Biçer et al. Journal of Cardiothoracic Surgery  (2015) 10:177 
DOI 10.1186/s13019-015-0385-8
RESEARCH ARTICLE Open Access
Long-term outcomes of pericardiectomy for
constrictive pericarditis
Murat Biçer1, Bülent Özdemir2*, İris Kan1, Ahmet Yüksel1, Mustafa Tok1 and Işık Şenkaya1
Abstract
Background: Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening
of the pericardium. The purpose of this study was to evaluate the long-term outcomes following treatment of
constrictive pericarditis by pericardiectomy.
Methods: Between September 1992 and May 2014, 47 patients who underwent pericardiectomy for constrictive
pericarditis were retrospectively examined. Demographic, pre-, intra- and postoperative data and long-term
outcomes were analyzed.
Results: Thirty of the patients were male, the mean age was 45.8 ± 16.7. Aetiology of constrictive pericarditis was
tuberculosis in 22 (46.8 %) patients, idiopathic in 15 (31.9 %), malignancy in 3 (6.4 %), prior cardiac surgery in 2
(4.3 %), non-tuberculosis bacterial infections in 2 (4.3 %), radiotherapy in 1 (2.1 %), uraemia in 1 (2.1 %) and post-
traumatic in 1 (2.1 %). The surgical approach was achieved via a median sternotomy in all patients except only 1
patient. The mean operative time was 156.4 ± 45.7 min. Improvement in functional status in 80 % of patients’ at
least one New York Heart Association (NYHA) functional class was observed. In-hospital mortality rate was 2.1 %
(1 of 47 patients). The cause of death was pneumonia leading to progressive respiratory failure. The late mortality
rate was 23.4 % (11 of 47 patients). The mean follow-up time was 61.2 ± 66 months. The actuarial survival rates
were 91 %, 85 % and 81 % at 1, 5 and 10 years, respectively. Recurrence requiring a repeat pericardiectomy was
developed in no patient during follow-up.
Conclusion: Pericardiectomy is associated with high morbidity and mortality rates. Cases with neoplastic diseases,
diminished cardiac output, cases in need of reoperation are expected to have high mortality rates and less chance
of functional recovery.
Keywords: Constrictive pericarditis, Pericardiectomy, postoperative results
Background overload and reduced cardiac output are progressive in
Constrictive pericarditis is caused by thickening of the nature.
pericardium. It causes diastolic dysfunction and at the The study conducted by Ling et al. revealed that the
end the filling of heart is impeded by the constricted majority of patients presented with congestive heart fail-
pericardium surrounding the heart. The aetiology is idio- ure. With decreasing frequencies the patients had pre-
pathic, prior cardiac surgery, postradiotherapy , postin- sented with chest pain, abdominal symptoms, cardiac
fective, connective tissue disease-related, neoplastic, tamponade, atrial arrhythmia and frank liver disease [3].
uremic, sarcoidosis, and miscellaneous [1, 2]. After oc- Definitive treatment for chronic constrictive pericardi-
currence of constriction; the symptoms related to fluid tis is pericardiectomy. In this paper we retrospectively
examined the data of pericadiectomies of 47 cases that
were operated between 1992 and 2014.
* Correspondence: buloz2@yahoo.com
2Department of Cardiology, Uludağ University Medical Faculty, Görükle
Kampüsü, Nilüfer, Bursa, 16000, Turkey Methods
Full list of author information is available at the end of the article We evaluated the data regarding patients that had pericar-
diectomy due to having constrictive pericarditis in the
© 2015 Biçer et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Biçer et al. Journal of Cardiothoracic Surgery  (2015) 10:177 Page 2 of 5
Research Hospital of Uludağ University Medical Faculty Table 1 Preoperative characteristics of the patients
between September 1992 and May 2014. Demographic Variable Result
and operative data were evaluated. The outcomes of the Mean age (years) 45.8 ± 16.7
patients were noted. Male/Female ratio 30/17
All patients underwent pericardiectomy via median
Symptoms (no. of patients, %)
sternotomy except for one case. A left anterior thoracot-
omy was performed in that case. In patients approached Dyspnoea 34 (72.3 %)
via sternotomy total pericardiectomy was performed be- Lower limb oedema 15 (31.9 %)
tween the two phrenic nerves and from the great vessels Chest pain 10 (21.3 %)
to the basal aspect of the heart. Partial pericardiectomy Abdominal distension 7 (14.9 %)
was achieved in one case that underwent left anterior Palpitation 3 (6.4 %)
thoracotomy.
