Jan 22, 2008 - Constrictive Pericarditis in the Modern Era. Novel Criteria for Diagnosis in the Cardiac Catheterization Laboratory. Deepak R. Talreja, MD, FACC, Rick A. Nishimura, MD, FACC, Jae K. Oh, MD, FACC,. David R. Holmes, MD, FACC. Rochester,
Apr 16, 2017 - BackgroundâThe clinical spectrum of constrictive pericarditis (CP) has been affected by a change in incidence of etiological factors. We sought to determine the impact of these changes on the outcome of pericardiectomy. Methods and R
Constrictive pericarditis is caused by fibrosis and calcification of the pericardium, processes that inhibit diastolic filling of the heart. This condition has posed a diagnostic dilemma since it was first recognised clinically.1. Al- though many dia
... of symptoms in many patients, accurate diagnosis of this dis- ... constrictive pericarditis from other causes of .... diastolic pressures and is accompanied by an.
T2W STIR. LGE. âRip-Roaringâ Transient Constrictive Pericarditis ... Pericardial effusion/tamponade. â¢ Constrictive ... treated with colchicine, especially if treated ...
An unusual case of constrictive pericarditis, caused by lodging of a needle in the heart wall,is presented and discussed. Attention is focused on the rapid ...
ting resolution of the congestive state and disappearance of the "typical" hemodynamic findings of constrictive pericarditis. T HE HEMODYNAMIC abnormalities.
of constrictive pericarditis. T HE HEMODYNAMIC abnormalities of constrictive pericarditis were firstde- scribed in1946 byBloomfield and asso- ciates' who stressed "the virtually normal. (right) ventricular systolic pressure, a low ven- tricular pulse
Echo Evaluation of Pericardial Diseases. â¢ Constriction ... Pericardial effusion on Echo. â¢ Treated with Ibuprofen 2400 mg/d,. Colchicine 0.6 mg BID. â¢ Not feeling ...
Jun 12, 2013 - OBJECTIVES: Constrictive pericarditis is the result of a spectrum of primary cardiac and non-cardiac conditions. Few data exist on the preoperative risk specific to survival after pericardiectomy. This study was designed to compare the
view this cause has never been proven unequivocally. It is the purpose of this paper to describe another case of this condition. Of special interest is the fact that constrictive pericarditis developed very rapidly in this patient, a point which rais
Oct 4, 2010 - In both typical constrictive pericarditis and effusive-constrictive pericarditis, cardiac filling is impeded by an external force. The normal pericardium can stretch to accommodate physiologic changes in cardiac volume, and only after t
May 18, 2015 - He was found to have pericardial and bilateral pleural effusions which grew P. acnes. ... colchicine 0.6mg twice daily were initiated for treatment.
A study has been made of 62 patients with constrictive pericarditis. ... because both diagnosis and treatment can sometimes cause perplexity. .... In a few patients the diastolic sound was accompanied by a thrust felt over the praecordium.
Nov 16, 1988 - Background. The pathogenesis of sodium and water accumulation in chronic constrictive pericarditis is not well understood and may differ from that in patients with chronic congestive heart failure due to myocardial disease. This study
Treatment of this disease is problematic because pericardio- centesis does not .... superimposed features of accompanying pericardial effusion or tamponade.
The characteristic intracardiac pressure patterns of four patients with constrictive pericarditis are described. The significance of a high ratio between right ...
The electrocardiographic findings of 1 8 patients with chronic constrictive pericarditis and their progress 16 to 80 months following radical pericardectomy.
has had catheterization studies. A case of amyloid of the heart is presented with catheterization studies and the reasons for the clinical and physiologic similarity to constrictive pericarlditis are discussed. T HE essential pathology of constrictiv
Constrictive pericarditis (CP) is an uncommon postin- flammatory disorder characterized by pericardial thick- ening, myocardial constriction, and impaired ...
pericarditis. Increasing size of the abdomen for the past two or three years requiring paracentesis was her main complaint. She was in sinus rhythm, blood.
