Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy

Applications of Artificial Intelligence in Constrictive Pericarditis: A Short Literature Review

PURPOSE OF REVIEW

Constrictive pericarditis (CP) is a potentially curable condition characterized by the thickening, scarring, and calcification of the pericardium. A comprehensive approach, including clinical evaluations and imaging techniques such as echocardiography, computed tomography, and magnetic resonance imaging, is essential for timely diagnosis and intervention to prevent chronic complications and enhance patient outcomes. However, the rarity of CP and the specialized expertise required present challenges in diagnosis.

RECENT FINDINGS

Emerging artificial intelligence applications show promise in enhancing clinical decision-making and improving outcomes. Studies utilizing cognitive machine learning and deep learning algorithms (ResNet50) achieved an AUC above 0.95 in distinguishing CP from restrictive cardiomyopathy. However, generalization and interpretability issues remain, and the development of AI applications for CP is still nascent due to challenges in obtaining large, high-quality echocardiographic datasets. Future research should evaluate the effectiveness of these models in diverse clinical scenarios, employing comprehensive echocardiography, point-of-care ultrasound, and other modalities to improve CP detection, individualized risk assessment, and treatment planning, ultimately enhancing patient prognosis.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

CT-derived myocardial strain measurement in patients with chronic constrictive pericarditis

BACKGROUND

We aimed to compare computed tomography (CT)-derived myocardial strain between patients with constrictive pericarditis (CP) and a matched healthy control group and to identify factors associated with clinical outcomes after pericardiectomy.

METHODS

This retrospective study included 65 patients with CP (mean age: 58.9 ​± ​8.0 years) and 65 healthy individuals (mean age: 58.0 ​± ​6.5 years) who underwent multiphase cardiac CT. The type of CP was classified as calcified CP or fibrotic CP. CT-derived strains from four cardiac chambers were compared between the CP and control groups, as well as between different types of CP. Clinical and CT-derived factors associated with adverse outcomes were identified using Cox regression analysis.

RESULTS

Compared with the control group, the CP group showed significantly lower values of left atrium (LA) reservoir strain (15.7 ​% vs. 27.4 ​%), right atrium (RA) reservoir strain (15.1 ​% vs. 27.0 ​%), left ventricle (LV) global longitudinal strain (GLS) (-17.0 ​% vs. -19.5 ​%), and right ventricle free wall longitudinal strain (-21.1 ​% vs. -25.9 ​%) (all p ​< ​0.001). Biatrial reservoir strains and LV GLS were significantly lower in those with calcified CP compared to those with fibrotic CP. LA reservoir strain (hazard ratio, 0.91-95 ​% confidence interval, 0.86-0.96- p ​= ​0.001) was an independent prognostic factor for adverse events in patients with CP.

CONCLUSION

Cardiac strain differences in CP were predominantly observed in the LA and RA compared to the healthy control group. Biatrial reservoir strains were specifically impaired in those with calcified CP than in those with fibrotic CP. LA reservoir strain was associated with prognosis in patients with CP following pericardiectomy.

Severe calcification in chronic constrictive pericarditis of tuberculous-related a case report and literature review

Chronic constrictive pericarditis is a pericardial affection that causes a severe impairment of myocardial compliance. Among its many etiologies, tuberculosis is the most common cause, mainly in developing countries. Multimodal imaging methods are essential tools for guiding diagnosis. We present the case of a 64-year-old man with no past medical history who presented with dyspnea stage II of NYHA and right heart failure. At admission, he was stable, with normal blood pressure and a normal heart rate. His ECG showed a low voltage of QRS complexes. Transthoracic echocardiography revealed significant pericardial thickening enveloping the ventricles, with significant respiratory flow variation. A thoracic CT scan and cardiac MRI confirmed the presence of pericardial thickening and calcifications. The patient underwent beat-heart pericardial decortication. The anatomopathological examination of the surgical piece revealed Mycobacterium tuberculosis. The postoperative check-up after 6 months showed good clinical and echocardiographic evolution.

Impact of preoperative clinical and imaging factors on post-pericardiectomy outcomes in chronic constrictive pericarditis patients

The present study was designed to identify the preoperative clinical and imaging findings influencing adverse clinical outcomes in patients with chronic constrictive pericarditis after pericardiectomy. Patients with constrictive pericarditis who underwent pericardiectomy between January 2009 and September 2023 were retrospectively analyzed. Preoperative evaluations included assessments of clinical symptoms, comorbidities, laboratory tests, cardiac computed tomography (CT), and transthoracic echocardiography. The volume of pericardial calcifications was quantified on calcium scoring CT. Adverse clinical events were defined as cardiovascular death or hospitalization due to cardiac causes, and all-cause mortality was assessed. Univariable and multivariable Cox proportional hazard model analysis were performed to find factors associated with adverse clinical events. Among the 91 patients with available preoperative CT scans, 26 (28.6%) experienced adverse clinical events after pericardiectomy, with 19 (20.9%) experiencing cardiovascular deaths. On multivariable Cox analysis, larger pericardial calcium volume hazard ratio [HR], 1.004 (95% confidence interval [CI], 1.001-1.006) per 1cm3 increase; p = 0.005), higher E/E' ratio (HR, 1.059, 95% CI, 1.015-1.105, p = 0.008), and lower albumin level (HR, 0.476, 95% CI, 0.229-0.986, p = 0.046) were significant factors associated with the adverse clinical events after pericardiectomy. The amount of pericardial calcification could be associated with the efficacy of pericardiectomy and potentially have implications for postoperative outcomes. Additionally, a high E/E ratio on echocardiography is indicative of unfavorable postoperative prognosis.