Constitutional (Fever, fatigue, weight loss, etc.) 19 (40.4 %)
One patient had concomitant mitral valve replacement
and 4 patients required concomitant coronary bypass Signs (no. of patients, %)
surgery. Cardiopulmonary bypass (CPB) was not used Peripheral oedema 20 (42.5 %)
during coronary artery bypass grafting except for 2 pa- Jugular venous distension 16 (34.0 %)
tients (off-pump technique). One patient was started Hepatosplenomegaly 11 (23.4 %)
with CPB and one patient was later converted to CPB Ascites 9 (19.1 %)
due to cardiac injury. All patients were monitored with
Pericardial knock 6 (12.8 %)
Swan-Ganz catheterization.
Postoperative death was defined as death occurring Pulsus paradoxus 3 (6.4 %)
within 30 days of operation or within the hospitalization
period for the operation. Mean duration of the pericardiectomy operation was
Continuous variables were expressed as the mean 156.4 ± 45.7. Cardiopulmonary bypass utilization was not
with standard deviation and categorical variables as per- high (12.8 %). The mean preoperative central venous pres-
centages. The chi-squared test and the Student’s t-test sures of the cases decreased significantly from 17.0 ± 2.9
were performed as appropriate. Survival was assessed to 10.8 ± 2.1 postoperatively (The data regarding oper-
by the Kaplan-Meier method. The Wilcoxon’s signed ation, post operative care and treatment are given in
rank test was used to compare the NYHA functional Table 3). The postoperative complications noted were
classes of patients preoperatively and postoperatively. A pleural effusion, pulmonary infection, long-term intub-
p value < 0.05 was considered statistically significant. ation, low output syndrome, bleeding (requiring surgical
Statistical analysis was performed using IBM SPSS revision), acute renal failure, hepatic failure, and wound
Statistics Version 20. infection. The frequencies are given in Table 4.
Discussion
Results The preoperative functional class of the patients in ma-
Forty-seven patients had operation for constrictive peri- jority belonged to NYHA Class II and III like previously
carditis. Mean age was 45.8 ± 16.7 for the patients and reported by Ghavidel et al. [4]. The comparison of pre
30 were males. The baseline characteristics of the pa- and post operative NYHA functional class of all the pa-
tients are given in Table 1. Dyspnoea was the most com- tients is given in Fig. 1. Dyspnoea and oedema was the
mon complaint of the patients. Peripheral oedema was most frequent symptoms. The constriction affects both
also most commonly noted during physical examination.
Table 2 Aetiologies of constrictive pericarditis
The majority of the cases had NYHA functional class II
and III. The functional class was improved at least one Etiological factor No. of patients (%)
NYHA functional class in 80 % of the cases. The most Tuberculosis 22 (46.8 %)
common etiologic factor for our patients was tubercu- Idiopathic 15 (31.9 %)
losis. Idiopathic constrictive pericarditis ranked second Malignancy 3 (6.4 %)
(Table 2). In-hospital mortality rate was 2.1 % (1 of 47 History of CABG operation 2 (4.3 %)
patients). The cause of death was pneumonia secondary
Non-tuberculosis bacterial infections 2 (4.3 %)
to progressive respiratory failure. The late mortality rate
was 23.4 % (11 of 47 patients). The mean follow-up time Radiotherapy 1 (2.1 %)
was 61.2 ± 66 months. The longest survival was 214 months. Uraemia 1 (2.1 %)
The actuarial survival rates were 91 %, 85 % and 81 % at 1, Post-traumatic 1 (2.1 %)
5 and 10 years, respectively. CABG: Coronary artery bypass grafting
Biçer et al. Journal of Cardiothoracic Surgery  (2015) 10:177 Page 3 of 5
Table 3 Intraoperative and postoperative data of the patients
35 Preopreative NYHA Functional
Variable Result 30 Class
30 Postoperative NYHA Functional
Mean operation time (minutes) 156.4 ± 45.7 Class at 3rd month
25
CPB utilization (no. of patients, %) 6 (12.8 %)
20
Concomitant procedures (no. of patients, %) 20 18
CABG 4 (8.6 %) 15 12
MVR 1 (2.1 %) 10
6
CVP change 5 3 3
1
Preoperative CVP (mmHg) 17.0 ± 2.9 0
  I   II   III  IV
Postoperative CVP (mmHg) 10.8 ± 2.1
Fig. 1 Functional Status of patients pre- and postoperatively
Inotropic support (no. of patients, %) 11 (23.4 %)
Low dose 8 (17.0 %)
Medium-high dose 3 (6.4 %) in the literature involve elevated jugular venous pressure
Blood product requirement (being most common), oedema, ascites, pulsus paradoxus,
No. of patients, % 26 (55.3 %) Kussmaul's sign, and pericardial knock [1, 3].
