Constrictive pericarditis as a complication of coronary artery bypass surgery

Constrictive pericarditis following surgical repair of a peritoneopericardial diaphragmatic hernia in a cat

A 4-year-old female spayed domestic longhair cat was referred for dyspnea. Further diagnostics revealed severe pleural effusion and a peritoneopericardial diaphragmatic hernia (PPDH). Following surgical correction of the PPDH the pleural effusion persisted. Re-check echocardiogram 4 weeks after initial evaluation revealed leftward deviation of the interventricular septum and interatrial septum occurring with inspiration. There were also exaggerated phasic changes in trans-tricuspid flow velocities suggestive of constrictive pericardial disease. Cardiac catheterization was performed and revealed elevated pressures in the right atrium and right ventricle. Constrictive pericarditis (CP) and epicarditis was confirmed at surgery, where subtotal pericardiectomy was performed with epicardial decortication. The cat continued to develop recurrent pleural effusion after surgery, although the volume and frequency of recurrence slowed over time. This is the first reported case of CP following PPDH repair in a cat.

Constrictive pericarditis after cardiac surgery

Constrictive pericarditis may develop as a midterm or late complication of cardiac surgery. Owing to limited incidence and scarce reports in the literature the pathophysiologic determinants of such conditions are scarcely known, although a number of mechanisms have been implicated. This disease often poses major diagnostic issues as its clinical picture at presentation is nonspecific, may develop at any moment during the postoperative follow-up, and transthoracic echocardiography may be not suggestive of the diagnosis. The present paper aims at critically revising the available literature on the topic, emphasizing the need to keep a high level of suspicion for all surgeons and physicians involved in the long-term care of cardiac surgery patients.

Characteristics of acute congestive heart failure with normal ejection fraction and less elevated B-type natriuretic peptide

BACKGROUND

Heterogeneity in B-type natriuretic peptide (BNP) levels, especially among individuals with acute heart failure with normal left ventricular ejection fraction (HFNEF), can cause confusion in interpreting results. We investigated the characteristics of cases of acute HFNEF with only modestly elevated BNP.

METHODS

One hundred forty-two patients with acute or acute exacerbation of chronic HFNEF were divided into two groups by BNP level: BNP < 100 pg/ml (NB group, n = 45) and BNP > or = 100 pg/ml (B group, n = 97). We compared clinical findings, echocardiography results, and neurohormonal factors between these two groups.

RESULTS

In the NB group, a history of open-heart surgery (OHS) was more frequent (71% vs. 22%, p < 0.0001) and hypertension was less frequent (p = 0.0005). Left atrial diameter (LAd) was higher (p = 0.0026), while interventricular septal thickness, posterior wall thickness, relative wall thickness, left ventricular mass index were lower (p = 0.0005, p = 0.0225, p = 0.0114, p = 0.0051, respectively) in the NB group. In patients with HFNEF, a history of OHS remained an independent predictor of BNP level (< 100 pg/ml) after adjustment for hypertension, age, LAd, and interventricular septal thickness (odds ratio 3.6, p = 0.0252).

CONCLUSION

We found associations between acute HFNEF with less elevated BNP and a history of OHS. In a patient suspected of HFNEF, a history of OHS is considered diagnostic evidence of presence of diastolic heart failure when plasma levels of BNP are less elevated.

Rapid Development of Fatal TB Constrictive Pericarditis After Cardiac Surgery

We report the case of a 75-year-old male of Asian origin who developed TB constrictive pericarditis less than 6 weeks after CABG. He had no history of active TB, but did show a strong Heaf test reaction in 1987, following a period of weight loss. This was thought to be indicative of previous infection and was not actively treated. Cases of postcardiac surgery constrictive pericarditis have been reported in the literature, but to our knowledge, there is no report of development of TB constrictive pericarditis in such a short period following surgery.

Early development of severe constrictive pericarditis after coronary bypass grafting

A 61-year-old patient developed severe constrictive pericarditis with exertional dyspnea, 3 weeks after coronary bypass surgery. The diagnosis was confirmed by echocardigraphy and computed tomography examination. Despite the short duration of the disease, the pericardium showed a thickness of about 1 cm. Because initial treatment with steroids, diuretics and antiinflammatory drugs was of no avail, the patient underwent pericardiectomy, with a satisfactory outcome. The relatively rapid progress of constriction and the marked thickness of the pericardium that developed after a short period of time are emphasized.

Role of transesophageal echocardiography in assessing diastolic dysfunction in a large clinical practice: a 9-year experience

BACKGROUND

Two-dimensional transthoracic echocardiography with respiratory monitoring has been used to characterize diseases that impair diastolic function. Transesophageal echocardiography (TEE) has emerged as a complementary technique to evaluate patients with these diseases. The purpose of this study was to evaluate in a large clinical practice the utility of TEE with respiratory monitoring for classification of patients with diastolic dysfunction.

