Diagnosis and management of purulent pericarditis. Experience with pericardiectomy

Twelve cases of purulent pericarditis seen over 6 years are described. Staphylococcus aureus was the most common causative organism (six patients), and a respiratory infection was the most common preceding illness. The chest radiograph and echocardiogram were useful pointers to the diagnosis, but the electrocardiogram was not reliable. Antibiotics, surgical drainage, and pericardiectomy were used in all 12 cases. There was one death (8.3%), which occurred in a patient who was seen late. A review of the literature dealing with the diagnosis and management of this condition is presented. The importance of early diagnosis before a significant degree of cardiac tamponade occurs is noted. Although there is general agreement that surgical drainage is mandatory, the approach, methods of drainage, and extent of pericardial resection have been the subject of some discussion, and at least seven techniques are available. We conclude that pericardiectomy has a definite place in the management of purulent pericarditis.     

Acute purulent pericarditis: clinical experience with primary pericardiectomy plus continuous pericardium lavage]

106 patients with acute purulent pericarditis were treated surgically with three different methods without operative mortality. The pericardiectomy plus continuous pericardial lavage was more effective than pericardiectomy without irrigation or simple pericardial drainage in several aspects, such as recovery of body temperature, elimination of infectious-toxic symptoms and cutting short hospitalization days. Besides, cardiac tamponade or late constriction of the pericardium could be avoided.     

Thoracoscopic pericardiectomy for purulent pericarditis: experience with 21 cases

Purpose: We present our experience in performing thoracoscopic pericardiectomy for purulent pericarditis in 21 children. Materials and Methods: Pericardiectomy was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at 2-4 mm Hg. Anterior pericardiectomy was performed from the left phrenic nerve to the right border of the sternum to free the anterior part of the heart, notably the cardiac apex and the original area of the great vessels. Purulent debris was removed prior to detaching the epicardial peel. Results: This study included 21 patients. Their mean age was 8 years. The time from onset of the disease to surgery ranged from 4 to 34 days (average, 15.2 days). Operative times ranged from 50 to 180 minutes (average, 100 minutes). There were no intraoperative or postoperative complications. All symptoms of cardiac tamponade disappeared immediately postoperatively. Follow-up ranged from 4 to 15 months and showed normal clinical manifestations, echocardiographs, and chest x-rays in all children. Conclusion: Thoracoscopic pericardiectomy with removal of a generous amount of the pericardium is feasible and safe for purulent pericarditis.     

Early and late results of pericardiectomy for constrictive pericarditis

Records of 231 patients (171 males, 60 females; aged 10 months to 83 years [median 45 years]) who underwent operation for constrictive pericarditis at the Mayo Clinic from 1936 through 1982 were reviewed. All had had hemodynamically significant pericardial constriction preoperatively, and pericardial disease was confirmed at operation. Preoperatively, 69% were in New York Heart Association Class III or IV and 81% had peripheral edema or ascites. Pericardiectomy was performed through a left anterolateral thoracotomy (34%), a median sternotomy (27%), a U incision (Harrington) (21%), or a bilateral anterior thoracotomy (18%). Postoperatively, 28% of patients had evidence of low cardiac output; 70% of the 32 deaths within 30 days of operation were due to low cardiac output. Operative risk was significantly (p less than 0.001) related to preoperative disability (1% for Class I or II; 10% for class III; 46% for Class IV). Median postoperative follow-up was 9 years (longest was 43 years). Probability of survival for patients dismissed alive from the hospital was 84% at 5 years, 71% at 15 years, and 52% at 30 years. Long-term survival (excluding operative mortality) was not significantly influenced by the disability class preoperatively, the operative approach, or the development of low cardiac output in the immediate postoperative period. At the end of the follow-up interval, there were 141 patients in whom functional capacity could be assessed; 140 were in Class I or II. We conclude that a poor hemodynamic result after complete pericardiectomy relates to the preoperative degree of constriction and resultant cardiomyopathy. We recommend early pericardiectomy when pericardial constriction is diagnosed, and we continue to use a left anterolateral thoracotomy as the preferred approach for most patients.     

Total pericardiectomy for uremic pericarditis

Between 1973 and 1975, 19 patients were treated for uremic pericarditis. The clinical presentation of the condition varied, with some patients having minimal symptoms (chest pain, fever) and others sustaining circulatory collapse. Pericardial friction rub, elevated central venous pressure, and paradoxical pulse were the most common physical findings. Serial chest radiography, echocardiography, and cardiac scan were most useful in establishing the diagnosis. Three patients had cardiac catheterization and angiography. Pericardiectomy was the initial procedure performed in 13 of 19 patients, and there was no operative mortality or recurrence of pericarditis. Four patients initially had a pericardial window created rather than a pericardiectomy. Two had recurrence of symptoms and one required later total pericardiectomy. Two patients underwent initial tube pericardiostomy. Both died after recurrent tamponade. Total pericardiectomy appears to be the treatment of choice for uremic pericarditis and the only form of therapy which is definitive. The risk of circulatory collapse from tamponade warrants early operative intervention in this critically ill group of patients.

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Résumé De 1973 à 1975, 19 patients ont été traités pour péricardite urémique. Les malades présentaient un tableau clinique très variable, certains avaient peu de symptômes (douleurs thoraciques, température) et d'autres étaient en collapsus. Les signes physiques les plus fréquents furent le frottement péricardique, l'élévation de la pression veineuse centrale et le pouls paradoxal. Les examens les plus utiles pour l'établissement du diagnostic sont la radiographie de thorax, l'échographie et la scintigraphie cardiaque. Trois patients ont subi un cathétérisme cardiaque et une angiographie. Treize malades sur 19 ont subi d'emblée une péricardectomie sans mortalité opératoire ni récidive de la péricardite. Chez 4 patients, une fenêtre antérieure a été créée dans le péricarde, les symptômes sont réapparus chez 2 malades et l'un d'eux dut subir une péricardectomie. Un simple drainage a été réalisé chez 2 patients qui succombèrent à une récidive de la tamponade cardiaque. La péricardectomie totale semble être l'intervention de choix de la péricardite urémique car elle seule réalise un traitement définitif de cette affection. Le risque de tamponade cardiaque justifie un traitement chirurgical précoce dans ce groupe de malades graves.