Mean amount used (units) 1.9 ± 1.2 In this study, our patients had tuberculosis and idio-
pathic causes as etiological factors. Also encountered
Mean duration of mechanical ventilation (hours) 28.5 ± 80.1
causes were malignancy, prior cardiac operation, and
Mean length of ICU stay (days) 2.8 ± 4.6 bacterial infection other than tuberculosis, radiotherapy,
Mean length of hospital stay (days) 9.2 ± 7.7 tuberculosis and trauma. In another report by Avgerinos;
In-hospital mortality (no. of patient, %) 1 (2.1 %) idiopathic, postoperative, post-radiation, and tubercu-
CPB: Cardiopulmonary bypass, CABG: Coronary artery bypass grafting, CVP: losis were found in decreasing frequency [6]. Talreja et
Central venous pressure, MVR: Mitral valve replacement, ICU: Intensive al. in their study that included 143 patients with proven
care unit
constriction who underwent pericardiectomy between
1993 and 1999, and compared the patients according to
ventricles and causes both left and right ventricular dys- the thickness of the pericardium. In their study both the
function but symptoms of right heart failure dominate. patients with normal pericardial thickness (≤2 mm) and
The congestive heart failure in the presence of normal patients with thickened pericardium (>2 mm) had fre-
left ventricular systolic functions should make us to quently the aetiology of a previous cardiac operation [7].
think about constrictive or restrictive type pathologies. But interestingly; in this study idiopathic disease was the
Also discrimination between restrictive cardiomyopa- most frequent disease in the group with thickened
thies and constrictive pericarditis is important. History, pericardium.
physical examination, electrocardiography, chest radiog- In our study the mean central venous pressure de-
raphy, echocardiography, cardiac CT or MRI, and creased from 17.0 ± 2.9 to 10.8 ± 2.1. In a study included
hemodynamic evaluation all are important modalities patients that had pericardiectomy due to constriction
used for the diagnosis [5]. Physical examination revealed the central venous pressure significantly decreased from
peripheral oedema, jugular venous distension, hepatos- 15.3 ± 3.7 mmHg to 8.8 ± 3.1 [8]. Postoperative mortality
plenomegaly and ascites in decreasing frequency in our occurred in one patient as in-hospital mortality due to
study. Physical examination findings commonly reported pneumonia. Late mortality was 17.4 %. Bertog et al. re-
ported a perioperative mortality of 6 % in their study. In
Table 4 Early postoperative complications his study idiopathic constrictive pericarditis had the best
Complication No. of patients (%) prognosis [2]. Lin et al. reported an in-hospital mortality
of 3.9 %. In his study; low cardiac output syndrome due
Pleural effusion 6 (12.8 %)
to right heart failure and acute renal failure were the
Pulmonary infection 4 (8.5 %) causes of mortalities [9]. In 47 pericardiectomy patients
Long-term intubation (over 48 hours) 4 (8.5 %) a 30-day mortality of 8.5 % occurred and 69 % of cases
Low output syndrome 3 (6.4 %) clinical improved with echocardiographic parameters
Bleeding (requiring surgical revision) 1 (2.1 %) normalizing eventually [10].
Acute renal failure 1 (2.1 %) In our series all the cases with malignancies died due
to the primary disease. Idiopathic group (n = 11) has no
Hepatic failure 1 (2.1 %)
fatalities with the maximum follow up of 84 months in
Wound infection 1 (2.1 %) one patient. The patients with tuberculosis (n = 17) has a
Biçer et al. Journal of Cardiothoracic Surgery  (2015) 10:177 Page 4 of 5
Fig. 2 Cumulative Survival of the patients
mortality rate of 23,5 %. Late mortality rates of patients review. IŞ contributed in writing. All authors read and approved the final
with tuberculosis that had pericardiectomy were at 5 manuscript.
and 10 years were 1.6 % and 9.7 %, respectively in a Author details
study conducted by Çınar et al. [11]. The cumulative 1Department of Cardiovascular Surgery, Uludağ University Medical Faculty,
2
survival data are given in Fig. 2. Long term survival of Bursa, Turkey. Department of Cardiology, Uludağ University Medical Faculty,
Görükle Kampüsü, Nilüfer, Bursa, 16000, Turkey.
pericardiectomy operations is dependent on the aeti-
ology of the constrictive pericarditis. High mortality Received: 7 March 2015 Accepted: 18 November 2015
rates in cases with malignancies and patients that had
radiotherapy are expected. In a small series of patients a
mean survival of 14.82 ± 4.4 months was reported in References
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