Chronic Constrictive Pericarditis in Northeast India: A 10-Year Single-Center Study of Demographic and Clinical Profiles

Introduction Chronic constrictive pericarditis (CCP) is a progressive disease characterized by thickening and fibrosis of the pericardium, leading to restricted diastolic filling and impaired cardiac function. In Northeast India, limited healthcare infrastructure poses challenges in diagnosing and managing CCP, potentially worsening patient outcomes. Therefore, this study aims to assess the demographic and clinical profiles of patients with CCP in this region over 10 years and compare our findings to the relevant but limited published literature in South Asia. Methods We retrospectively analyzed the medical records of 42 patients diagnosed with CCP referred to our department from 2011 to 2020. Demographic, clinical, and paraclinical data during hospitalization and follow-up were collected. All patients underwent clinical examination imaging studies, including high-resolution chest computed tomography and echocardiography. Symptomatic patients underwent open pericardiectomy, and postoperative histopathological examination was performed. Results Of the 42 patients, 34 (81%) were male and eight (19%) were female. A significant proportion of the patients were under the age of 20 years (n = 18, 42.9%), followed by the 21- to 40-year age group (n = 13, 31%). Eighteen patients (42.9%) were from Meghalaya, 12 (28.6%) were from Assam, and seven (16.7%) were from Nagaland. Twenty-two patients (52.4%) had a prior history of pulmonary or extrapulmonary tuberculosis (TB) and had received antitubercular therapy for at least six months. Dyspnea on exertion was the most common symptom among the patients: 12 (28.6%) of them were classified as New York Heart Association class IV, 20 (47.6%) as class III, and 10 (23.8%) as class II. Clinical examination revealed pedal edema in 36 (85.7%), hepatomegaly in 22 (52.4%), ascites in 15 (35.7%), and pleural effusion in 13 (31%) patients. Echocardiography showed septal bounce in 26 (61.9%), pericardial calcification in 17 (40.5%), and hepatic vein flow reversal in 12 (28.6%) patients. All patients were on diuretics and digoxin before surgery. Postoperative biopsy confirmed TB as the etiology in 28 (66.7%) patients and nonspecific etiology in 14 (33.3%) of them. Conclusions CCP in Northeast India predominantly affects young males and is largely associated with TB. Despite efforts to control TB, it remains a major contributor to CCP in this region. Recognizing the clinical presentation and diagnostic profile is essential for improving management strategies and patient outcomes.

Diagnosis and surgical management of pericardial constriction after cardiac surgery

OBJECTIVES

Previous cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment.

METHODS

We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation.

RESULTS

Median patient age was 64 (56-72) years, and the median interval between previous operation and pericardiectomy was 2.7 years (range, 0-54 years). Previous operations included coronary artery bypass grafting in 114 (43%), valve surgery in 85 (32%), combined coronary artery bypass grafting and valve surgery in 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate-to-severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P = .013), diabetes (P = .019), and nonelective pericardiectomy within 2 years of cardiac surgery (P < .001) were associated with decreased long-term survival.

CONCLUSIONS

Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.

Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review

Remarkable advances have occurred in the understanding of the pathophysiology of pericardial diseases and the role of multimodality imaging in this field. Medical therapy and surgical options for pericardial diseases have also evolved substantially. Pericardiectomy is indicated for chronic or irreversible constrictive pericarditis, refractory recurrent pericarditis despite optimal medical therapy, or partial agenesis of the pericardium with a complication (eg, herniation). A multidisciplinary evaluation before pericardiectomy is essential for optimal patient outcomes. Overall, given the good outcomes reported, radical pericardiectomy on cardiopulmonary bypass, if feasible, is the preferred approach. Due to patient complexity, as well as the technical aspects of the surgery, pericardiectomy should be performed at high-volume centers that have the required expertise. The current review highlights the essential features of this multidisciplinary approach from diagnosis to recovery in patients undergoing pericardiectomy.

[Management of Constrictive Pericarditis : A study of 43 operated cases]

Chronic constrictive pericarditis is a rare condition characterized by clinical signs of right heart failure, due to the symphysis of the two pericardial leaflets. Our study focused on a retrospective analysis of 43 CCP surgery observations collected over an 11-year period (2003-2013). The mean age of the patients was 32 years; 65% were male; exercise dyspnea (95%) was the most frequent sign. Two main etiologies were observed: tuberculosis 58% and idiopathic causes 42%. All of our patients received a subtotal pericardectomy per median sternotomy, of which 95% had no cardiopulmonary bypass.

The Utility of Invasive Hemodynamic Assessment in Diagnosing Constrictive Pericarditis: A Case Report

Pericarditis leading to constrictive physiology is rarely diagnosed given its vague presentation. Abnormal diastolic filling from a stiff pericardium brings about signs and symptoms consistent with right-sided heart failure. We report the case of a 57-year-old female who presented with worsening shortness of breath and signs of volume overload. Chest computed tomography showed evidence of pericardial calcifications with pericardial effusion. Further evaluation with right heart catheterization suggested findings diagnostic of constrictive pericarditis.

Echocardiography-Based Deep Learning Model to Differentiate Constrictive Pericarditis and Restrictive Cardiomyopathy

BACKGROUND

Constrictive pericarditis (CP) is an uncommon but reversible cause of diastolic heart failure if appropriately identified and treated. However, its diagnosis remains a challenge for clinicians. Artificial intelligence may enhance the identification of CP.

OBJECTIVES

The authors proposed a deep learning approach based on transthoracic echocardiography to differentiate CP from restrictive cardiomyopathy.

METHODS

Patients with a confirmed diagnosis of CP and cardiac amyloidosis (CA) (as the representative disease of restrictive cardiomyopathy) at Mayo Clinic Rochester from January 2003 to December 2021 were identified to extract baseline demographics. The apical 4-chamber view from transthoracic echocardiography studies was used as input data. The patients were split into a 60:20:20 ratio for training, validation, and held-out test sets of the ResNet50 deep learning model. The model performance (differentiating CP and CA) was evaluated in the test set with the area under the curve. GradCAM was used for model interpretation.

RESULTS

A total of 381 patients were identified, including 184 (48.3%) CP, and 197 (51.7%) CA cases. The mean age was 68.7 ± 11.4 years, and 72.8% were male. ResNet50 had a performance with an area under the curve of 0.97 to differentiate the 2-class classification task (CP vs CA). The GradCAM heatmap showed activation around the ventricular septal area.

CONCLUSIONS

With a standard apical 4-chamber view, our artificial intelligence model provides a platform to facilitate the detection of CP, allowing for improved workflow efficiency and prompt referral for more advanced evaluation and intervention of CP.

Pericardiectomy for Constrictive Pericarditis with or without Cardiopulmonary Bypass

Aim

We aim to access the effect of pericardiectomy for constrictive pericarditis with or without cardiopulmonary bypass.

Methods

This was a review of pericardiectomy for constrictive pericarditis.

Results

Cardiopulmonary bypass is actually an important maneuver to attain complete relief of the constriction. The short additional time of cardiopulmonary bypass during the procedure has very little effect on the risk of morbidity of the main operation.

Conclusion

Incomplete pericardiectomy perhaps was the cause of postoperative remnant constriction and high diastolic filling pressure leading to multiorgan failure. Complete pericardiectomy (removal of phrenic-to-phrenic and the postero-lateral and inferior wall pericardial thickening) using cardiopulmonary bypass should be the routine for total relief of the constriction of the heart.

