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Hartzell V. Schaff - One of the best experts on this subject based on the ideXlab platform.

  • outcomes of Pericardiectomy for constrictive pericarditis following mediastinal irradiation
    Journal of Cardiac Surgery, 2021
    Co-Authors: Siddharth Pahwa, John M. Stulak, Joseph A. Dearani, Hartzell V. Schaff, William R. Miranda, Juan A Crestanello, Annalisa Bernabei, Andreas Polycarpou, Alberto Pochettino, Richard C. Daly
    Abstract:

    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.

  • meld and meld xi scores as predictors of mortality after Pericardiectomy for constrictive pericarditis
    Mayo Clinic proceedings, 2021
    Co-Authors: Juan Diaz C Soto, Hartzell V. Schaff, Brian D Lahr, William J Mauermann, Sushil A Luis, Mark M Smith
    Abstract:

    Abstract 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 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.

  • experience with Pericardiectomy for constrictive pericarditis over eight decades
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Takashi Murashita, John M. Stulak, Katherine S. King, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Kevin L. Greason
    Abstract:

    Background The purpose of this study was to review the surgical outcomes of Pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period. Methods We reviewed all patients who underwent Pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990–2013) group (n = 807). Results Patients in the contemporary group were older (61 versus 49 years; p p p p p p p p  = 0.014). Conclusions There was a significant change in disease etiology over the study period. Long-term survival after Pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

  • Pericardiectomy after previous bypass grafting analyzing risk and effectiveness in this rare clinical entity
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Erin A Gillaspie, Kevin L. Greason, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Lyle D Joyce, John M. Stulak
    Abstract:

    Background Historically the most common causes of pericarditis necessitating Pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. Methods From January 1993 to December 2013, 938 patients underwent Pericardiectomy at our institution. We identified 98 patients who underwent Pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38–81 years), and 91 of the patients (93%) were men. The indication for Pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%–71%) and median NYHA functional class was III (91% were class III/IV). Results The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03–3.7]; p  = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. Conclusions The rate of early mortality for Pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.

  • a 20 year experience with isolated Pericardiectomy analysis of indications and outcomes
    The Journal of Thoracic and Cardiovascular Surgery, 2016
    Co-Authors: Erin A Gillaspie, John M. Stulak, Kevin L. Greason, Richard C. Daly, Hartzell V. Schaff, Lyle D Joyce, Joseph A. Dearani
    Abstract:

    Abstract Objectives Outcome after Pericardiectomy depends on many factors, but no large study has provided clarity on the effects of patient variables or cause of pericarditis on patient survival. We report early and late results from a 20-year experience with isolated Pericardiectomy. Methods From January 1993 to December 2013, 938 patients underwent Pericardiectomy at our institution. In order to establish a homogeneous population to analyze the impact of Pericardiectomy, we excluded patients with prior chest radiation, malignancy, and concomitant valvular or coronary procedures. We identified a cohort of 521 who underwent isolated Pericardiectomy; of these, 513 patients gave consent for research and comprise the cohort for this analysis; median age at operation was 57 years (range, 18-84 years) and 363 (71%) were men. Indications for Pericardiectomy were effusive/chronic relapsing pericarditis in 158 (31%) and pericardial constriction in 355 (69%). Prior coronary artery bypass grafting had been performed in 84 patients (14%). Median preoperative left ventricular ejection fraction was 60% (range, 24%-80%), and 77% of patients were in New York Heart Association (NYHA) functional class III/IV. Results Surgical approach was median sternotomy in 412 (80%), left thoracotomy in 71 (14%), and clamshell in 30 (5%). Extent of pericardial resection was radical in 414 (81%), subtotal in 71 (14%), and completion in 28 (5%). Cardiopulmonary bypass was used in 205 (40%). Overall mortality was 12/513 (2.3%); 3/158 (1.9%) for the effusive/chronic relapsing group versus 9/355 (2.5%) for the constriction group ( P  = .65). In the absence of multivariate predictors, which could not be identified, univariate predictors associated with increased risk of early death included lower left ventricular ejection fraction (hazard ratio [HR], 1.09; P  = .03) and preoperative renal insufficiency (HR, 9.9; P P P P  = .02), diabetes (HR, 1.83; 95% CI, [1.2, 2.7]; P  = .004), completion Pericardiectomy (HR, 2.4; 95% CI, [1.2, 4.7]; P  = .01), and chronic obstructive pulmonary disease (HR, 2.45; 95% CI, [1.5, 3.9]; P  = .004). During the follow-up period, 80% of patients were free from NYHA functional class III/IV symptoms at 5 years and 78% at 10 years. Conclusions Whereas early mortality after isolated Pericardiectomy is low irrespective of the indication for surgery, late follow-up demonstrates better outcomes after Pericardiectomy for effusive/chronic relapsing pericarditis compared with pericardial constriction. Importantly, the majority of patients were free from significant heart failure symptoms during follow-up.

