infection with pericardial effusion 9 months after HT for idiopathic dilated cardiomyopathy. Two months later, he presented with leg oedema and ascites and was treated by diuretics for volume overload. He was readmitted 8 months later with features of right heart failure. Multimodal imaging investigations were suggestive of CP. He successfully recovered after a radical pericardiectomy.

Discussion

Constrictive pericarditis is a rare complication in HT. Heart transplant recipients (HTR) with a history of post-operative pericardial effusion, or with rejection episodes are at high risk of developing CP. Differentiating CP from other conditions that cause apparent congestive heart failure in HTR is challenging. Management of CP is mainly surgical pericardiectomy.

Successful Combined Heart and Kidney Transplantation in Patient With Fabry's Disease: A Case Report

Fabry's disease is a X-linked hereditary disease that causes the accumulation of glycosphingolipids in tissues and organs, including the kidneys and heart. This can result in both chronic kidney disease and cardiac dysfunction, including arrhythmias and heart failure. We describe a case of a 62-year-old male with Fabry's disease undergoing successful combined heart and kidney transplantation for chronic renal failure and low-output systolic heart failure. The patient has normal cardiac function and normal renal function 7 years after transplantation, while being maintained on enzyme replacement therapy with recombinant human alpha-galactosidase A. Fabry's disease is not a contraindication for organ transplantation, even in patients presenting with both renal failure and heart failure.

Constrictive Pericarditis in the Presence of Remaining Remnants of a Left Ventricular Assist Device in a Heart Transplanted Patient

Constrictive pericarditis (CP) is a severe subform of pericarditis with various causes and clinical findings. Here, we present the unique case of CP in the presence of remaining remnants of a left ventricular assist device (LVAD) in a heart transplanted patient. A 63-year-old man presented at the Heidelberg Heart Center outpatient clinic with progressive dyspnea, fatigue, and loss of physical capacity. Heart transplantation (HTX) was performed at another heart center four years ago and postoperative clinical course was unremarkable so far. Pharmacological cardiac magnetic resonance imaging (MRI) stress test was performed to exclude coronary ischemia. The test was negative but, accidentally, a foreign body located in the epicardial adipose tissue was found. The foreign body was identified as the inflow pump connection of an LVAD which was left behind after HTX. Echocardiography and cardiac catheterization confirmed the diagnosis of CP. Surgical removal was performed and the epicardial tubular structure with a diameter of 30 mm was carefully removed accompanied by pericardiectomy. No postoperative complications occurred and the patient recovered uneventfully with a rapid improvement of symptoms. On follow-up 3 and 6 months later, the patient reported about a stable clinical course with improved physical capacity and absence of dyspnea.