Calcific constrictive pericarditis following tumour necrosis factor-alpha inhibition

Background

Tumour necrosis factor (TNF)-alpha inhibition is a core therapeutic avenue for a broad range of inflammatory and autoimmune disorders including rheumatoid arthritis and inflammatory bowel disease, as well as dermatological conditions such as hidradenitis suppurativa. Adalimumab has become one of the most common TNF-alpha-inhibiting agents, which is used for many of these conditions. Treatment with such agents is associated with numerous systemic side effects, though cardiac complications remain relatively rare. These include reports of pericarditis and pericardial effusions1-3.

Case summary

A 63-year-old lady was referred to the outpatient respiratory clinic with a 1-year history of increasing breathlessness, on a background of 4 years of treatment with adalimumab for Stage III hidradenitis suppurativa. A high-resolution computed tomography (CT) thorax revealed evidence of pericardial calcification. Subsequent left and right heart catheterization study revealed equalization of intraventricular pressures, consistent with constrictive pericarditis. A QuantiFERON test was negative, and rheumatological serology was unremarkable. The patient was initially managed conservatively with close follow-up, before undergoing surgical pericardectomy when she developed signs of cardiac failure.

Discussion

Adalimumab is associated with a range of systemic side effects, though cardiac complications are relatively rare. This case highlights a potentially novel complication associated with prolonged adalimumab therapy. Given that there are reports in the literature of pericarditis and pericardial effusions associated with TNF-alpha inhibition1-3, it is reasonable to hypothesize that the calcific constrictive pericarditis seen in this case may demonstrate a novel cardiac phenomenon associated with this therapy, given the lack of any traditional aetiological factors.

Outcomes and Risk Factors Associated with Pericardiectomy in Patients with Constrictive Pericarditis: A Retrospective Study from China

PURPOSE

Pericardiectomy is the definitive treatment option for constrictive pericarditis and is associated with a high prevalence of morbidity and mortality. However, information on the associated outcomes and risk factors is limited. We aimed to report the mid-term outcomes of pericardiectomy from a single center in China.

METHODS

We retrospectively reviewed data collected from patients who underwent pericardiectomy at our institute from April 2018 to January 2023.

RESULTS

Eighty-six consecutive patients (average age, 46.1 ± 14.7 years; 68.6 men) underwent pericardiectomy through midline sternotomy. The most common etiology was idiopathic (n = 60, 69.8%), and 82 patients (95.3%) were in the New York Heart Association function class III/IV. In all, 32 (37.2%) patients underwent redo sternotomies, 36 (41.9%) underwent a concomitant procedure, and 39 (45.3%) required cardiopulmonary bypass. The 30-day mortality rate was 5.8%, and the 1-year and 5-year survival rates were 88.3% and 83.5%, respectively. Multivariable analysis revealed that preoperative mitral insufficiency (MI) ≥moderate (hazard ratio [HR], 6.435; 95% confidence interval [CI] [1.655-25.009]; p = 0.007) and partial pericardiectomy (HR, 11.410; 95% CI [3.052-42.663]; p = 0.000) were associated with increased 5-year mortality.

CONCLUSION

Pericardiectomy remains a safe operation for constrictive pericarditis with optimal mid-term outcomes.

Multimodal Imaging of Constrictive Pericarditis Induced by Long-term Pergolide Treatment for Parkinson's Disease

We herein report the first case of constrictive pericarditis (CP) induced by long-term pergolide treatment for Parkinson's disease that was assessed using multimodal imaging in a 72-year-old patient with leg edema and dyspnea. The patient was correctly diagnosed with CP using multimodal imaging and successfully treated with pericardiectomy. The treatment history of Parkinson's disease and pathological findings of the removed pericardium suggested that long-term pergolide was the cause of CP. Properly recognizing pergolide as the cause of CP and accurately diagnosing CP using multimodal imaging may contribute to the early detection and treatment of pergolide-induced CP.

Cardiac surgery for radiation associated heart disease in Hodgkin lymphoma patients

Much of the modern focus of Hodgkin's Lymphoma (HL) treatment involves the prevention of secondary organ injury. Despite rationalisations of radiotherapy fields, many patients still develop late radiation-related cardiotoxicity that is severe and requires interventional management. No guidelines exist to direct management of these complex patients who often present with multiple concurrent cardiac pathologies. Despite possessing a greater mortality risk than in the general population, cardiac surgery has an important role in treating radiation-associated heart disease. This review summarises the body of literature surrounding cardiac surgery in HL survivors post-radiotherapy, highlighting the benefits and risks unique to this cohort. The pathophysiology and presentation of radiation-associated heart disease is also explored in relation to HL patients.

Multimodality Imaging in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy: A Comprehensive Overview for Clinicians and Imagers

In the evaluation of heart failure, 2 differential diagnostic considerations include constrictive pericarditis and restrictive cardiomyopathy. The often outwardly similar clinical presentation of these 2 pathologic entities routinely renders their clinical distinction difficult. Consequently, initial assessment requires a keen understanding of their separate pathophysiology, epidemiology, and hemodynamic effects. Following a detailed clinical evaluation, further assessment initially rests on comprehensive echocardiographic investigation, including detailed Doppler evaluation. With the combination of mitral inflow characterization, tissue Doppler assessment, and hepatic vein interrogation, initial differentiation of constrictive pericarditis and restrictive cardiomyopathy is often possible with high sensitivity and specificity. In conjunction with a compatible clinical presentation, successful differentiation enables both an accurate diagnosis and subsequent targeted management. In certain cases, however, the diagnosis remains unclear despite echocardiographic assessment, and additional evaluation is required. With advances in noninvasive tools, such evaluation can often continue in a stepwise, algorithmic fashion noninvasively, including both cross-sectional and nuclear imaging. Should this additional evaluation itself prove insufficient, invasive assessment with appropriate expertise may ultimately be necessary.

Transient pericardial constriction: A not so rare entity

Constrictive pericarditis is a rare, potentially treatable, cause of heart failure with preserved ejection fraction that is characterized by insidious onset, challenging diagnosis and dismal prognosis, even following complete surgical pericardiectomy, particularly in advanced disease stages. In recent years it has been proposed that transient pericardial constriction may occur, with an even rarer frequency, during early phases of acute pericarditis and may resolve following specific treatment without progressing to the chronic, irreversible form. We recently observed two cases of well-documented transient pericardial constriction. In the present work we describe these two cases and provide a review on this rare condition, that, if unrecognized and left untreated, may lead to irreversible constrictive pericarditis.

