Pericardial Constriction

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DNA test for Joan of Arc
Kim Willsher in Paris
Tuesday February 14, 2006
The Guardian

History contends that the ashes of Saint Joan of Arc were gathered from the pyre on which she was burned alive and tossed into the river Seine. Anxious to avoid creating a martyr, the English, who had ordered her death in 1431, wanted nothing left of the 19-year-old French heroine. According to legend, however, a devoted follower managed to find and conceal some of her remains, including fragments of charred rib and material from clothing, that today are one of the Roman Catholic church's most precious relics.

Now DNA tests are to be carried out on the Pucelle d'Orléans (the Maid of Orleans), who was killed 575 years ago for being a heretic and a witch after she claimed voices from God had told her to drive the English from France. Philippe Charlier, a genetic specialist at the Raymond-Pointcaré hospital at Garches, west of Paris, said the tests would solve the mystery over the relic.

"The remains include fragments of ribs, material, wood and traces of human body tissues on pieces of bone and wood from the pyre," he said.

Joan of Arc, was burned at the stake, but because her heart remained intact - seen in the 15th century as a miracle - her remains were cremated on two more occasions before being thrown in the river. "Today we can give medical reasons for why the heart, lungs and intestines might not have burned but in those days it was considered a miracle," said Dr Charlier. "They burned the remains twice more as they were very determined there should be nothing left."

He added: "We won't be able to say, 'Yes this is Joan of Arc', but within six months we will able to say if these remains belong to a female of 19 years old whose body was burned three times in Rouen in 1431."

Born in Domrémy in 1412, Joan of Arc began hearing voices at 13 telling her to liberate France from the English. At 17 she led an army to relieve Orleans. After accepting the surrender of Troyes, she and her army escorted Charles VII to Rheims for his coronation in 1429.

She was later captured and handed over to the English and then tried by a group of clergy who had to be coerced into finding her guilty in 1431. She was made a saint in 1920.

Shelley's Heart
Published: August 6, 1995
To the Editor:

I read with interest Robert McCrum's review of "Shelley's Heart," by Charles McCarry (June 25). I agree with Mr. McCrum's statement that the novel's title demands explanation, but he neglected to mention the well-documented story of Percy Bysshe Shelley's actual heart.

After Shelley's death by drowning, his body was cremated in the presence of his friends Edward Trelawny and Leigh Hunt. Strangely, Shelley's heart did not burn and was retrieved from the fire by Trelawny, who gave the heart to Hunt, who ultimately gave it to Shelley's wife, Mary. The heart was finally buried in 1889, 67 years after Shelley's death, with the body of his son Sir Percy Florence Shelley. In a 1955 article in The Journal of the History of Medicine, Arthur Norman suggested that Shelley may have suffered from "a progressively calcifying heart . . . which indeed would have resisted cremation as readily as a skull, a jaw or fragments of bone." ALEXA SELPH Atlanta

J Card Surg. 2007 Jul-Aug;22(4):295-9.
BioGlue: a protective barrier after pericardiotomy.
Wang ND, Doty DB, Doty JR, Yuksel U, Flinner R.
Division of Cardiovascular and Thoracic Surgery, LDS Hospital, Salt Lake City, Utah, USA.

BACKGROUND: Repeat operation on the heart composes about 20% of procedures in contemporary practice of cardiac surgery. A sheet of material providing a barrier against cardiac adhesion to the sternum would be desirable. METHODS: Anterior pericardiectomy was performed in rats. BioGlue milled to a 0.4 mm sheet was applied to the anterior surface of the heart in 16 rats; Surgicel plus liquid BioGlue in seven; Surgicel alone in three; and nothing (control) in eight. The operative site was reexamined for gross evidence of adhesion, scarring, and residual BioGlue 1, 3, and 6 months later. RESULTS: There was formation of a loose connective tissue barrier containing blood vessels without scar formation in all animals treated with milled BioGlue. Surgicel plus BioGlue resulted in a barrier containing more denser connective tissue with collagen fibers. Surgicel alone resulted in a similar barrier. No barrier formed in the control experiments. CONCLUSIONS: A sheet of milled BioGlue applied over the surface of the heart but not attached to it after partial pericardiectomy has been shown to stimulate formation of a loose connective tissue barrier containing blood vessels. This barrier is unique compared to dense fibrous scar which usually forms after opening the pericardium for cardiac operations.