JOURNAL OF THE ASSOCIATION OF PHYSICIANS OF INDIA â¢ MARCH 2014 â¢ VOL. 62. 67. Occult Constrictive Pericarditis. SR Mittal*. *Department of Cardiology,. St. Francis Hospital, Ajmer. Received: 01.09.2010;. Accepted: 07.10.2013. Case 1. A 45 years m
predominantly at thisannulus, the effect on the heart was similar to that resulting from more generalized constriction. In the fifth, signs of functional pulmonary, mitral, and aortic stenosis developed seven years after the original operation for co
Sep 29, 1970 - acterized by effusion into a free pericardial space associated with constriction of the heart by the visceral pericardium. The pericardial disease was idiopathic (nine patients) or subsequent to radiotherapy (four patients), with a max
Constrictive Pericarditis in the Modern Era Evolving Clinical Spectrum and Impact on Outcome After Pericardiectomy Lieng H. Ling, MBBS, MRCP; Jae K. Oh, MD; Hartzell V. Schaff, MD; Gordon K. Danielson, MD; Douglas W. Mahoney, MSc; James B. Seward, MD; A. Jamil Tajik, MD
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Background—The clinical spectrum of constrictive pericarditis (CP) has been affected by a change in incidence of etiological factors. We sought to determine the impact of these changes on the outcome of pericardiectomy. Methods and Results—The contemporary spectrum of CP in 135 patients (76% male) evaluated at the Mayo Clinic from 1985 to 1995 was compared with that of a historic cohort. Notable trends were an increasing frequency of CP due to cardiac surgery and mediastinal radiation and presentation in older patients (median age, 61 versus 45 years). Perioperative mortality decreased (6% versus 14%, P50.011), but late survival was inferior to that of an age- and sex-matched US population (5768% at 10 years). The long-term outcome was predicted independently by 3 variables in stepwise logistic regression analyses: (1) age, (2) NYHA class, and most powerfully, (3) a postradiation cause. Of 90 late survivors in whom functional class could be determined, functional status had improved markedly (2.660.7 at baseline versus 1.560.8 at latest follow-up [P,0.0001]), with 83% being free of clinical symptoms. Conclusions—The evolving profile of CP, with increasingly older patients and those with radiation-induced disease in the past decade, significantly affects postoperative prognosis. Long-term results of pericardiectomy are disappointing for some patient groups, especially those with radiation-induced CP. By contrast, surgery alleviates or improves symptoms in the majority of late survivors. (Circulation. 1999;100:1380-1386.) Key Words: pericarditis n prognosis n surgery
onstrictive pericarditis (CP), although uncommon, commands substantial clinical interest because of the perceived potential for surgical cure. In the past 15 years, several reports have highlighted changes in the spectrum of CP in the United States, characterized chiefly by a declining incidence of tuberculous pericarditis and an increase in the frequency of cases resulting from therapeutic mediastinal radiation and cardiac surgery.1–3 Few data, however, exist on the impact of these changes on outcome after pericardiectomy. In addition, outcome analysis has focused predominantly on a mortality end point; markers for recurrent congestive heart failure (CHF) symptoms, for example, are unknown. We hypothesized that the observed changes in the clinical spectrum of CP influence postoperative prognosis in the current era. Because the epidemiology of CP is strongly influenced by geography and referral bias, changes in disease patterns are most appropriately defined vis-a`-vis a historic cohort from the same institution. Accordingly, we reviewed the cases of patients with proven CP evaluated at the Mayo Clinic in the past decade and identified contemporary trends in relation to 231 patients examined at our institution from 1936 through 1982.4
Methods All patients with the diagnosis of CP in the medical and surgical indexes of the Mayo Clinic from January 1985 through June 1995 were screened. Only patients with CP confirmed at surgery or autopsy were included. During this period, 135 patients were identified: 133 at surgery and 2 at autopsy. Case histories were reviewed, and clinical findings by a staff cardiologist were recorded. Follow-up of patients was done with a mailed questionnaire, hospital records, and telephone calls to the patients, their relatives, and their physicians. The circumstances and causes of death recorded in death certificates were verified whenever possible with the patient’s physician or the coroner who certified the death. Concomitant medical illnesses were assigned weights and summed as a comorbidity index for survival analyses.