Pattern of pericardial calcification determines mid-term postoperative outcomes after pericardiectomy in chronic constrictive pericarditis

OBJECTIVES

Although pericardiectomy is an effective treatment for constrictive pericarditis (CP), clinical outcomes are not always successful. Pericardial calcification is a unique finding in CP, although the amount and localization of calcification can vary. We investigated how the pattern and amount of pericardial calcification affect mid-term postoperative outcomes after pericardiectomy to treat CP.

METHODS

All patients of total pericardiectomy in our hospital from 2010 to 2020 were enrolled. Preoperative Computed tomography (CT) scans of 98 consecutive patients were available and analyzed. Medical records were reviewed retrospectively. Cardiovascular events were defined as cardiovascular death or hospitalization associated with a heart failure symptom, and all-cause events were defined as any event that required admission. CT scans were analyzed, and the volume and localization pattern of peri-calcification were determined. Pericardium calcium scores are presented using Agatston scores.

RESULTS

Of the 98 patients, 25 (25.5%) were hospitalized with heart failure symptoms after pericardiectomy. The median follow-up duration for all patients was 172 weeks. The group with a cardiovascular event had a lower calcium score than patients without an event. Multivariate Cox proportional analysis showed that high ln(calcium score+1) before pericardiectomy was a dependent predictor of cardiovascular event (hazard ratio, 0.90; p = 0.04) after pericardiectomy. When we set the cut-off value (ln(calcium score+1) = 7.22), there was a significant difference in cardiovascular events in the multivariate Cox proportional analysis (p = 0.04).

CONCLUSION

A low burden of pericardial calcification was associated with a high rate of mid-term clinical events after pericardiectomy to treat CP.

Challenges and solutions of echocardiography generalization for deep learning: a study in patients with constrictive pericarditis

Purpose

The inherent characteristics of transthoracic echocardiography (TTE) images such as low signal-to-noise ratio and acquisition variations can limit the direct use of TTE images in the development and generalization of deep learning models. As such, we propose an innovative automated framework to address the common challenges in the process of echocardiography deep learning model generalization on the challenging task of constrictive pericarditis (CP) and cardiac amyloidosis (CA) differentiation.

Approach

Patients with a confirmed diagnosis of CP or CA and normal cases from Mayo Clinic Rochester and Arizona were identified to extract baseline demographics and the apical 4 chamber view from TTE studies. We proposed an innovative preprocessing and image generalization framework to process the images for training the ResNet50, ResNeXt101, and EfficientNetB2 models. Ablation studies were conducted to justify the effect of each proposed processing step in the final classification performance.

Results

The models were initially trained and validated on 720 unique TTE studies from Mayo Rochester and further validated on 225 studies from Mayo Arizona. With our proposed generalization framework, EfficientNetB2 generalized the best with an average area under the curve (AUC) of 0.96 (± 0.01 ) and 0.83 (± 0.03 ) on the Rochester and Arizona test sets, respectively.

Conclusions

Leveraging the proposed generalization techniques, we successfully developed an echocardiography-based deep learning model that can accurately differentiate CP from CA and normal cases and applied the model to images from two sites. The proposed framework can be further extended for the development of echocardiography-based deep learning models.

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.

Dopamine agonists for the treatment of pituitary tumours: From ergot extracts to next generation therapies

Dopamine agonists are a key tool in the therapeutic arsenal of endocrinologists worldwide. They exert their effects by binding to dopamine-2 (D2) receptors expressed by pituitary tumour cells to modulate hormonal secretion and tumour size. They are the established first-line treatment for prolactinomas which express high levels of D2 receptors. Growing data support their use as an adjuvant treatment option for other pituitary tumours including growth hormone, adrenocorticotrophic hormones, thyroid hormone secreting adenomas and nonfunctional pituitary tumours, all of which have been shown to express D2 receptors as well, albeit to varying extents. For those pituitary tumours inadequately treated by dopamine agonist alone, combined agonism of D2 and somatostatin receptors represent a new frontier in clinical development. Here we review the development and role of dopamine agonist for the treatment of prolactinomas, the literature supporting their adjuvant use for the treatment of all other pituitary tumours, and recent progress in the development of the next generation of chimeric compounds that target D2 and other receptor subtypes highly expressed on pituitary tumour cells.

Case report: Mechanical-electric feedback and atrial fibrillation-Revelation from the treatment of a rare atrial fibrillation caused by annular constrictive pericarditis

Atrial fibrillation (AF) is one of the most common arrhythmias encountered in clinical practice. The pathophysiological mechanisms responsible for its development are complex, vary amongst individuals, and associated with predisposing factors. Here, we report a case of AF caused by annular constrictive pericarditis (ACP), which is extremely rare due to its unusual anatomical form. In our patient, AF was refractory to multiple antiarrhythmic medications; however, spontaneous conversion to sinus rhythm occurred when the ring encircling the right and left ventricular (RV and LV) cavities along the atrioventricular (AV) groove was severed. This suggests that atrial stretch due to atrial enlargement and increased left atrial (LA) pressure may contribute to the initiation and maintenance of AF. This report highlights the importance of the careful investigation of rare predisposing factors for AF using non-invasive diagnostic approaches and mechanical-electric feedback (MEF) as a pathophysiological mechanism for AF initiation and maintenance.

Tamponnade cardiaque

La tamponnade cardiaque est une urgence vitale. Elle se définit comme une accumulation de liquide dans l’espace intrapéricardique, favorisant une augmentation de la pression intrapéricardique et une altération du remplissage cardiaque. Il s’agit d’une des causes du choc obstructif, et la rapidité d’installation détermine le degré d’instabilité hémodynamique. La morbidité et la mortalité dépendent de la rapidité du diagnostic et de sa prise en charge. Peu fréquemment, l’étiologie est tumorale. Ce type d’étiologie se traduit le plus souvent par des tableaux cliniques d’installation lente et progressive. C’est le cas du sujet qui est présenté dans cet article : un homme de 50 ans sans suivi médical et consommateur d’alcool et de tabac, vivant dans un contexte social difficile. L’issue fatale du cas clinique témoigne de la gravité du tableau de présentation initiale. L’électrocardiogramme peut révéler des signes caractéristiques comme le microvoltage du QRS et l’alternance électrique. La méthode standard pour détecter un épanchement péricardique est l’échocardiographie : le diagnostic de tamponnade cardiaque requiert la présence de collapsus complet du coeur droit et dans les cas plus graves des cavités gauches. Les compétences de l’urgentiste en termes d’échographie permettent un diagnostic plus rapide et précis. Le traitement de la tamponnade cardiaque repose principalement sur le soutien hémodynamique (administration volumique et traitement des éventuels troubles du rythme secondaires) en urgence. Cependant, le traitement définitif reste le drainage du liquide accumulé par péricardiocentèse ou par approche chirurgicale.