Heart Lung Circ. 2007 Jul 9;
Pericardiectomy Using the Starfish Heart Positioner.
Almeida AA, Al-Shawawreh J, Zimmet AD.
Cardiothoracic Surgery Unit, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia; The Epworth Hospital, Bridge Road, Richmond Victoria 3121, Australia.

We describe the use of the Starfish 2 heart positioning device as an aid to performing pericardiectomy for constrictive pericarditis. Whilst mainly a tool for off-pump coronary artery surgery, the Starfish device allows excellent cardiac positioning and haemodynamic stability during pericadiectomy via median sternotomy, without the need for cardiopulmonary bypass.

Ann Thorac Surg. 2007 Jun;83(6):2222-4.
Localized pericardial constriction resulting in a "dumbbell" heart.
Hamdulay ZA, Kumar P, Ali M, Bhojraj SS, Jain SB, Patwardhan AM.
Department of Cardiovascular Surgery, Prince Aly Khan Hospital, Mumbai, India.

We describe an unusual case of a young man presenting with calcific constrictive pericarditis. The patient had a history of restrictive cardiomyopathy and pericardial effusion during infancy and received antituberculous treatment. Investigations revealed the presence of thickened pericardium and a thickened calcific constrictive band around the atrioventricular groove posteriorly and over the infundibulum anteriorly. Intraoperatively, the band caused the heart to have a "dumbbell" appearance. A pericardiectomy was performed along with excision of the constricting band. The patient had an uneventful recovery.

Dig Dis Sci. 2007 Jun 16;
Chronic Pericarditis and Pericardial Tamponade Associated with Ulcerative Colitis.
Cappell MS, Turkieh A.
Division of Gastroenterology, William Beaumont Hospital, Administration Bldg. West, 3rd Floor, 3601 W. Thirteen Mile Road, Royal Oak, MI, 48073, USA,

Unlike other extraintestinal inflammatory manifestations of ulcerative colitis, cardiac involvement is infrequently reported and inadequately characterized, with only 9 previously reported cases of pericardial tamponade associated with inflammatory bowel disease. A 32 year old male with ulcerative colitis, treated with orally administered mesalamine for ten years, developed chronic pericarditis. Extensive clinical and laboratory evaluation failed to find any cause of the pericarditis other than the ulcerative colitis. Although the pericarditis remitted with indomethacin therapy, this medicine had to be discontinued because of a reactivation of ulcerative colitis attributed to this nosteroidal antiinflammatory drug (NSAID). The pericarditis then responded well to high-dose corticosteroid therapy, but the patient represented with chest pain, dyspnea, tachypnea, and engorged neck veins after tapering the corticosteroid therapy. Angiography revealed near equalization of end diastolic pressures in both ventricles, a finding consistent with pericardial tamponade. The patient underwent subtotal pericardiectomy. Thoracotomy revealed a thickened pericardial wall and a large pericardial effusion. The patient's symptoms resolved postpericardiectomy. This case extends the clinical spectrum of pericarditis associated with ulcerative colitis, by describing a case of pericarditis that was chronic, refractory to maintenance medical therapy, caused pericardial tamponade, and was successfully treated by pericardiectomy.

Rev Med Liege. 2007 Apr;62(4):184-7.
Clinical case of the month. Constrictive pericarditis with a macroscopically normal pericardium: apropos of a case
Hoffer E, Materne P, Limet R, Boland J.
Service de Cardiologie, CHR de la Citadelle, Liège.

The diagnosis of constrictive pericarditis is not easy to make. This rare condition can be suggested by clinical, echocardiograohic, hemodynamic, and radiological signs. It must be distinguished from restrictive cardiomyopathy as therapeutic options are radically different. We present an ambiguous case of constrictive pericarditis with macroscopically normal pericardium recognized 10 years after open-chest cardiac surgery: a large pericardiectomy rapidly induced clinical improvement.