Definitions Radical pericardiectomy was defined as wide excision of the pericardium anteriorly between the 2 phrenic nerves and from the great arteries superiorly to the diaphragm inferiorly, posterior to the left phrenic nerve (which is left on a pedicle) to the left pulmonary veins, and including the pericardium on the diaphragmatic and posterior surfaces of the ventricles.4 Constricting layers of epicardium were also removed. The atria and venae cavae were decorticated only if the dissection could be accomplished easily, without risk of hemorrhage.4,5 Pericardiectomy was considered partial if both ventricles could not be decorticated completely because of dense myopericardial adhesions or calcification.
TABLE 1. Candidate Predictors of Outcome Used in Univariate Proportional Hazards Analyses Clinical
Age Serum creatinine Completeness of Sex Serum sodium pericardiectomy* NYHA class Serum bilirubin Concomitant CABG or Symptom duration Serum transaminases valve surgery Peripheral edema Serum albumin Requirement for Ascites Atrial fibrillation or atrial flutter cardiopulmonary bypass* Pericardial knock Low ECG voltage Radiation cause Cardiothoracic ratio Known CAD† Calcification on CXR Smoking history Comorbidity index Diuretic dose‡
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CABG indicates coronary artery bypass graft surgery; CAD, coronary artery disease; and CXR, chest radiograph. *Variables not used as baseline predictors in multivariate analyses as generally unpredictable before pericardiectomy. †Includes patients with previous documented myocardial infarction and coronary bypass surgery or coronary artery narrowing (diameter stenosis .70%) demonstrated by “screening” coronary angiography before pericardiectomy. ‡Defined as dose in milligrams of furosemide or bumetanide, multiplied by a conversion factor of 40, and stratified as no diuretic use, #80 mg, or .80 mg.
For uniformity with other studies, perioperative death was defined as that occurring within 30 days after surgery. However, all deaths within the same hospitalization as for surgery were included in analysis of predictors of perioperative death. Cardiac-related death was defined as death due to cardiac causes, such as progressive CHF or sudden death. Sudden unexpected death was defined according to the criteria of Hinkle and Thaler,6 whereas sudden expected death was abrupt death occurring in the setting of progressive CHF or an episode of CHF in the preceding 12 months. A poor cardiovascular outcome was defined as any combination of the end points of perioperative death, late cardiovascular death, and new-onset or recurrent New York Heart Association (NYHA) class III to IV CHF.
Statistical Analysis Categorical data, expressed as percentages, were compared by the t test or x2 test, as appropriate. Continuous variables, expressed as mean6SD or median values, were compared by the 2-sample Wilcoxon rank sum test. The rates of all-cause mortality, perioperative death, late survival, late cardiac-related death, recurrent NYHA class III to IV CHF, and a poor late cardiovascular outcome were estimated by the Kaplan-Meier method. Late survival curves were compared with those of a normal 1990 US population matched for age and sex by the log-rank test. Baseline predictors of subsequent sudden death were identified by univariate Cox proportional hazards analysis initially performed on candidate variables (Table 1). Variables univariately significant on the basis of a threshold value of P#0.15 were entered stepwise into a multivariable logistic regression model to confirm independent predictive value. A value of P,0.05 was considered statistically significant.