Severely Calcified Pericardium Causing Constrictive Pericarditis

Constrictive pericarditis (CP) is a type of diastolic heart failure caused by an inelastic pericardium that impairs cardiac filling. Diagnosing CP can be challenging, and a variety of imaging techniques may be necessary. We present a unique case of severely calcified pericardium leading to CP.

Unilateral Transudative Pleural Effusion due to rare Cause – A Case Report

Transudative pleural effusions are characterized by low protein and lactate dehydrogenase according to Light’s criteria. Common causes are congestive cardiac failure, nephrotic syndrome, liver cirrhosis, and protein-losing enteropathy. Constrictive pericarditis is a rare cause of transudative pleural effusion. It can cause bilateral or unilateral recurrent effusions and chylothorax rarely. Common causes of constrictive pericarditis include infections such as viruses and tuberculosis, radiation, and cardiac surgery. We present a treated case of pulmonary tuberculosis presenting with massive, left-sided, and transudative pleural effusion due to constrictive pericarditis diagnosed by computed tomography scan and 2D echo with classical findings. Incidental findings were internal jugular vein thrombus and right lower lobar pulmonary embolus. This case highlights the atypical presentation of constrictive pericarditis as unilateral pleural effusion. A proper history with a high index of suspicion is essential in the workup of constrictive pericarditis which can be cured by pericardiectomy.

Predictors of low cardiac output after isolated pericardiectomy: an observational study

Background

Low cardiac output is the main cause of perioperative death after pericardiectomy for constrictive pericarditis. We investigated the associated risk factors and consequences.

Methods

We selected constrictive pericarditis patients undergoing isolated pericardiectomy from January 2013 to January 2021. Postoperative low cardiac output was defined as requiring mechanical circulatory support or more than one inotrope to maintain a cardiac index > 2.2 L •min⁻¹ •m⁻² without hypoperfusion, despite adequate filling status. Uni- and multivariable analysis were used to identify factors associated with low cardiac output. Cox regression was used to identify factors associated with length of hospital stay.

Results

Among 212 patients with complete data, 55 (25.9%) developed low cardiac output within postoperative day 1 (quartiles 1 and 2), which caused seven of the nine perioperative deaths. The rates of atrial arrhythmia, renal dysfunction, hypoalbuminemia, modest-to-severe hyponatremia, and hyperbilirubinemia caused by constrictive pericarditis were 9.4%, 12.3%, 49.1%, 10.4%, and 81.6%. The mean preoperative central venous pressure and cardiac index were 18 ± 5 cmH₂O and 1.87 ± 0.45 L•min⁻¹•m⁻². Univariable analysis showed that low cardiac output patients had higher rates of atrial arrhythmia (OR 3.32 [1.35, 8.17], P = 0.007), renal dysfunction (OR 4.24 [1.94, 9.25], P < 0.001), hypoalbuminemia (OR 1.99 [1.06, 3.73], P = 0.031) and hyponatremia (OR 6.36 [2.50, 16.20], P < 0.001), greater E peak velocity variation (difference 2.8 [0.7, 5.0], P = 0.011), higher central venous pressure (difference 3 [2,5] cmH₂O, P < 0.001) and lower cardiac index (difference − 0.27 [− 0.41, − 0.14] L•min⁻¹•m⁻², P < 0.001) than patients without low cardiac output. Multivariable regression showed that atrial arrhythmia (OR 4.04 [1.36, 12.02], P = 0.012), renal dysfunction (OR 2.64 [1.07, 6.50], P = 0.035), hyponatremia (OR 3.49 [1.19, 10.24], P = 0.023), high central venous pressure (OR 1.17 [1.08, 1.27], P < 0.001), and low cardiac index (OR 0.36 [0.14, 0.92], P = 0.032) were associated with low cardiac output (AUC 0.79 [0.72–0.86], P < 0.001). Cox regression analysis showed that hyperbilirubinemia (HR 0.66 [0.46, 0.94], P = 0.022), renal dysfunction (HR 0.51 [0.33, 0.77], P = 0.002), and low cardiac output (HR 0.42 [0.29, 0.59], P < 0.001) were associated with length of hospital stay.

Conclusions

Early recognition and management of hyponatremia, renal dysfunction, fluid retention, and hyperbilirubinemia may benefit constrictive pericarditis patients after pericardiectomy.

Early-onset post-cardiotomy severe constrictive pericarditis: a case report

Background

Constrictive pericarditis (CP) can be one of the most challenging conditions to diagnose within cardiovascular medicine. Iatrogenic causes of CP are increasingly recognized in higher income countries. This case provides insight into the need for clinical suspicion when diagnosing this relatively under recognized clinical entity as well as the need for multimodality imaging combined with invasive haemodynamic assessment.

Case summary

A 68-year-old man presented with decompensated heart failure 4 weeks after open-heart surgery. A diagnosis of early-onset post-cardiotomy CP was made using multimodality imaging and invasive haemodynamic assessment, which demonstrated the cardinal features of constrictive physiology. Surgical intervention with two pericardiectomy procedures was pursued given the aggressive and recalcitrant nature of his presentation. Our patient died shortly after his second surgery due to progressive multi-organ dysfunction.

Conclusion

Constrictive pericarditis is a challenging but important clinical entity to diagnose. Differentiating CP from restrictive cardiomyopathy is important as there are key differences in management and prognosis. Our case supports the clinical utility of multimodality imaging combined with invasive haemodynamic assessment in patients with suspected CP.

A curious case of pulmonary hypertension in a child

Background

Pulmonary hypertension in young children can be due to a myriad of conditions. Few aetiologies of pulmonary hypertension are potentially reversible. An extensive workup for the cause of pulmonary hypertension is a must before attributing it to idiopathic pulmonary hypertension. We describe an uncommon aetiology of pulmonary hypertension in a young boy.

Case presentation

A 12-year-old child, with past history of tubercular pleural effusion, presented with dyspnoea on exertion and easy fatiguability for 2 years. He was evaluated elsewhere and was being treated as primary pulmonary hypertension with pulmonary vasodilators. The child was revaluated since the clinical features were not completely favouring the diagnosis. On detailed evaluation, a diagnosis of constrictive pericarditis was made. He was referred for pericardiectomy.