Allan L Klein - One of the best experts on this subject based on the ideXlab platform.

  • meta analysis of population characteristics and outcomes of patients undergoing Pericardiectomy for constrictive pericarditis
    American Journal of Cardiology, 2021
    Co-Authors: Aspasia Tzani, Allan L Klein, Ilias P Doulamis, Andreas Tzoumas, Dimitrios V Avgerinos, Dimitrios Koudoumas, Gerasimos Siasos, Manolis Vavuranakis, Polydoros N Kampaktsis
    Abstract:

    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.

  • Pericardiectomy is associated with improvement in longitudinal displacement of left ventricular free wall due to increased counterclockwise septal to lateral rotational displacement
    Journal of The American Society of Echocardiography, 2015
    Co-Authors: Arun Dahiya, Zoran B Popovic, Hirohiko Motoki, Chadi M Alraies, Kazuaki Negishi, Tomoko Negishi, Srisakul Chirakarnjanakorn, Allan L Klein
    Abstract:

    Background Pericardiectomy is an effective intervention for constrictive pericarditis. Speckle-tracking echocardiography can provide quantitative information not only about longitudinal strain (LS) but about longitudinal displacement (LD) and septal-to-lateral rotational displacement (SLRD). The aim of this study was to investigate whether Pericardiectomy improves myocardial mechanics using speckle-tracking analysis. Methods Eighty-three patients with constrictive pericarditis who underwent echocardiography were retrospectively assessed (mean age, 58 ± 12 years; 72 men; 50 idiopathic, 20 postoperative, four viral, three radiation, and six others) and compared with 20 healthy volunteers. LD and SLRD were measured from the apical four-chamber view and global LS from three apical views. Results LD was less in the constrictive pericarditis group compared with control subjects ( P P P  = .48). In pre- and post–pericardial surgery comparisons ( n  = 27), values of septal and lateral LD were almost identical (mean, 13.6 ± 4.7 vs 13.3 ± 5.4 mm; P  = .70) before Pericardiectomy, but septal LD decreased (mean, 9.3 ± 3.5 mm; P P  = .0106) after the surgery, even though the difference in LS between the septal and lateral walls decreased (from 5.6 ± 5.3% to 2.5 ± 4.2%, P  = .008). Systolic whole-heart swinging motion significantly increased to a counterclockwise direction after surgery (mean SLRD, −0.8 ± 3.3° vs 2.1 ± 3.0°; P  = .001). Although the change in SLRD after Pericardiectomy was not different between patients with decreases and increases in New York Heart Association class, SLRD change was significantly greater in patients who received fewer diuretics after surgery (mean, 4.00 ± 0.91 vs 0.27 ± 1.47; P  = .027). Conclusions After surgical removal of the pericardium, LD of the septal and lateral walls became significantly different, and counterclockwise SLRD increased, reflecting loss of pericardial support.

  • right ventricular dilatation post Pericardiectomy causes tricuspid regurgitation
    Journal of the American College of Cardiology, 2015
    Co-Authors: Muhammad Tariq, Wahaj Aman, Abhishek Karwa, Rudolfo Benatti, Allan L Klein
    Abstract:

    Tricuspid Regurgitation (TR) often develops after Pericardiectomy, resulting in persistence of right heart failure symptoms, hence translates into failure of Pericardiectomy. We aimed to identify the incidence and mechanism of this complication at our center. Pre and post-operative echocardiograms

  • predictors of qrs voltage recovery post Pericardiectomy in patients with constrictive pericarditis
    European Heart Journal, 2013
    Co-Authors: M C Alraies, Wael Aljaroudi, Mohammed A Chamsipasha, Alpana Senapati, Allan L Klein
    Abstract:

    Introduction: There are no known pathognomonic ECG findings in constrictive pericarditis (CP). Increased pericardial thickness in CP is associated with low QRS voltage secondary to thickening and calcification. We sought to study the correlation between pericardial thickness identified by cardiac magnetic resonance (CMR) and ECG changes pre and post Pericardiectomy. Methods and results: 80 consecutive patients with proven constriction underwent Pericardiectomy at a Cleveland Clinic between 2009 and 2011. Baseline characteristics, CMR, and pathological specimens were reviewed retrospectively (Table one). Paired t-test and McNemar test were used to analyze pre and post ECG changes for continuous and categorical variables, respectively. There were significantly less patients with Afib, LBBB, RBBB or 1st degree AVB post-Pericardiectomy (table1). Also, significant increase in limb and precordial R-wave voltage postop (ΔR 8.2±3.7 and 9±4.3, respectively, p <0.001). On multivariate linear logistic regression, pericardial thickness (β 0.3 [0.078-0.52], p 0.009), low preop R wave voltage (β -0.54 [-1.1 to -0.60], p0.001) and age (β 0.18 [0.002-0.09] p=0.04) were predictors of R wave recovery postop. there was statistically significant correlation between pericardial thickness and mean R wave recovery (r 0.34, p 0.002) (figure 1). View this table: ECG Pre and Post surgery Conclusion: In patient with CP, rhythm and electrical conduction improve post Pericardiectomy. Thickened pericardium on CMR is an independent predictor of improvement of R wave with significant correlation.

  • changes in left atrial mechanics following Pericardiectomy for pericardial constriction
    Journal of The American Society of Echocardiography, 2013
    Co-Authors: Hirohiko Motoki, Arun Dahiya, Chadi M Alraies, Roberto M Saraiva, Mazen Hanna, Thomas H Marwick, Allan L Klein
    Abstract:

    Background Although impaired left ventricular (LV) filling in constrictive pericarditis (CP) is attributable to external constraints by a tethered pericardium, impaired left atrial (LA) function can further impair LV filling. Previous studies focused on the impact of a tethered pericardium on LV diastolic behavior, but its impact on LA function has been largely overlooked. The objectives of this study were to evaluate LA mechanics in CP and to assess the impact of Pericardiectomy on LA mechanics. Methods A total of 52 patients with CP (mean age, 57 ± 12 years) and 19 control subjects were studied retrospectively. All patients with CP underwent echocardiography before (median, 12 days; interquartile range, 5–34 days) and after Pericardiectomy (median, 20 days; interquartile range, 5–64 days). Global LA longitudinal strain (e) was calculated, which included peak negative e (e negative ), peak positive e (e positive ), and the sum of those values, total LA e (e total ), using speckle-tracking echocardiography with Velocity Vector Imaging. The regional difference of LA e between the septal and lateral walls was assessed before and after the procedure. Results Patients with CP showed depressed global LA e negative , LA e total , and LA e positive compared with controls. LA contractile (global LA e negative ) and reservoir functions (global LA e total ) showed significant increases after Pericardiectomy. Regional analysis revealed that the improvement in LA function after surgery was more apparent in lateral segments, while the regional function of septal walls was depressed after surgery. Conclusions Patients with CP have impaired LA mechanics, presumably because of the constrictive tethering process involving the left atrium. Speckle-tracking echocardiography showed consistent results of changes in LA mechanics with conventional echocardiographic parameters early after the procedure. Regional e analysis aided in recognition of the impact of constrictive tethering and Pericardiectomy on LA function.

Joseph A. Dearani - One of the best experts on this subject based on the ideXlab platform.

  • outcomes of Pericardiectomy for constrictive pericarditis following mediastinal irradiation
    Journal of Cardiac Surgery, 2021
    Co-Authors: Siddharth Pahwa, John M. Stulak, Joseph A. Dearani, Hartzell V. Schaff, William R. Miranda, Juan A Crestanello, Annalisa Bernabei, Andreas Polycarpou, Alberto Pochettino, Richard C. Daly
    Abstract:

    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.