Radiologe. 2007 Apr;47(4):342-9.
Evaluation of diastolic function in patients with constrictive pericarditis before and after pericardectomy.
Bauner K, Schoenberg SO, Schmoeckel M, Reiser MF, Huber A.
Institut für Klinische Radiologie, Klinikum Grosshadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.

PURPOSE: The aim of the study was to evaluate diastolic function in patients with constrictive pericarditis using velocity-encoded flow measurements before and after pericardectomy. MATERIALS AND METHODS: Velocity-encoded flow measurements were performed at the atrioventricular valves in nine patients with constrictive pericarditis. The resulting flow curves were evaluated. For assessment of diastolic function the amplitudes of the E and A waves were measured and the E to A wave ratios calculated. Appearance of mid-diastolic flow, indicating diastolic dysfunction, was registered. RESULTS: The measurements at the mitral valves prior to pericardectomy revealed diastolic dysfunction grade I in two patients, grade II in three patients, and grade III in three patients. Mid-diastolic flow was detected in two patients. At the tricuspid valves diastolic dysfunction grade I was present in two patients, grade II in four patients, and grade III in three patients. Improvement of diastolic function after pericardectomy was documented in five patients at the mitral valve and in two patients at the tricuspid valve. CONCLUSION: Velocity-encoded flow measurements are feasible and a valuable tool for assessment of diastolic function in patients with constrictive pericarditis prior to and after pericardectomy.

Rev Cardiovasc Med. 2006 Fall;7(4):238-43.
Constrictive pericarditis after coronary artery bypass.
Halawa A, Iskandar S, Garcia I.
East Tennessee State University, James H. Quillen College of Medicine, Johnson City, TN.

A 67-year-old male patient received a coronary artery bypass graft. Less than 2 months afterward, he presented with recurrent exacerbations of congestive heart failure. His response to a standard treatment regimen for heart failure was partly successful, but a few days after discharge he was readmitted for worsening dyspnea and edema. Doppler echocardiography suggested the hemodynamics of constrictive pericarditis. Magnetic resonance imaging showed thickened pericardium with exudates in the pericardial space. Cardiac catheterization confirmed the diagnosis, showing equalization of diastolic pressures of the left and right ventricles. The patient underwent subtotal pericardiectomy with resolution of the pericardial disease, but he died from respiratory insufficiency.

Ann Thorac Cardiovasc Surg. 2006 Oct;12(5):373-5.
Constrictive pericarditis with atrial septal defect.
Tanoue Y, Tomita Y, Kajiwara T, Tominaga R.
Department of Cardiovascular Surgery, Kyushu University, Fukuoka, Japan.

We report on a case of constrictive pericarditis (CP) with atrial septal defect (ASD) in a 50-year-old man. The combination of CP with ASD is rare and occasionally difficult to diagnose. Transthoracic echocardiography demonstrated ASD, but the finding of a thickened pericardium was poor. Diagnosis was confirmed by cardiac catheterization. Pericardiectomy and direct closure of ASD was performed during cardioplegic arrest under the support of cardiopulmonary bypass. The postoperative course was uneventful with marked improvement in symptoms.

Interact Cardiovasc Thorac Surg. 2006 Oct;5(5):652-4. Epub 2006 Jul 24.
Primary and secondary purulent pericarditis in otherwise healthy adults.
Leoncini G, Iurilli L, Queirolo A, Catrambone G.
Unit of Thoracic Surgery, San Martino University Hospital, Genoa, Italy.

The records of five previously healthy adult patients with primary and secondary purulent pericarditis are reported, in order to review the literature about such a rare condition and to discuss the options for treatment. Primary purulent pericarditis occurred in a five months pregnant woman and in a lady who had experienced a serous pericarditis two months before. A man presented with pyo-pneumo-pericardium. He had an episode of acute prostatitis 30 days before. Two further patients had purulent pericarditis secondary to pulmonary and mediastinal infections. The diagnosis was made late in all cases, after tamponade and shock occurred. Pre-operative catheter drainage failed to prevent recurrent tamponade and sepsis in two patients. All patients underwent thoracotomy and partial pericardiectomy. A downward transdiaphragmatic spreading collection was evident in one patient and laparotomy was needed. The mean postoperative stay was 30.4 days (20-48 days). All patients were discharged home in good health. The lady who was pregnant experienced an uncomplicated vaginal delivery. The follow-up time ranged between 5 months to 12 years. No patient has signs of pericardial constriction. We conclude that effective control of sepsis and prevention of possible further constriction are achieved safely by open surgical drainage and partial pericardiectomy.