METHODS

Over a 9-year period TEE was used to examine 192 patients referred to an echocardiography laboratory for additional evaluation of abnormal diastolic function. We performed pulsed-wave Doppler TEE of the left ventricular inflow and pulmonary veins and respiratory monitoring to categorize patients as showing restrictive physiologic features, constriction with or without effusion, mixed constriction and restriction, abnormal relaxation, pseudonormalization, large pericardial effusion or tamponade, or normal diastolic function.

RESULTS

Patients with diastolic dysfunction underwent 3% of the total number of transesophageal studies conducted during the study period. Among the 192 patients referred for TEE, abnormal diastolic function was found in 181 (94%); 11 (6%) had normal diastolic function. Seventy-one (39%) of the 181 patients had restrictive physiologic features. Constrictive pericarditis was found in 54 (30%) of the patients and was confirmed for all 31 patients who underwent pericardiectomy. Mixed constriction and restriction was present in 21 (12%) of the patients. The other 35 patients (19%) had abnormal relaxation, pseudonormalization, or large pericardial effusion or tamponade. The cause of diastolic dysfunction was idiopathic for 32% of the patients, previous cardiac operation for 26%, cardiac amyloidosis for 23%, radiation therapy for 11%, and hypertension or advanced ischemic heart disease for 8%.

CONCLUSION

Two-dimensional and Doppler TEE with respiratory monitoring is useful in categorizing patients with impaired diastolic function, primarily into those with restrictive physiologic features or constrictive pericarditis.

Constrictive pericarditis and pleuropulmonary disease linked to ergot dopamine agonist therapy (cabergoline) for Parkinson's disease

Cabergoline is one of several ergoline dopamine agonist medications used in the treatment of Parkinson's disease (PD). We diagnosed constrictive pericarditis (CP) in a patient with PD receiving cabergoline therapy (10 mg daily), who had symptoms and signs of congestive heart failure (CHF). In the absence of previous reported cases of this condition linked to ergoline drugs, cabergoline was not initially identified as the cause. Shortly thereafter, however, the patient developed of a severe pleuropulmonary inflammatory-fibrotic syndrome, a recognized complication of ergoline medications, thus suggesting a common pathogenesis due to cabergoline therapy. To our knowledge, this is the first case in the English literature, although we speculate that CP may be more common than reported among patients with PD who are treated with an ergoline drug (cabergoline, bromocriptine, pergolide, or lisuride). The diagnosis of CP is difficult and requires a high level of suspicion; symptoms may masquerade as CHF due to common mechanisms such as coronary artery disease. In patients with PD who are taking not only cabergoline but also one of the other ergoline drugs, CP should be suspected if symptoms of CHF develop.

Constrictive pericarditis after coronary artery bypass surgery as a cause of unexplained dyspnea: a report of five cases

Constrictive pericarditis after coronary artery bypass grafting (CABG) is rare and can present as unexplained dyspnea. We report five consecutive cases of post-CABG constrictive pericarditis seen within a period of 17 months at our institution. All patients presented with heart failure of unknown etiology within a period of 8-84 months after surgery. During the initial post-CABG period, two patients had developed postcardiotomy syndrome that was successfully treated with steroids. They were all assessed noninvasively and invasively. In all patients, the diagnosis of constriction was initially suspected clinically (symptoms, high jugular venous pressure with deep "X" and "Y" descents, pericardial knock). Echocardiography showed transmitral flow typical of constriction in all patients and hepatic venous flow in two. Two patients showed rapid left ventricular relaxation. In all patients, hemodynamic assessment showed diastolic equalization of pressures in all chambers, "W" shape waveform in right atrial pressure, and "dip and plateau" configuration in right and left ventricular pressure waveforms. Diagnosis was confirmed surgically in four patients who were subjected to pericardiectomy-pericardial stripping (three survived, one died). One patient refused surgery. We conclude that constrictive pericarditis, although rare, should be suspected in every case of unexplained dyspnea post CABG. It can appear early or late after surgery, and clinical examination plays an important role in its early recognition. It requires a full noninvasive and invasive assessment in case of clinical suspicion.

Chronic cardiac rejection masking as constrictive pericarditis

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.

Constrictive pericarditis after cardiac surgery: report of three cases and review of the literature

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%.

Constrictive pericarditis after cardiac surgery

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.

Postoperative fibrous cardiac constriction

Two patients with postoperative fibrous cardiac constriction are described. Unlike postoperative pericardial or epicardial constriction, the fibrous constricting layer in these patients envelopes the vein bypass grafts and is separate from the pericardium, which is not involved. Surgical management of these patients is difficult and hazardous; a strategy is outlined.

Urgent coronary artery bypass surgery in the presence of Dressler's syndrome

The clinical features of Dressler's syndrome which developed in a patient following a third myocardial infarction responded to a short course of prednisolone. However, angina at rest precipitated urgent coronary artery bypass surgery and pericardectomy.