  • experience with Pericardiectomy for constrictive pericarditis over eight decades
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Takashi Murashita, John M. Stulak, Katherine S. King, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Kevin L. Greason
    Abstract:

    Background The purpose of this study was to review the surgical outcomes of Pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period. Methods We reviewed all patients who underwent Pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990–2013) group (n = 807). Results Patients in the contemporary group were older (61 versus 49 years; p p p p p p p p  = 0.014). Conclusions There was a significant change in disease etiology over the study period. Long-term survival after Pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

  • Pericardiectomy after previous bypass grafting analyzing risk and effectiveness in this rare clinical entity
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Erin A Gillaspie, Kevin L. Greason, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Lyle D Joyce, John M. Stulak
    Abstract:

    Background Historically the most common causes of pericarditis necessitating Pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. Methods From January 1993 to December 2013, 938 patients underwent Pericardiectomy at our institution. We identified 98 patients who underwent Pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38–81 years), and 91 of the patients (93%) were men. The indication for Pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%–71%) and median NYHA functional class was III (91% were class III/IV). Results The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03–3.7]; p  = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. Conclusions The rate of early mortality for Pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.

  • a 20 year experience with isolated Pericardiectomy analysis of indications and outcomes
    The Journal of Thoracic and Cardiovascular Surgery, 2016
    Co-Authors: Erin A Gillaspie, John M. Stulak, Kevin L. Greason, Richard C. Daly, Hartzell V. Schaff, Lyle D Joyce, Joseph A. Dearani
    Abstract:

    Abstract Objectives Outcome after Pericardiectomy depends on many factors, but no large study has provided clarity on the effects of patient variables or cause of pericarditis on patient survival. We report early and late results from a 20-year experience with isolated Pericardiectomy. Methods From January 1993 to December 2013, 938 patients underwent Pericardiectomy at our institution. In order to establish a homogeneous population to analyze the impact of Pericardiectomy, we excluded patients with prior chest radiation, malignancy, and concomitant valvular or coronary procedures. We identified a cohort of 521 who underwent isolated Pericardiectomy; of these, 513 patients gave consent for research and comprise the cohort for this analysis; median age at operation was 57 years (range, 18-84 years) and 363 (71%) were men. Indications for Pericardiectomy were effusive/chronic relapsing pericarditis in 158 (31%) and pericardial constriction in 355 (69%). Prior coronary artery bypass grafting had been performed in 84 patients (14%). Median preoperative left ventricular ejection fraction was 60% (range, 24%-80%), and 77% of patients were in New York Heart Association (NYHA) functional class III/IV. Results Surgical approach was median sternotomy in 412 (80%), left thoracotomy in 71 (14%), and clamshell in 30 (5%). Extent of pericardial resection was radical in 414 (81%), subtotal in 71 (14%), and completion in 28 (5%). Cardiopulmonary bypass was used in 205 (40%). Overall mortality was 12/513 (2.3%); 3/158 (1.9%) for the effusive/chronic relapsing group versus 9/355 (2.5%) for the constriction group ( P  = .65). In the absence of multivariate predictors, which could not be identified, univariate predictors associated with increased risk of early death included lower left ventricular ejection fraction (hazard ratio [HR], 1.09; P  = .03) and preoperative renal insufficiency (HR, 9.9; P P P P  = .02), diabetes (HR, 1.83; 95% CI, [1.2, 2.7]; P  = .004), completion Pericardiectomy (HR, 2.4; 95% CI, [1.2, 4.7]; P  = .01), and chronic obstructive pulmonary disease (HR, 2.45; 95% CI, [1.5, 3.9]; P  = .004). During the follow-up period, 80% of patients were free from NYHA functional class III/IV symptoms at 5 years and 78% at 10 years. Conclusions Whereas early mortality after isolated Pericardiectomy is low irrespective of the indication for surgery, late follow-up demonstrates better outcomes after Pericardiectomy for effusive/chronic relapsing pericarditis compared with pericardial constriction. Importantly, the majority of patients were free from significant heart failure symptoms during follow-up.