Conclusions

Constrictive pericarditis presenting with severe pulmonary hypertension without congestive symptoms is very rare. In patients presenting with pulmonary hypertension, always look for a reversible cause before labeling them as idiopathic PAH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-022-00294-6.

Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts

Purpose of Review

The unique pathophysiological changes of constrictive pericarditis (CP) can now be identified with better imaging modalities, thereby helping in its early diagnosis. Through this review, we outline the pathophysiology of CP and its translation into symptomology and various imaging findings which then are used for both diagnosis and guiding treatment options for CP.

Recent Findings

Multimodality imaging has provided us with the capability to recognize early stages of the disease and identify patients with a potential for reversibility and can be treated with medical management. Additionally, peri-procedural planning and prediction of post-operative complications has been made possible with the use of advanced imaging techniques.

Summary

Advanced imaging has the potential to play a greater role in identification of patients with reversible disease process and provide peri-procedural risk stratification, thereby improving outcomes for patients with CP.

Tuberculosis of the Heart: A Diagnostic Challenge

Tuberculosis of the heart is relatively rare and presents a significant diagnostic difficulty for physicians. It is the leading cause of death from infectious illness. It is one of the top 10 leading causes of death worldwide, with a disproportionate impact in low- and middle-income nations. The radiologist plays a pivotal role as CMR is a non-invasive radiological method that can aid in identifying potential overlap and differential diagnosis between tuberculosis, mass lesions, pericarditis, and myocarditis. Regardless of similarities or overlap in observations, the combination of clinical and certain particular radiological features, which are also detected by comparison to earlier and follow-up CMR scans, may aid in the differential diagnosis. CMR offers a significant advantage over echocardiography for detecting, characterizing, and assessing cardiovascular abnormalities. In conjunction with clinical presentation, knowledge of LGE, feature tracking, and parametric imaging in CMR may help in the early detection of tuberculous myopericarditis and serve as a surrogate for endomyocardial biopsy resulting in a quicker diagnosis and therapy. This article aims to explain the current state of cardiac tuberculosis, the diagnostic utility of CMR in tuberculosis (TB) patients, and offer an overview of the various imaging and laboratory procedures used to detect cardiac tuberculosis.

Pericardiectomy for constrictive pericarditis at a single Japanese center: 20 years of experience

OBJECTIVE

Constrictive pericarditis (CP) is a rare disease, and the diagnosis and surgical treatment of CP remain challenging. The aim of this study was to evaluate our Japanese single-center experience with isolated pericardiectomy for CP to elucidate the factors associated with improved outcomes.

METHODS

Over a 20-year period, 44 consecutive patients underwent isolated pericardiectomy at our institution. The cause of CP was: idiopathic (59%), postsurgical (32%), tuberculosis (7%), and postradiation (2%) of the patients. All patients were diagnosed with CP using multiple modalities, including echocardiography, cardiac catheterization, computed tomography, or magnetic resonance imaging (MRI). Median sternotomy was performed in 42 (95%) patients. Twenty-eight (68%) patients underwent radical pericardiectomy.

RESULTS

The postoperative diagnosis in all patients was CP. Among the multiple modalities, cardiac MRI had the greatest diagnostic sensitivity (97.2%). There were no operative or hospital deaths; late mortality occurred in seven (15.9%) patients in the series. Multivariable analysis showed that preoperative low LVEF was a risk factor for long-term mortality. Seven patients were readmitted for heart failure postoperatively. Multivariable analysis showed incomplete pericardiectomy and use of a preoperative inotrope were risk factors for readmission for heart failure.

CONCLUSIONS

The diagnosis using multimodality imaging for CP was effective in our institution and tagged cine MRI had the greatest sensitivity in diagnosing CP. Preoperative condition, including preoperative low LVEF or inotrope use, was correlated with long-term outcome after pericardiectomy. Pericardiectomy should be performed early and as radically as possible to prevent recurrent heart failure.

Constrictive Pericarditis: An Unusual Presentation of Rheumatoid Vasculitis

We describe a case of rheumatoid vasculitis with an atypical presentation of constrictive pericarditis. A 51-year-old man who was previously admitted for diffuse lymphadenopathy, presented with chest pain and a lower extremity rash. Extensive workup including multimodality imaging, serology tests, and biopsy, resulted in the diagnosis of rheumatoid vasculitis.

Pericardiectomy for constrictive pericarditis in a resource constraint setting

Introduction

Constrictive pericarditis is the endpoint of the natural history of acute pericarditis of different aetiologies where a chronic inflammatory process results in a thickened, fibrotic and inelastic pericardium with consequent impairment of diastolic function and systemic congestion.

Aim

To evaluate the clinical features, diagnosis, surgical management and outcome of patients with constrictive pericarditis as managed in a local setting of a tertiary hospital in Ghana.

Material and methods

A retrospective review of the medical records of patients who had undergone pericardiectomy for constrictive pericarditis at a teaching hospital.

Results

Ten patients underwent pericardiectomy for the period of study. There were 8 (80%) males and 2 (20%) females. The mean age was 20.4 ±17.2 years. Six of the patients 6 (60%) were in NYHA class III. Preoperative diagnostics included chest X-ray, echocardiography, and computed tomography scan. The surgical approach for the pericardiectomy was median sternotomy. The mean operative time was 159.9 ±43.0 min. The mean postoperative days spent before being discharged was 6.9 ±2.3 days. Nine (90%) of the patients were in NYHA class I after a mean follow-up of 19.3 ±16.7 months. One patient died 6 weeks after surgery with heart failure and one patient was lost to follow-up.

Conclusions

Surgical pericardiectomy via median sternotomy is still the standard modality of treatment for constrictive pericarditis with excellent results even in resource constraint settings.

Outcomes of pericardiectomy for constrictive pericarditis following mediastinal irradiation

BACKGROUND

Pericardiectomy for postradiation constrictive pericarditis has been reported to generally have unfavorable outcomes. This study sought to evaluate surgical outcomes in a large cohort of patients undergoing pericardiectomy for radiation-associated pericardial constriction.

METHODS

A retrospective analysis of all patients (≥18 years) who underwent pericardiectomy for a diagnosis of constrictive pericarditis with a prior history of mediastinal irradiation from June 2002 to June 2019 was conducted. There were 100 patients (mean age 57.2 ± 10.1 years, 49% females) who met the inclusion criteria. Records were reviewed to look at the surgical approach, the extent of resection, early mortality, and late survival.