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Presented at the 49th Annual Scientific Session of the American Heart Association, Miami Beach, Florida, November 15–18, 1976.     

Early and late results of pericardiectomy in 118 cases of constrictive pericarditis

The medical records of 118 patients (86 male, 32 female, age 10-50 (mean 27) years) who underwent pericardiectomy for constrictive pericarditis at the Christian Medical College Hospital, Vellore, from 1954 to 1985 were reviewed. All had appreciable pericardial constriction. Preoperatively 97 of the 118 were in class III or IV of the New York Heart Association classification and 100 had peripheral oedema or ascites. Tuberculosis was proved as the cause in 72 patients. Pericardiectomy was accomplished through a standard anterolateral thoracotomy (107 cases), median sternotomy (3 cases), or bilateral thoracotomy (8 cases). Postoperatively an apparent low cardiac output state was seen in 34 patients, 12 of whom died. Hospital mortality in the last 12 years was 11%. Mortality was higher in NYHA class III and IV patients. The improved surgical results recently may be related to increased use of inotropic support and prolonged ventilation. At follow up there were 72 patients in whom functional capacity could be assessed; 63 were in class I or II. The poor results of pericardiectomy in some patients are likely to be related to advanced preoperative disability and early pericardiectomy is therefore recommended.     

Total robotic-enhanced pericardiectomy for effusive pericarditis

With the DaVinci Robot only recently in clinical use, limitations of video-assisted thoracoscopy could disappear due to Endo-Wrist features, tremor cancellation and three-dimensional view. This report describes the total endoscopic pericardiectomy successfully achieved with robotic assistance in a 50-year-old man suffering from effusive pericarditis.     

Mitral regurgitation after pericardiectomy for constrictive pericarditis

We report a case of constrictive pericarditis in which trace mitral valve regurgitation was detected preoperatively and temporarily worsened after a pericardiectomy was performed. The early postoperative data suggested that the increased mobility of the lateral wall, in conjunction with an increase in the left ventricular volume, might be one of the causes of the perioperative mitral valve dysfunction. The mitral valve function returned to the preoperative baseline thirteen months after the pericardiectomy.     

Mitral regurgitation after pericardiectomy for constrictive pericarditis.

We report a case of constrictive pericarditis in which trace mitral valve regurgitation was detected preoperatively and temporarily worsened after a pericardiectomy was performed. The early postoperative data suggested that the increased mobility of the lateral wall, in conjunction with an increase in the left ventricular volume, might be one of the causes of the perioperative mitral valve dysfunction. The mitral valve function returned to the preoperative baseline thirteen months after the pericardiectomy.     

Futility of pericardiectomy for postirradiation constrictive pericarditis?

Two patients underwent pericardiectomy for postirradiation constrictive pericarditis. Both had received radiotherapy (more than 6,000 rads) for treatment of Hodgkin's disease 17 (patient 2) and 20 years (patient 1) earlier. At the time of operation, the patients were in New York Heart Association functional class III-IV or IV. Preoperative catheterization showed the following pressures for patients 1 and 2, respectively: right atrial, 30 and 14 mm Hg; right ventricular end-diastolic, 28 and 14 mm Hg; wedge, 29 and 13 mm Hg; and left ventricular end-diastolic, 27 and 14 mm Hg. Complete epicardiectomy and pericardiectomy was attempted in both patients. However, hospital mortality was 100%; patient 1 died of multiorgan failure after six days, and patient 2 died of biventricular failure after 3 months. A review of the literature revealed 44 cases of pericardiectomy for postirradiation constrictive pericarditis and a late survival rate of less than 50%. The poor results in these patients compared with patients having pericardiectomy for other reasons seem to be due mainly to the various kinds of radiation-induced damage to the heart as a whole, including untimely coronary artery disease, myocardial fibrosis, atrioventricular conduction disturbances, and valve dysfunction, with the result that complete relief by epicardiectomy and pericardiectomy may not be technically feasible.     

Left ventricular dysfunction after pericardiectomy for constrictive pericarditis

A 56-year-old man was admitted to our hospital with a diagnosis of suspected constrictive pericarditis. After the diagnosis was confirmed by cardiac catheterization, an elective pericardiectomy was performed without complication. Four days after surgery dyspnea developed in the patient, and he was found to have an acute decrease in left ventricular ejection fraction (LVEF) by echocardiography. The patient's symptoms and the LVEF improved over time and returned to normal 4 weeks after surgery. Transient hemodynamic dysfunction of the left ventricle has previously been reported after pericardiectomy or pericardiocentesis; however, we know of no reports in the literature that confirm an acute reduction in LVEF by echocardiography after pericardiectomy for constrictive pericarditis.     

Reoperation for calcific constrictive pericarditis 43 years after pericardiectomy

The case of calcific pericarditis in a 63-year-old male with a 1-year history of progressive right heart failure 43 years after pericardiectomy in 1960 is reported. The recurrent constriction was caused by the calcification of the residual posteroinferior pericardium and the impressing sternum of a pectus excavatum encasing the heart like a skull. The patient underwent total pericardiectomy of his residual pericardium through median sternotomy using cardiopulmonary bypass resulting in complete relief of his symptoms.