Results Incidence and Causes The causes of CP in the 135 study patients and the 231 patients of the historic series are depicted in Figure 1. An indeterminate cause of CP was significantly less common in the contemporary cohort (33% versus 73%, P,0.0001). The 3 most common identifiable causes were cardiac surgery (18%), pericarditis (16%), and mediastinal irradiation (13%). Patients who had received radiotherapy most commonly had Hodgkin’s lymphoma (8 patients) or breast cancer (7
Figure 1. Causes of 366 cases of CP confirmed at surgery (or autopsy) at the Mayo Clinic in the 2 periods surveyed: 1936 through 1982 (n5231) and 1985 to June 1995 (n5135).
patients), a median of 13.1 years (range, 1.0 to 40.6 years) before pericardiectomy. Of the patients with connective tissue disease or arthritides, 6 had rheumatoid arthritis and 1 each had rheumatic fever (with myopericarditis), polymyalgia rheumatica, psoriatic arthropathy, and Still’s disease. Infectious causes identified were fungal pericarditis (histoplasmosis and candidiasis) in 2 patients and tuberculosis and Whipple’s disease in 1 patient each. Miscellaneous causes included myeloproliferative disorders, malignancy, trauma, asbestosis, drug-induced causes, and complicated pacemaker lead replacement. CP was diagnosed in 2 patients at autopsy: 1 had had cardiac surgery and the other had tumor encasement by non-Hodgkin’s lymphoma.
Clinical Characteristics Clinical characteristics of the study population are shown in Table 2. The presentation was CHF in 90 patients (67%), chest pain in 11 (8%), abdominal symptoms in 8 (6%), cardiac tamponade in 7 (5%), atrial arrhythmia in 6 (4%), and frank liver disease in 5 (4%). In the other 8 patients, the initial presentation included postoperative low cardiac output state, recurrent pleural effusion, transient ischemic attack, and syncope. The median symptomatic duration before pericardiectomy was 11.7 months (range, 3 days to 29.1 years). Chronicity of symptoms characterized patients with an indeterminate cause of CP (mean, 17.4 months).
Surgery Pericardiectomy was performed in 132 of the 135 patients. One patient who had previously had radiotherapy underwent triple coronary artery bypass graft surgery and a tricuspid annuloplasty, but the patient’s condition deteriorated intraoperatively and pericardiectomy was not performed. Radical pericardiectomy was performed in 117 patients (89%). Pericardial resection was deemed incomplete in the other 15 patients (11%). Ultrasonic debridement of calcified pericardium was performed in 12 patients (9%), coronary artery bypass grafting was performed in 10 patients (8%), valve replacement or repair in 5 (4%), and a combined coronary artery-valve procedure, atrial septal defect closure, resection of subaortic stenosis, and right ventricular outflow tract enlargement in 1 patient (0.8%) each. Cardiopulmonary bypass was used in 45 patients; the mean extracorporeal circulation time was 88658 minutes.
September 28, 1999 TABLE 2. Preoperative Characteristics of 135 Patients With CP Diagnosed From January 1985 Through June 1995 Compared (Where Data Available) With a Historic Mayo Cohort From 1936 Through 1982 1985–1995 Cohort (n5135) Characteristic
No. or Value
1936 –1982 Cohort (n5231) No. or Value
Age, y 56616
Symptom duration, mo Median
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Pericardial knock or S3
Low QRS voltage
JVP indicates jugular venous pressure; CAD, coronary artery disease; and NA, not available. *Indeterminate in 7 of 135 patients.
Information about death was available for all except 1 patient (99%) and for other end points in 129 patients (98%). In patients dismissed from the hospital, the mean follow-up period was 3.963.0 years (maximum, 12.2 years). There were 39 deaths (30%), of which 26 occurred after hospital dismissal. At 5 and 10 years, overall survival was 7165% and 5268%, respectively. Independent determinants of overall survival were age, previous radiotherapy, NYHA class, and serum concentration of sodium (Table 3).