  • completion Pericardiectomy for recurrent constrictive pericarditis importance of timing of recurrence on late clinical outcome of operation
    The Annals of Thoracic Surgery, 2012
    Co-Authors: Yang Hyun Cho, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Soon J Park
    Abstract:

    Background Recurrent right-side heart failure after operation for constrictive pericarditis (CP) may be caused by incomplete Pericardiectomy, recurrent constriction due to exuberant scar tissue, or diastolic dysfunction. Because the risks and benefits of reoperation are not well defined, we reviewed the outcome of completion Pericardiectomy. Methods From 1993 to December 2010, 41 patients underwent redo Pericardiectomy. Thirty-eight patients had the initial operation elsewhere, and 3 had first Pericardiectomy at our clinic. All patients had the diagnosis of CP at initial operation. We divided patients into two groups according to the interval between the first and second pericardiectomies: group A, 1 year or less, n=20; group B, more than 1 year, n=21. Results The mean age was 57.6 ± 12.7 years, and there were 34 males (83%). Twenty-six patients (63%) were in New York Heart Association class II, 10 (24%) were in class III, and 5 (12%) were in class IV. Etiologies were idiopathic in 20 (49%), prior cardiac surgery in 13 (32%), radiation in 6 (15%), and trauma in 2 (5%). There was no significant difference in patient characteristics between group A and group B. The 30-day and in-hospital mortalities were 7% (n = 3) and 12% (n = 5), respectively. Overall 5-year survival was 49%, and was significantly better in group A than group B (73% versus 29%, p = 0.032). In multivariate analysis, New York Heart Association class III or IV and the interval between operations longer than 1 year were significant risk factors for death ( p = 0.010 and p = 0.027, respectively). Conclusions The significant early mortality of repeat Pericardiectomy emphasizes the importance of complete pericardial resection at first operation and accurate diagnosis of recurrent constriction. The poor clinical outcome of late (more than 1 year) reoperation suggests that many of these patients may have unrecognized diastolic dysfunction or recurrent mediastinal scarring as the cause of right-side heart failure rather than incomplete initial Pericardiectomy.

John M. Stulak - One of the best experts on this subject based on the ideXlab platform.

  • outcomes of Pericardiectomy for constrictive pericarditis following mediastinal irradiation
    Journal of Cardiac Surgery, 2021
    Co-Authors: Siddharth Pahwa, John M. Stulak, Joseph A. Dearani, Hartzell V. Schaff, William R. Miranda, Juan A Crestanello, Annalisa Bernabei, Andreas Polycarpou, Alberto Pochettino, Richard C. Daly
    Abstract:

    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.

  • clinical features and prognosis of surgically proven constrictive pericarditis after orthotopic heart transplantation
    Journal of Heart and Lung Transplantation, 2021
    Co-Authors: James W Lloyd, John M. Stulak, Richard C. Daly, Robert R Frantz, Luis S Allen, William R. Miranda
    Abstract:

    Abstract Constrictive pericarditis (CP) results in pericardial noncompliance and diastolic dysfunction. Definitive treatment is Pericardiectomy, but data on CP following orthotopic heart transplantation (OHT) are limited. Accordingly, a retrospective review of eight cases of surgically proven CP post-OHT undergoing Pericardiectomy was conducted. In this series, all patients were male. Median time to symptomatic CP following OHT was 1.7 years (0.8-18.1 years). Echocardiographic assessment was diagnostic for CP in three cases (38%). Cross-sectional imaging was performed in six cases, revealing ≥ mild pericardial thickening in all. Six patients (75%) underwent cardiac catheterization, which revealed CP in five (83%). Post-Pericardiectomy 30-day mortality was 13% (one patient). Median survival following Pericardiectomy was 2.3 years (18 days to 14.6 years), and 5-year survival 29%. Overall, CP post-OHT represents a subset of CP patients with high morbidity and mortality, and multimodality assessment is essential for its diagnosis. Despite relatively low surgical mortality, long-term survival is poor.