RESULTS

The overall operative mortality was 10.1% (n = 10). The rate of operative mortality decreased over the study period; however, the test of the trend was not statistically significant (p = .062). Hodgkin's disease was the most common malignancy (64%) for which mediastinal radiation had been received. Only 27% of patients had an isolated pericardiectomy, and concomitant pericardiectomy and valve surgery were performed in 46% of patients. Radical resection was performed in 50% of patients, whereas 47% of patients underwent subtotal resection. Prolonged ventilation (26%), atrial fibrillation (21%), and pleural effusion (16%) were the most common postoperative complications. The overall 1, 5-, and 10-years survival was 73.6%, 53.4%, and 32.1%, respectively. Increasing age (hazard ratio, 1.044, 95% confidence interval 1.017-1.073) appeared to have a significant negative effect on overall survival in the univariate model.

CONCLUSION

Pericardiectomy performed for radiation-associated constrictive pericarditis has poor long-term outcomes. The early mortality, though high (~10%), has been showing a decreasing trend in the test of time.

Pericardiectomy for Constrictive Tuberculous Pericarditis: A Systematic Review and Meta-analysis on the Etiology, Patients' Characteristics, and the Outcomes

Tuberculosis (TB) is the most common etiology of constrictive pericarditis in the developing world. In this study, we collected currently available data to evaluate the outcomes following pericardiectomy in patients with constrictive tuberculous pericarditis. We retrieved electrical databases, including PubMed and PubMed Central, from 1985 AD and onwards. We included articles that had more than 80% TB as the etiology and articles with mixed etiologies. Pooled analysis was done in Review Manager (RevMan) version 5.2 (The Nordic Cochrane Centre, Copenhagen). and Stata Statistical Software, Release 16 ( StataCorp LLC, College Station, TX). We compared the mortality in patients after pericardiectomy due to TB with other etiologies. In-hospital mortality versus one-year mortality was analyzed in studies with constrictive pericarditis of mixed etiologies. We also compared pre-operative New York Heart Association (NYHA) grade to post-operative NYHA grade one year after pericardiectomy. We calculated the pooled mean of postoperative hospital stay, postoperative intensive care unit (ICU) stay, and in-hospital mortality. A total of 12 articles and 859 patients were included in the final analysis. Pericardiectomy was performed mostly on middle-aged men with or without previous comorbidity. Total pericardiectomy was the preferred surgical procedure performed on a mean of 93% of patients. The pooled analysis shows a significant decrease in all-cause mortality in patients with TB as compared to other etiologies (pooled risk ratios (RR) 0.34 CI [0.12,1.01] I2 = 61%) and a lower but insignificant in-hospital mortality in comparison to one-year mortality in studies with mixed etiologies (RR 0.59 [0.11,3.11] I2= 61%). There was a significant improvement in the NYHA grade of the patients one year following pericardiectomy (RR 8.04, CI [5.20,12.45], I2= 0%). The mean postoperative hospital stay and the postoperative ICU stay were calculated and reported in terms of days. The mean postoperative hospital stays in studies with more than 80% of TB cases is 13.34 (10.21, 16.47) with a mean standard deviation of 4.46 (2.87, 6.05). The mean postoperative ICU stay is 1.93 (1.47, 2.39), with a mean standard deviation of 3.26 (2.51, 4.00), and the mean in-hospital mortality is 0.07 (0.02, 0.12). Similarly, the mean postoperative hospital stay in studies with mixed etiologies is 19.40 (11.93, 26.87) with a mean standard deviation of 8.26 (4.21, 12.52). The mean postoperative ICU stay is 3.52 (1.93, 5.10) with a mean standard deviation of 2.34 (1.36, 3.32). The mean in-hospital mortality is 0.06 (0.04, 0.08). There is significant heterogeneity along with a number of methodological concerns, and therefore, generalization of the data should be done with caution, and a randomized controlled trial in the future may be beneficial.

Speckle-Tracking Echocardiography in Cardio-Oncology and Beyond

Speckle-tracking echocardiography has enabled clinicians to detect changes in myocardial function with more sensitivity than that afforded by traditional diastolic and systolic functional measurements, including left ventricular ejection fraction. Speckle-tracking echocardiography enables evaluation of myocardial strain in terms of strain (percent change in length of a myocardial segment relative to its length at baseline) and strain rate (strain per unit of time). Both measurements have potential for use in diagnosing and monitoring the cardiovascular side effects of cancer therapy. Regional and global strain measurements can independently predict outcomes not only in patients who experience cardiovascular complications of cancer and cancer therapy, but also in patients with a variety of other clinical conditions. This review and case series examine the clinical applications and overall usefulness of speckle-tracking echocardiography in cardio-oncology and, more broadly, in clinical cardiology.

Here's the rub: A case of constrictive pericarditis in an adult with cystic fibrosis

We present a rare coexistence of constrictive pericarditis in a patient with cystic fibrosis. Careful attention to cardiac friction rub auscultated on initial examination prompted echocardiography revealing constrictive pericarditis further confirmed by cardiac magnetic resonance imaging that allowed for dedicated treatment in addition to management of his concurrent respiratory infection.

•

Only the third reported case of constrictive pericarditis in a patient with cystic fibrosis.

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Symptoms of severe cystic fibrosis and constrictive pericarditis are similar.

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Cardiac knocks or friction rubs should raise suspicion for a pericardial process.

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Annulus paradoxus and reversus are echo hallmarks for constrictive pericarditis.

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Management of constrictive pericarditis requires dedicated treatment and monitoring.

Prognostic importance of mitral e' velocity in constrictive pericarditis

AIMS

Increased medial mitral annulus early diastolic velocity (e') plays an important role in the echocardiographic diagnosis of constrictive pericarditis (CP) and mitral e' velocity is also a marker of underlying myocardial disease. We assessed the prognostic implication of mitral e' for long-term mortality after pericardiectomy in patients with CP.

METHODS AND RESULTS

We studied 104 surgically confirmed CP patients who underwent echocardiography and cardiac catheterization within 7 days between 2005 and 2013. Patients were classified as primary CP (n = 45) or mixed CP (n = 59) based on the clinical history of concomitant myocardial disease. On multivariable analysis, medial e' velocity and mean pulmonary artery pressure were independently associated with long-term mortality post-pericardiectomy. There were significant differences in survival rates among the groups divided by cut-off values of 9.0 cm/s and 29 mmHg for medial e' and mean pulmonary artery pressure, respectively (both P < 0.001). Ninety-two patients (88.5%) had elevated pulmonary artery wedge pressure (PAWP) (≥15 mmHg); there was no significant correlation between medial E/e' and PAWP (r = 0.002, P = 0.998). However, despite the similar PAWP between primary CP and mixed CP groups (21.6 ± 5.4 vs. 21.2 ± 5.8, P = 0.774), all primary CP individuals with elevated PAWP had medial E/e' <15 as opposed to 34 patients (57.6%) in the mixed CP group (P < 0.001).