At last follow-up, 93 of the 119 operative survivors (78.2%) were alive. Survival at 5 and 10 years was 7865% and 5768%, respectively, and was inferior to that of an age- and sex-matched US population (log-rank P,0.001) (Figure 2). This difference was not observed for the historic cohort, which had an identical proportion of patients with advanced NYHA symptoms.4 In stepwise multivariate analysis, independent predictors of late survival were age, NYHA class, and previous radiation (Table 3 and Figure 3). The difference from expected survival was still statistically significant even when patients with radiation disease were excluded (log-rank P50.016) (Figure 2).
Perioperative Deaths The 30-day perioperative mortality was 6% (8 of 132). This compares favorably with the 14% perioperative mortality in the historic cohort (x256.40, P50.011). A total of 13 patients died in hospital. The principal causes of death were low output state in 6 patients, sepsis in 3, uncontrolled hemorrhage in 2, and renal failure and respiratory insufficiency in 1 each. Of these 13 patients, pericardiectomy was incomplete in 6 (univariate P,0.0001 for prediction of perioperative death), and cardiopulmonary bypass was required in 9.
Late Cardiovascular Deaths The late deaths in 26 patients resulted from cardiac-related causes in 17, pleuropulmonary disease in 2, noncardiac illness in 6, and an unknown cause in 1. None of the patients who had radiation therapy died of recrudescent neoplastic disease.
Ling et al TABLE 3. Multivariate Predictors of Outcome After Pericardiectomy in 132 Patients With CP Adjusted Hazard Ratio
Outcome Overall survival
No. of Events 39
Serum sodium Late survival
Previous radiation Late CV death
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Cardiac-related deaths were due to progressive CHF in 14 patients (4 terminated in sudden expected death) and were sudden and unexpected in 3. The cumulative incidence of cardiovascular deaths was 1464% and 3569% at 5 and 10 years, respectively. Independent predictors of late cardiacrelated deaths were previous radiotherapy, NYHA class III to IV symptoms, and age (Table 3).
Late NYHA Class III to IV CHF Symptoms Recurrent or new NYHA class III to IV symptoms supervened in 37 of 119 patients (31%) at some stage of late follow-up. The median time to onset of new or recurrent CHF symptoms was 7.1 months (range, 0.4 to 137.1 months). Three patients were reoperated on for recurrent CP. The 5- and 10-year incidence of late NYHA class III to IV CHF, 2565% and 4169%, respectively, parallels that of late
cardiovascular deaths, consistent with the observation that most severely symptomatic patients died eventually of a cardiac-related cause. Multivariate predictors of late CHF were age, radiation, and the presence of ascites (Table 3). Of the 89 patients alive at latest follow-up with complete follow-up information, 74 (83%) were either asymptomatic or mildly symptomatic (Figure 4). Mean functional class was 2.660.7 at baseline, compared with 1.560.8 after pericardiectomy (mean change, 1.160.9, P,0.0001).
Freedom From Poor Cardiovascular Outcome Of 129 patients with complete follow-up information, 75 (58%) were alive and free of CHF at latest follow-up. At 5 and 10 years, 7065% and 4368% of patients, respectively, were free of a poor cardiovascular outcome. This end point occurred in 15 of 17 patients (88%) who had received radiation, including 13 deaths, and in 31 of 112 patients (28%) without a radiation basis for CP (P,0.0001). The dismal outcome for patients with radiation disease was reflected in a 1266% freedom from any cardiovascular event by 5 years.