J Trauma. 2006 Sep;61(3):582-5.
Comment in: J Trauma. 2007 Jan;62(1):264. J Trauma. 2007 May;62(5):1317; author reply 1317-8.
Blind subxiphoid pericardiotomy for cardiac tamponade because of acute hemopericardium.
Kurimoto Y, Hase M, Nara S, Yama N, Kawaharada N, Morishita K, Higami T, Asai Y.
Department of Traumatology and Critical Care Medicine, Sapporo Medical University, Sapporo, Japan.

OBJECTIVE: Percutaneous catheter drainage (PCD) is not always effective in a case of hemopericardium. Acute occlusion of catheter and cardiac perforation can happen more often. To perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method after finger dissection by subxiphoid approach. We report the usefulness of blind subxiphoid pericardiotomy (BSP) based on the results of a prospective control study. METHODS: We designed a study to determine a favorable management for cardiac tamponade resulting from hemopericardium. In an emergency case of cardiac tamponade because of hemopericardium, board certified surgeons should perform BSP and other emergency physicians should perform PCD, with or without local anesthesia. PCD (n = 67) and BSP (n = 16) were performed for patients with cardio-pulmonary arrest (CPA) or near CPA because of cardiac tamponade secondary to trauma (n = 7), acute aortic dissection (n = 65), and cardiac rupture following acute myocardial infarction (n = 11) in our emergency medical center from January 2000 to December 2004. RESULTS: BSP was effective in all cases but PCD was ineffective in five cases because of clotting in pericardium (p = 0.260). No complication was observed in the BSP group but five critical complications and three infeasible drainage complications were observed in the PCD group (p = 0.146). Ten patients (BSP, 4; PCD, 6; p = 0.077) survived after emergency surgery (n = 8) or conservative treatment (n = 2). CONCLUSION: BSP was safe and could be performed quickly in an emergency situation. Percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clotting in pericardium.

Ann Thorac Surg. 2006 Feb;81(2):522-9.
Comment in: Ann Thorac Surg. 2006 Feb;81(2):529-30.
Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques.
Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, Seth S, Mishra PK, Pradeep KK, Sathia S, Venugopal P.
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND: This study was designed to compare the outcomes after total versus partial pericardiectomy clinically, echocardiographically, and hemodynamically. METHODS: Three hundred ninety-five patients undergoing pericardiectomy for constrictive pericarditis between January 1985 and December 2004 were studied. Age was 10 months to 71 years (mean, 25.1 +/- 13.4 years). Three hundred thirty-eight patients (85.6%) underwent total pericardiectomy (group I), and 57 patients (14.4%) underwent partial pericardiectomy (group II). RESULTS: Operative and late mortality rates were 7.6% and 4.9%, respectively. Preoperative high right atrial pressure, hyperbilirubinemia, renal dysfunction, atrial fibrillation, pericardial calcification, thoracotomy approach, and partial pericardiectomy were significant risk factors for death. The risk of death was 4.5 times higher (95% confidence interval: 2.05 to 9.75) in patients undergoing partial pericardiectomy. At a mean follow-up of 17.9 +/- 0.3 years (95% confidence interval: 17.3 to 18.6), actuarial survival was 83.8% +/- 0.04% in group I and 73.9% +/- 0.06% in group II (p = 0.004). At their last follow-up, 96.3% survivors of group I and 79.1% survivors of group II were in New York Heart Association class I/II (p < 0.001). CONCLUSIONS: Total pericardiectomy is associated with lower perioperative and late mortality, and confers significant long-term advantage by providing superior hemodynamics that appear to be independent of the etiology of constrictive pericarditis.