CONCLUSION

Increased mitral e' velocity is associated with better outcomes in patients with CP. A paradoxical distribution of the relationship between E/e' and PAWP is present in these patients but there is no direct inverse correlation between them.

Cardiac Decompression by Pericardiectomy for Constrictive Pericarditis: Multimodality Imaging to Identify Patients at Risk for Prolonged Inotropic Support

BACKGROUND

Post-pericardiectomy right ventricular (RV) failure has been reported but it remains not well-studied. To investigate imaging parameters that could predict RV function and the outcome of patients post-pericardiectomy.

METHODS

We analysed data from a total of 53 CP patients undergoing pericardiectomy. Preoperative, early and at 6 months postoperative echocardiographic (echo) imaging datasets were analysed and correlated with preoperative cardiac magnetic resonance (CMR), cardiac computed tomography scans and histology. The primary endpoint of the study was RV functional status early postoperatively and at 6 months. Secondary endpoint was the need for prolonged inotropic support.

RESULTS

A cause of CP was identified in 26 patients (49%). Inotropic support ≥ 48 hours was required in n = 28 (53%) of patients and was correlated with lower preoperative RV areas by echo or RV volumes by CMR (p < 0.05 for all). A pericardial score based on pericardial thickness/calcification and epicardial fat thickness had good diagnostic accuracy to identify patients requiring prolonged use of inotropes (area under the curve, 0.825; 95% confidence interval, 0.674–0.976). Pericardiectomy resulted in RV decompression and impaired RV function early postoperatively (fractional area change: 40.5% ± 8.8% preoperatively vs. 31.4% ± 10.4% early postoperatively vs. 42.5% ± 10.2% at 6 months, p < 0.001).

CONCLUSIONS

We show that a smaller RV cavity size and a pericardial scoring system are associated with prolonged inotropic support in CP patients undergoing pericardiectomy. RV systolic impairment post decompression is present in most patients, but it is only transient.

Meta-Analysis of Population Characteristics and Outcomes of Patients Undergoing Pericardiectomy for Constrictive Pericarditis

We sought to systematically describe the epidemiology, etiology, clinical and operative characteristics as well as outcomes of patients who underwent pericardiectomy for constrictive pericarditis in the contemporary era. We conducted a systematic search of the MEDLINE, Embase, and Cochrane databases from their inception to April 1, 2020 for studies assessing the outcomes of pericardiectomy in patients with constrictive pericarditis. Studies with patients enrolled before 1985, pediatric patients or studies including >10% tuberculous pericarditis were excluded. The impact of pericarditis etiology on outcomes was evaluated with a meta-analysis. We analyzed 27 eligible studies and 2,114 patients. Etiology was most commonly idiopathic (50.2%), followed by after-cardiac surgery (26.2%) and radiation (6.9%). Patients were mostly men (76%), mean age 58 and with advanced symptoms (NYHA III/IV 70.1%). Total pericardiectomy was preferred (85.8%) and concomitant cardiac surgery was relatively common (23.8%). Operative mortality was 6.9% and 5-year mortality was 32.7%. Radiation and after-cardiac surgery patients had 3 and 2 times higher long-term risk for mortality respectively compared with idiopathic. A sensitivity analysis did not result in changes in the results. Thirty percent of included studies had more than low bias primarily originating from follow up and selection. Pericardiectomy is therefore performed mostly in middle-aged men with advanced symptoms and low co-morbidity burden and still caries significant operative mortality. Radiation and after-cardiac surgery patients have a significantly higher mortality risk compared with idiopathic. Several methodological issues and significant heterogeneity limit the generalization of these data and randomized controlled trials may have to be considered.

Short term clinical and echocardiography outcomes of pericardiectomy in constrictive pericarditis

Introduction: Tuberculous pericarditis continues to be a leading cause of chronic constrictive pericarditis (CCP) in developing countries. Echocardiography plays a key role in the assessment and diagnosis.

Methods: Twelve patients who underwent pericardiectomy for CCP in last 18 months of the study period were subjected to clinical and New York Heart Association (NYHA) functional class assessment along with comprehensive echocardiographic evaluation. The data were compared with their preprocedural status.

Results: Significant reduction was noted in the incidence of inferior vena cava (IVC) congestion(P < 0.001) and mean left atrial (LA) size from 43.75 ± 4.43 mm to 31.58 ± 3.03 mm (P < 0.001), post pericardiectomy.Respiratory variation of 34.17 ± 8.76 % in the mitral E velocity was significantly reduced to 17 ± 3.69 % (P < 0.001) after surgery. Similarly, respiratory variation in tricuspid E velocities showed significant reduction from 62.17 ± 13.16 % to 32.58 ± 4.7 % (P < 0.001).Prior to pericardiectomy, medial e’ and lateral e’ mitral annular velocities was 15.5±1.24 cm/sec and13.08 ± 1.08 cm/sec, respectively. Following surgery, the medial e’ and lateral e’ was 12.5±1.17 cm/sec(P = 0.001) and 15.42±1.83 (P = 0.004), respectively.

Conclusion: Echocardiography provides useful insight in pericardial constriction hemodynamics and worthwhile effects of pericardiectomy.

Pericardial Involvement in Cancer

Despite the monumental advances in the diagnoses and therapeutics of malignancy, several cancer patients have presented with pericardial involvement, including acute pericarditis, constrictive pericarditis, and pericardial effusion. Multiple factors can contribute to acute pericarditis, including direct metastasis to the heart, pericardial hemorrhage, infections due to immunosuppression, and cancer therapies that include chemotherapy, immunotherapy, and radiation. Pericardial effusion, either due to cancer invasion or cancer treatment, is one of the most common incidental findings in cancer patients, which significantly worsens morbidity and mortality. If left untreated, pericardial effusion is known to cause complications such as pericardial tamponade. Constrictive pericarditis can be due to radiation exposure, chemotherapy, or is a sequela of a previous episode of acute pericarditis. In conclusion, early detection, prompt treatment, and understanding of pericardial diseases are necessary to help improve the quality of life of cancer patients, and we aim to summarize the knowledge of pericardial involvement in patients with cancer.

MELD and MELD XI Scores as Predictors of Mortality After Pericardiectomy for Constrictive Pericarditis

OBJECTIVE

To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis.

PATIENTS AND METHODS

Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity.

RESULTS

A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays.

CONCLUSION

Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.