Discussion In comparing our contemporary patients with a historical cohort that had pericardiectomy at the Mayo Clinic4 —a total experience spanning nearly 6 decades—several trends were observed: (1) patients in the last decade were older (median age, 61 years versus 45 years), (2) previous open heart surgery and mediastinal irradiation emerged as important causes of CP, (3) operative mortality was significantly lower, but (4) late survival was not as good as expected. The increasing importance of iatrogenic causes of CP2,3,7–9 is reflected in the marked decline in the proportion of indeterminate causes in the present series. Postoperative CP may not be as uncommon as previously believed.2,7,9,10 At the current level of 725 000 such procedures performed annually in the United States, a conservative 0.3% incidence could yield up to 2200 new cases annually. Therapeutic radiation could also remain a significant cause of pericardial disease. Cardiac structures are exquisitely sensitive to the effects of radiation, which often become manifest decades later.11,12 In addition, improved cancer cure rates have resulted in greater longevity and thus the likelihood of developing cardiovascular sequelae.13 Active tuberculous CP, present in 6.1% of patients in the series of McCaughan et al,4 was rare in our patients (0.7%). This declining trend is in contradistinction to recent reports from other geographic regions,14 –16 emphasizing again the heterogeneity of disease patterns.
Figure 2. Late survival (perioperative deaths excluded) after pericardiectomy for CP compared with that of an age- and sexmatched US population (left) and after patients with radiationinduced disease were excluded (right). Numbers at bottom represent percentage of expected survival for specified intervals.
The decline in operative mortality at our institution from 25% in the earlier half of this century5 to 6% at present probably is related to improvements in surgical technique, anesthesia, and postoperative care. Despite the inclusion of older patients and those with radiation-induced CP, our results compare favorably with the 6% to 19% rate of larger series published after 1985.1–3,14,15,17
September 28, 1999
Figure 3. Late survival stratified by age #55 years versus .55 years (left), NYHA class I to III versus class IV (middle), and nonradiation versus radiation causes (right). Baseline NYHA class was indeterminate in 2 patients.
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Unlike our earlier experience, late survival was inferior to that of an age- and sex-matched control population. The difference in survival was not entirely explained by the increased prevalence of radiation-induced CP. Two reasons may account for this observation. First, patients with CP often have systemic or pleuropulmonary disease that increases the risk of non– cardiac-related deaths. However, comorbidity was not a significant predictor of late survival in our study. Second, improved perioperative management and medical therapy could have deferred attrition in patients with associated myocardial disease. This latter possibility is supported by 2 observations: (1) preoperative NYHA class independently predicted late cardiac-related deaths and (2) the survival curves diverged early, after only 18 months. Late death occurred suddenly in 6 patients. Sudden death has been reported in the setting of CP18 and after pericardiectomy.1,5,19 Occult atherosclerotic coronary artery disease may be suspected, but the pericardial process can also obliterate epicardial vessels and cause myocardial ischemia.20,21 This is unlikely after pericardiectomy unless it was incomplete. In 2 of our patients with radiation disease, sudden death could have resulted from accelerated coronary atherosclerosis.8,22
Predictors of Late Events All long-term outcomes were predicted consistently by 3 baseline variables: age, NYHA class, and a radiation cause for CP.
A correlation between NYHA class and overall or late survival has been observed by us and others and is the basis for advocating early pericardiectomy.1,4,17 However, the effect of age on survival after pericardiectomy has not previously been apparent because of the uniformly young populations studied, especially from regions in which tuberculosis is endemic.1,4,14,23,24 The median age of our patients is at least a decade older than that in other series.1,4,14,19,20,25–30 Greater physician awareness and a comprehensive Doppler echocardiographic examination could have been instrumental in diagnosing CP in these older patients.31 Previous radiotherapy was the most powerful predictor of all outcome measures. The deleterious late effects of radiation on cardiac structures other than the pericardium have been well described.8,12,32,33 Pericardiectomy is more challenging because of mediastinal fibrosis, which limits complete resection,34,35 and postoperative recovery may be prolonged because of chest wall fibrosis. Long-term survival is also compromised by pulmonary interstitial disease, impaired immunological responses, and recurrent primary tumor or secondary neoplasms from chemotherapy. However, all deaths in our patients with radiation pericarditis were cardiacrelated. Our study confirms the guarded long-term outcome of these patients, even if some derived initial symptomatic relief after pericardiectomy. The recognition of such poorrisk subgroups also facilitates objective comparisons of survival data. For instance, although Tirilomis et al17 reported a 5-year overall survival of 85% after pericardiectomy, the mean age of their patients was 44 years, and only 1 patient had radiation-induced CP.