Echocardiography. 2005 May;22(5):431-3.
Continuous intraoperative transesophageal echocardiography during pericardiectomy for constrictive pericarditis revealing dynamic change in chamber size.
Kasravi B, Ng D, Chandraratna PA.
Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, Orange, CA, USA.

We review a case of a 50-year-old man with diagnosis of constrictive pericarditis, who underwent pericardial stripping with continuous intraoperative transesophageal echocardiography (TEE). This patient demonstrates the immediate dynamic changes in chamber size after successful surgical removal of pericardium as demonstrated by TEE.

Circ J. 2005 Apr;69(4):458-60.
Clinical characteristics and treatment of constrictive pericarditis in Taiwan.
Chen RF, Lai CP.
Department of Thoracic and Cardiovascular Surgery, Taipei Medical University Hospital and Wan-Fang Hospital, Taipei, Taiwan.

BACKGROUND: Constrictive pericarditis is an uncommon disease that prevents the normal diastolic filling of the heart and pericardiectomy is the only satisfactory treatment. METHODS AND RESULTS: The clinical characteristics and treatment of patients who underwent pericardiectomy for constrictive pericarditis (n = 23) were reviewed. Surgery was performed via left anterolateral thoracotomy plus transsternal extension in 3 patients, and median sternotomy in 20 patients. There were 2 deaths, resulting in an overall mortality rate of 8.7%. Of the 23 patients, 8 had Mycobacterium tuberculosis (Tb) infection, 2 had streptococcus infection, 1 had strongyloidiasis (Strongyloides stercoralis) and 1 developed the condition after a myocardial infarction; 2 patients underwent pericardial substitute insertion as post-heart surgery, and 3 patients had connective tissue disorders; 6 patients had idiopathic disease. CONCLUSION: These results show that bacterial infection, especially Tb, is a major etiology of constrictive pericarditis in Taiwan and that median sternotomy is an excellent approach for exposing the heart for pericardiectomy.

Herz. 2004 Dec;29(8):802-5.
Effectiveness of intrapericardial administration of streptokinase in purulent pericarditis.
Tomkowski WZ, Gralec R, Kuca P, Burakowski J, Orlowski T, Kurzyna M.
Intensive Care Unit, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland.

BACKGROUND AND PURPOSE: Purulent pericarditis is very rare. However, among patients suffering from this disease the mortality rate is very high. The aim of this study was to evaluate the effectiveness and side effects of intrapericardial streptokinase administration in patients with confirmed purulent pericarditis. PATIENTS AND METHODS: Three patients, one 50-year-old man and two women aged 64 and 40 years, who were admitted to the intensive care unit (ICU) due to purulent pericarditis, entered the study. In all three cases a subxiphoid pericardiotomy followed by insertion of a drainage line into the pericardial space was performed. Antibiotic therapy was started immediately on admission to the hospital. Despite continued antibiotic therapy in all three patients, daily drainage from the pericardium--during several days after surgery--staggered between 50-200 ml/day. Due to considerable purulent pericardial drainage loculations and/or fibrin deposits confirmed by echocardiography, streptokinase (500,000 IU dissolved in 50 ml of normal saline) was administered into the pericardial space over 10 min, using the previously inserted drainage catheter. This regimen was repeated after 12 and 24 h. The total dose of streptokinase was 1,500,000 IU. RESULTS: The clinical effect of intrapericardial streptokinase administration was excellent. Several days after intrapericardial administration of streptokinase, drainage of purulent pericardial fluid stopped. No complications associated with intrapericardial streptokinase administration were observed. In the follow-up echocardiography (in two patients repeated 6 and 9 months after delivery of streptokinase), pericardial fluid and echocardiographic signs of pericardial constriction were not observed. CONCLUSION: Intrapericardial administration of streptokinase in purulent pericarditis is effective and safe.