  • clinical features and prognosis of surgically proven constrictive pericarditis after orthotopic heart transplantation
    Journal of Heart and Lung Transplantation, 2021
    Co-Authors: James W Lloyd, John M. Stulak, Richard C. Daly, Robert R Frantz, Luis S Allen, William R. Miranda
    Abstract:

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

  • experience with Pericardiectomy for constrictive pericarditis over eight decades
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Takashi Murashita, John M. Stulak, Katherine S. King, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Kevin L. Greason
    Abstract:

    Background The purpose of this study was to review the surgical outcomes of Pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period. Methods We reviewed all patients who underwent Pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990–2013) group (n = 807). Results Patients in the contemporary group were older (61 versus 49 years; p p p p p p p p  = 0.014). Conclusions There was a significant change in disease etiology over the study period. Long-term survival after Pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

  • Pericardiectomy after previous bypass grafting analyzing risk and effectiveness in this rare clinical entity
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Erin A Gillaspie, Kevin L. Greason, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Lyle D Joyce, John M. Stulak
    Abstract:

    Background Historically the most common causes of pericarditis necessitating Pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. Methods From January 1993 to December 2013, 938 patients underwent Pericardiectomy at our institution. We identified 98 patients who underwent Pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38–81 years), and 91 of the patients (93%) were men. The indication for Pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%–71%) and median NYHA functional class was III (91% were class III/IV). Results The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03–3.7]; p  = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. Conclusions The rate of early mortality for Pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.

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  • outcomes of Pericardiectomy for constrictive pericarditis following mediastinal irradiation
    Journal of Cardiac Surgery, 2021
    Co-Authors: Siddharth Pahwa, John M. Stulak, Joseph A. Dearani, Hartzell V. Schaff, William R. Miranda, Juan A Crestanello, Annalisa Bernabei, Andreas Polycarpou, Alberto Pochettino, Richard C. Daly
    Abstract:

    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.

  • clinical features and prognosis of surgically proven constrictive pericarditis after orthotopic heart transplantation
    Journal of Heart and Lung Transplantation, 2021
    Co-Authors: James W Lloyd, John M. Stulak, Richard C. Daly, Robert R Frantz, Luis S Allen, William R. Miranda
    Abstract:

    Abstract Constrictive pericarditis (CP) results in pericardial noncompliance and diastolic dysfunction. Definitive treatment is Pericardiectomy, but data on CP following orthotopic heart transplantation (OHT) are limited. Accordingly, a retrospective review of eight cases of surgically proven CP post-OHT undergoing Pericardiectomy was conducted. In this series, all patients were male. Median time to symptomatic CP following OHT was 1.7 years (0.8-18.1 years). Echocardiographic assessment was diagnostic for CP in three cases (38%). Cross-sectional imaging was performed in six cases, revealing ≥ mild pericardial thickening in all. Six patients (75%) underwent cardiac catheterization, which revealed CP in five (83%). Post-Pericardiectomy 30-day mortality was 13% (one patient). Median survival following Pericardiectomy was 2.3 years (18 days to 14.6 years), and 5-year survival 29%. Overall, CP post-OHT represents a subset of CP patients with high morbidity and mortality, and multimodality assessment is essential for its diagnosis. Despite relatively low surgical mortality, long-term survival is poor.

  • clinical features and prognosis of surgically proven constrictive pericarditis after orthotopic heart transplantation
    Journal of Heart and Lung Transplantation, 2021
    Co-Authors: James W Lloyd, John M. Stulak, Richard C. Daly, Robert R Frantz, Luis S Allen, William R. Miranda
    Abstract:

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

  • experience with Pericardiectomy for constrictive pericarditis over eight decades
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Takashi Murashita, John M. Stulak, Katherine S. King, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Kevin L. Greason
    Abstract:

    Background The purpose of this study was to review the surgical outcomes of Pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period. Methods We reviewed all patients who underwent Pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n = 259) and a contemporary (1990–2013) group (n = 807). Results Patients in the contemporary group were older (61 versus 49 years; p p p p p p p p  = 0.014). Conclusions There was a significant change in disease etiology over the study period. Long-term survival after Pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

  • Pericardiectomy after previous bypass grafting analyzing risk and effectiveness in this rare clinical entity
    The Annals of Thoracic Surgery, 2017
    Co-Authors: Erin A Gillaspie, Kevin L. Greason, Richard C. Daly, Joseph A. Dearani, Hartzell V. Schaff, Lyle D Joyce, John M. Stulak
    Abstract:

    Background Historically the most common causes of pericarditis necessitating Pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. Methods From January 1993 to December 2013, 938 patients underwent Pericardiectomy at our institution. We identified 98 patients who underwent Pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38–81 years), and 91 of the patients (93%) were men. The indication for Pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%–71%) and median NYHA functional class was III (91% were class III/IV). Results The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03–3.7]; p  = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. Conclusions The rate of early mortality for Pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.