Late Functional Status
Figure 4. Change in NYHA functional class in 93 late survivors, showing marked symptomatic improvement in most patients after pericardiectomy. NYHA class was indeterminate in 1 patient before surgery and unknown in 3 patients at latest follow-up.
Pericardiectomy provided excellent relief of symptoms in most late survivors in our study. However, nearly one third of these patients experienced either new or recurrent NYHA class III to IV symptoms at some time during follow-up. This could be due to incomplete surgical resection.36 –38 In our study, incomplete pericardiectomy was significantly associated with recurrence of late CHF in univariate analysis. However, the majority of patients in whom recurrent symptoms developed had had radical surgery. The culprit pathophysiological mechanisms in these instances are not well characterized but include immobilization atrophy, myoperi-
Ling et al cardial involvement by the same pathological process (exemplified by radiation disease), or physical extension of pericardial calcification into the myocardium.20,39 – 41 Residual myocardial fibrosis was likely in our patients who had recurrent CHF symptoms, because (1) many had radiationinduced disease and (2) restrictive left ventricular filling could be documented by serial Doppler echocardiography in some patients.31,42 Involvement of adjacent pleuropulmonary structures by the constrictive disease process39 and concomitant chronic obstructive lung disease limited functional recovery in nearly a fifth of patients. Clearly, these mechanisms are not mutually exclusive in individual cases.
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Selecting cases of CP on the basis of thoracotomy findings to reflect incidence represents a bias of all surgical studies. It is likely that more cases remain unoperated on, because of underdiagnosis, minimal symptoms, or high operative risk. However, inspection of the pericardium remains the gold standard for the diagnosis of CP and may be the only way to prove the diagnosis in relation to restrictive cardiomyopathy.31,43 Incomplete functional recovery in some patients may be the result of gradual adaptation of the released ventricles to loading conditions and may not represent the permanent functional state. However, nearly all our patients had follow-up of at least 1 year, and myocardial recovery should have occurred by that time.44,45 Unlike other investigators,1 we did not include cardiac catheterization variables for prediction of outcome. This test, which was done in 65 of the 132 patients, is currently not performed routinely in the workup of CP at our institution unless echocardiographic findings are nondiagnostic. Because patients who had concomitant surgical procedures were excluded from our historic cohort, a direct comparison of outcome between the historic and contemporary patient groups may preferentially favor the former. However, the occasional need for concomitant coronary artery bypass graft surgery and valvular procedures did not have significant impact on early and late mortality in univariate analyses, consistent with the findings of other studies.29,36
Conclusions CP is a heterogeneous disease. Increasingly important causes in the current era include previous mediastinal irradiation and cardiac surgery. Although pericardiectomy is often performed, it may not offer a cure or good long-term result for patients with CP that is advanced or due to radiation disease. Cardiac transplantation could be considered in selected patients without recurrent tumor and with good pulmonary reserve, particularly if severe valvular disease coexists. However, postoperative prognosis and functional outcomes remain good for most other patients with CP and excellent for younger patients without radiation pericarditis.
Acknowledgment Dr Ling was supported by a Faculty Development Program Scholarship from the National University Hospital, Singapore, and by the Mayo Clinic. We thank Jami A. Spitzer for help with preparation of the manuscript.
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Constrictive Pericarditis in the Modern Era: Evolving Clinical Spectrum and Impact on Outcome After Pericardiectomy Lieng H. Ling, Jae K. Oh, Hartzell V. Schaff, Gordon K. Danielson, Douglas W. Mahoney, James B. Seward and A. Jamil Tajik Downloaded from http://circ.ahajournals.org/ by guest on April 10, 2017
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