Interact Cardiovasc Thorac Surg. 2003 Dec;2(4):626-8.
Constrictive pericarditis following a pyopericardium due to Staphylococcus aureus.
Farhat F, Dubreuil O, Durand PG, Jegaden O.
Department of Cardiovascular Surgery B, Unité 31, Professor Jegaden, Louis Pradel Hospital, 28, avenue du doyen Lepine, BP Lyon-Monchat, 69394 Lyon, France.

We report the case of a 58-year-old man who presented 3 weeks after a purulent pericarditis due to Staphylococcus aureus with a constrictive pericarditis confirmed by computed tomography-scan and haemodynamic findings. Pericardiectomy and epicardiectomy were performed with an excellent immediate and mid-term result. Constrictive pericarditis due to S. aureus is rare and pericardiectomy is associated with a high mortality risk.

Interact Cardiovasc Thorac Surg. 2003 Sep;2(3):322-6.
Surgical approach for pericardiectomy: a comparative study between median sternotomy and left anterolateral thoracotomy.
Tiruvoipati R, Naik RD, Loubani M, Billa GN.
Department of Cardiothoracic Surgery, Osmania General Hospital, Hyderabad, Andhra Pradesh, India.

Pericardiectomy is the definitive treatment for constrictive pericarditis but the best surgical approach remains controversial. In this study we compared the results of pericardiectomy performed on 36 patients with constrictive pericarditis between 1995 and 2001. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. All patients were reviewed at 6 weeks post operatively. Both groups of patients were similar in age, sex distribution, NYHA shortness of breath status, aetiology, presenting symptoms and duration of symptoms. Mortality was similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. NYHA status improved in both thoracotomy (3.0+/-0.8 to 1.6+/-0.7; P=3.3x10(-6)) and median sternotomy (2.9+/-0.7 to 1.5+/-0.6; P=2.8x10(-5)) groups. The degree of improvement was not significant between the two groups (P=0.63). In addition ionotropic support and postoperative hospital stay were similar between the two groups. There was a higher incidence of wound infections (23.8 versus 6.6%; P=0.13) and pulmonary complications (23.8 versus 13.3%; P=0.33) associated with thoracotomy. In conclusion pericardiectomy improves NYHA status in all patients and mortality rates are similar in both the approaches.

Tunis Med. 2001 Nov;79(11):638-41.
The role of Doppler echocardiography in chronic constrictive pericarditis
Mahdhaoui A, Bouraoui H, Ernez-Hajri S, Jeridi G, Saadaoui A, Ammar H.
Service de Cardiologie CHU Farhat Hached 4000 Sousse Tunisie.

Constrictive péricarditis (CCP) is a rare but serious disease. It still poses diagnostic difficulties. The purpose of our work is to study the contribution of the echocardiographic Doppler in the diagnosis of the CCP. The authors report six cases of CCP proven after surgery. Study by ultrasound Doppler of intracardiac blood flow and their respiratory variations showed the existence of abnormalities. The decrease of 25% of the mitral E wave in inspiration compared to the value observed in expiration, the increase of 100% of the ebb in sus hépatic vein in expiration and the modifications of the flux in pulmonary insufficiency are the most reliable signs for the diagnosis of the CCP. This method seems so interesting for the diagnosis and to estimate the degree of constriction of the CCP.

J Am Vet Med Assoc. 1997 Sep 15;211(6):736-40.
Pericardiectomy in dogs: 22 cases (1978-1994).
Kerstetter KK, Krahwinkel DJ, Millis DL, Hahn K.
Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville 37901-1071, USA.

OBJECTIVE: To determine long-term outcome of dogs with neoplastic and nonneoplastic pericardial disease that undergo pericardiectomy. DESIGN: Retrospective study. ANIMALS: 22 dogs. PROCEDURE: Dogs that underwent pericardiectomy and in which the diagnosis had been confirmed histologically were included. Data collected from each record included signalment, history, clinical signs, results of diagnostic evaluations, operative management, postoperative complications, histologic diagnosis, and outcome. Dogs were grouped on the basis of underlying cause of pericardial disease (neoplastic vs nonneoplastic), and survival times were determined by means of Kaplan-Meier analyses. RESULTS: 9 dogs had neoplastic pericardial disease (chemodectoma, 4; hemangiosarcoma, 2; malignant mesothelioma, 2; lymphoblastic lymphoma, 1). Thirteen dogs had nonneoplastic pericardial disease (benign idiopathic pericarditis, 10; lymphocytic plasmacytic pericarditis, 2; osseous metaplasia of unknown cause, 1). Thoracic radiography and echocardiography were the most specific methods for diagnosis of pericardial effusion. Pleural effusion was the most common postoperative complication (8/22 dogs). Prevalence of postoperative complications was not associated with underlying cause of pericardial disease, surgical approach, or surgical procedure (subtotal vs total pericardiectomy). Median survival time of dogs with neoplastic disease (52 days) was significantly shorter than median survival time of dogs with nonneoplastic disease (792 days). Dogs that developed pleural effusion > 30 days after pericardiectomy had a poor prognosis for survival. CLINICAL IMPLICATIONS: Radiography and echocardiography are useful for diagnosis of pericardial effusion in dogs. Dogs with neoplastic pericardial disease have a significantly shorter survival time than do dogs with nonneoplastic pericardial disease.

Echocardiography. 1995 Jan;12(1):29-34.
Echocardiography in patients with constrictive pericarditis before and after pericardiectomy: Are there predictors of surgical outcome?
Tokgözoglu SL, Kes S, Oram A, Demircin M, Pasaoglu I, Ugurlu S.
Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Fifteen patients with constrictive pericarditis were prospectively evaluated with echocardiography and Doppler recordings during respiratory monitoring. Eleven who agreed to surgery also underwent right heart catheterization and a repeat echocardiography with Doppler 10 days after pericardiectomy. Preoperatively, there was a significant inspiratory decrease in the mitral E wave (P < 0.05) and increase in the tricuspid E wave velocities (P < 0.05), which both normalized after pericardiectomy. The mitral deceleration times increased from 110 +/- 40 to 149 +/- 46 msec (P < 0.05) postoperatively. The preoperative hepatic vein velocities showed an accentuated systolic flow pattern. The systolic to diastolic ratio of the hepatic vein velocities was higher in patients who improved with surgery (1.42 +/- 0.31 vs 0.65 +/- 0.13) (P < 0.05). Postoperatively the diastolic flow became more pronounced. There was a 100% expiratory diastolic flow reversal in eight patients preoperatively, which normalized after pericardiectomy. Clinically these patients improved significantly postoperatively. Left atrial size, ejection fraction, and mitral and tricuspid filling velocities during respiratory monitoring could not predict surgical outcome. Pericardiectomy improved Doppler filling dynamics in all patients although this was not parallel to clinical improvement.

Ann Thorac Surg. 1980 Feb;29(2):146-52.
Operation for chronic constrictive pericarditis: Do the surgical approach and degree of pericardial resection influence the outcome significantly?
Culliford AT, Lipton M, Spencer FC.

Our experience with 27 patients undergoing pericardiectomy at New York University Medical Center over the past 13 years has evolved a radical pericardiectomy operation suggesting that two traditional concepts are erroneous: (1) pericardiectomy limited to the anterior and lateral surfaces of the ventricles is an adequate operation and (2) delayed recovery is due to myocardial "atrophy" and not to inadequate operation. Radical pericardiectomy entails removal of virtually the entire parietal pericardium from all cardiac surfaces including that of both ventricles, the right atrium, and the venae cavae. Performed in 22 patients by dissecting a cleavage plane between the thickened parietal pericardium and underlying epicardium, all procedures were done through a sternotomy. Intraoperative monitoring of arterial pressure, cardiac output, and wedge pressure is essential because of displacement of the left ventricle. The left ventricle can be completely mobilized so that at the end of the operation the entire heart can be lifted upward and the course of the coronary sinus fully visualized. Intraoperative pressure measurements demonstrate that this radical resection immediately corrects hemodynamic abnormalities (elevated right atrial and ventricular end-diastolic pressures), as demonstrated in 10 patients. Most patients undergo massive diuresis (7 to 16 kg) within two weeks, with an uneventful recovery. These findings contrast markedly with early experiences using a conventional limited pericardiectomy.

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