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The Journal of Cardiovascular Aging 2022Postoperative atrial fibrillation (POAF), characterized as AF that arises 1-3 days after surgery, occurs after 30%-40% of cardiac and 10%-20% of non-cardiac surgeries,...
INTRODUCTION
Postoperative atrial fibrillation (POAF), characterized as AF that arises 1-3 days after surgery, occurs after 30%-40% of cardiac and 10%-20% of non-cardiac surgeries, and is thought to arise due to transient surgery-induced triggers acting on a preexisting vulnerable atrial substrate often associated with inflammation and autonomic nervous system dysfunction. Current experimental studies often rely on human atrial tissue samples, collected during surgery prior to arrhythmia development, or animal models such as sterile pericarditis and atriotomy, which have not been robustly characterized.
AIM
To characterize the demographic, electrophysiologic, and inflammatory properties of a POAF mouse model.
METHODS AND RESULTS
A total of 131 wild-type C57BL/6J mice were included in this study. A total of 86 (65.6%) mice underwent cardiothoracic surgery (THOR), which consisted of bi-atrial pericardiectomy with 20 s of aortic cross-clamping; 45 (34.3%) mice underwent a sham procedure consisting of dissection down to but not into the thoracic cavity. Intracardiac pacing, performed 72 h after surgery, was used to assess AF inducibility. THOR mice showed greater AF inducibility (38.4%) compared to Sham mice (17.8%, = 0.027). Stratifying the cohort by tertiles of age showed that the greatest risk of POAF after THOR compared to Sham occurred in the 12-19-week age group. Stratifying by sex showed that cardiothoracic (CT) surgery increased POAF risk in females but had no significant effect in males. Quantitative polymerase chain reaction of atrial samples revealed upregulation of transforming growth factor beta 1 and interleukin 6 (IL6) and 18 (IL18) expression in THOR compared to Sham mice.
CONCLUSION
Here, we demonstrate that the increased POAF risk associated with CT surgery is most pronounced in female and 12-19-week-old mice, and that the expression of inflammatory cytokines is upregulated in the atria of THOR mice prone to inducible AF.
PubMed: 36337729
DOI: 10.20517/jca.2022.21 -
Journal of Cardiothoracic Surgery Nov 2015Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening of the pericardium. The purpose of this study was to evaluate the...
BACKGROUND
Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening of the pericardium. The purpose of this study was to evaluate the long-term outcomes following treatment of constrictive pericarditis by pericardiectomy.
METHODS
Between September 1992 and May 2014, 47 patients who underwent pericardiectomy for constrictive pericarditis were retrospectively examined. Demographic, pre-, intra- and postoperative data and long-term outcomes were analyzed.
RESULTS
Thirty of the patients were male, the mean age was 45.8 ± 16.7. Aetiology of constrictive pericarditis was tuberculosis in 22 (46.8 %) patients, idiopathic in 15 (31.9 %), malignancy in 3 (6.4 %), prior cardiac surgery in 2 (4.3 %), non-tuberculosis bacterial infections in 2 (4.3 %), radiotherapy in 1 (2.1 %), uraemia in 1 (2.1 %) and post-traumatic in 1 (2.1 %). The surgical approach was achieved via a median sternotomy in all patients except only 1 patient. The mean operative time was 156.4 ± 45.7 min. Improvement in functional status in 80 % of patients' at least one New York Heart Association (NYHA) functional class was observed. In-hospital mortality rate was 2.1 % (1 of 47 patients). The cause of death was pneumonia leading to progressive respiratory failure. The late mortality rate was 23.4 % (11 of 47 patients). The mean follow-up time was 61.2 ± 66 months. The actuarial survival rates were 91 %, 85 % and 81 % at 1, 5 and 10 years, respectively. Recurrence requiring a repeat pericardiectomy was developed in no patient during follow-up.
CONCLUSION
Pericardiectomy is associated with high morbidity and mortality rates. Cases with neoplastic diseases, diminished cardiac output, cases in need of reoperation are expected to have high mortality rates and less chance of functional recovery.
Topics: Female; Follow-Up Studies; Hospital Mortality; Humans; Male; Middle Aged; Morbidity; Pericardiectomy; Pericarditis, Constrictive; Postoperative Period; Retrospective Studies; Survival Rate; Time Factors; Turkey
PubMed: 26613929
DOI: 10.1186/s13019-015-0385-8 -
The Journal of Thoracic and... Aug 2016Outcome 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...
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 < .001). Median duration of follow-up was 29 months (maximum 20.5 years) and overall 5-, 10-, and 15-year survival was 80%, 60%, and 38%, respectively. Overall survival according to surgical indication was higher in the effusive/chronic relapsing group when compared with the constriction cohort (P < .001). Independent predictors associated with increased risk of overall mortality identified on multivariate analysis included older age (HR, 1.05; 95% confidence interval [CI], [1.03, 1.07]; P < .001), congestive heart failure (HR, 1.49; 95% CI, [1.03, 2.2]; 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.
Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Chi-Square Distribution; Comorbidity; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Pericardiectomy; Pericarditis; Pericarditis, Constrictive; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Stroke Volume; Time Factors; Treatment Outcome; Ventricular Function, Left; Young Adult
PubMed: 27210468
DOI: 10.1016/j.jtcvs.2016.03.098 -
Cureus May 2020Constrictive pericarditis arises as a result of the fibrous thickening of the pericardium due to chronic inflammatory changes from various injuries. Increased pulmonary... (Review)
Review
Constrictive pericarditis arises as a result of the fibrous thickening of the pericardium due to chronic inflammatory changes from various injuries. Increased pulmonary and systemic venous pressures manifest clinical features of left and right heart failure. Idiopathic or post-viral pericarditis is the most common cause followed by postpericardiotomy, radiation-induced causes. Right-sided heart failure symptoms predominate over left-sided heart failure symptoms due to the equalization of pressures. No single diagnostic test can provide a definitive diagnosis or evidence of constrictive pericarditis. Medical management is difficult for constrictive pericarditis. The treatment of choice for constrictive pericarditis is pericardiectomy.
PubMed: 32528763
DOI: 10.7759/cureus.8024 -
Journal of Cardiothoracic Surgery Mar 2020The first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal...
BACKGROUND
The first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection.
CASE PRESENTATION
A 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell's Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5 cm × 2 cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4 cm × 4 cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31 mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient's hemodynamics stabilized. A vented Gore-Tex 6 cm × 6 cm patch was sewn along the pericardial edges with interrupted 4-0 prolene to close the pericardial defect.
CONCLUSION
This potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3 cm × 3 cm that extends from the mid- to inferior portions of the heart.
Topics: Adult; Female; Heart Diseases; Humans; Myasthenia Gravis; Pericardiectomy; Pericardium; Phrenic Nerve; Postoperative Complications; Robotic Surgical Procedures; Sternotomy; Thymectomy; Thymoma; Thymus Gland; Thymus Neoplasms; Tomography, X-Ray Computed
PubMed: 32228645
DOI: 10.1186/s13019-020-01093-3 -
Heart and Vessels Jan 2020Predictors of early and late failure of pericardiectomy for constrictive pericarditis (CP) have not been established. Early and late outcomes of a cumulative series of...
Predictors of early and late failure of pericardiectomy for constrictive pericarditis (CP) have not been established. Early and late outcomes of a cumulative series of 81 (mean age 60 years; mean EuroSCORE II, 3.3%) consecutive patients from three European cardiac surgery centers were reviewed. Predictors of a combined endpoint comprising in-hospital death or major complications (including multiple transfusion) were identified with binary logistic regression. Non-parametric estimates of survival were obtained with the Kaplan-Meier method. Predictors of poor late outcomes were established using Cox proportional hazard regression. There were 4 (4.9%) in-hospital deaths. Preoperative central venous pressure > 15 mmHg (p = 0.005) and the use of cardiopulmonary bypass (p = 0.016) were independent predictors of complicated in-hospital course, which occurred in 29 (35.8%) patients. During follow-up (median, 5.4 years), preoperative renal impairment was a predictor of all-cause death (p = 0.0041), cardiac death (p = 0.0008), as well as hospital readmission due to congestive heart failure (p = 0.0037); while partial pericardiectomy predicted all-cause death (p = 0.028) and concomitant cardiac operation predicted cardiac death (p = 0.026), postoperative central venous pressure < 10 mmHg was associated with a low risk both of all-cause and cardiac death (p < 0.0001 for both). Ten-year adjusted survival free of all-cause death, cardiac death, and hospital readmission were 76.9%, 94.7%, and 90.6%, respectively. In high-risk patients with CP, performing pericardiectomy before severe constriction develops and avoiding cardiopulmonary bypass (when possible) could contribute to improving immediate outcomes post-surgery. Complete removal of cardiac constriction could enhance long-term outcomes.
Topics: Aged; Cardiopulmonary Bypass; Cause of Death; Female; France; Hospital Mortality; Humans; Italy; Male; Middle Aged; Patient Readmission; Pericardiectomy; Pericarditis, Constrictive; Postoperative Complications; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Failure
PubMed: 31236676
DOI: 10.1007/s00380-019-01464-4 -
BMJ Case Reports Jan 2021Constrictive pericarditis is a relatively uncommon form of cardiac failure and presents due to scarring and consequent loss of the normal elasticity of the pericardial...
Constrictive pericarditis is a relatively uncommon form of cardiac failure and presents due to scarring and consequent loss of the normal elasticity of the pericardial sac. This results in abnormal/limited ventricular filling and symptoms of heart failure. The aetiology is varied, from infective causes to idiopathic causes, or can manifest after cardiothoracic surgery. This case involves a 46-year-old man presenting with acute group A beta haemolytic streptococcus infection, and over the subsequent 6 months develops constrictive pericarditis due to what is believed to be a rheumatic aetiology. The patient subsequently underwent pericardiectomy and had restoration of normal filling dynamics confirmed on follow-up echocardiography. This case provides a subject matter for the review of the features of constrictive pericarditis and its investigation and management. This case is that it highlights the fact that pericarditis is not a benign condition. Emerging evidence suggests that pericarditis is due to a failure in inflammatory regulatory mechanisms, and patients suffering this condition have a preponderance to 'autoinflammation'. Pericarditis should be recognised early and treated fully with anti-inflammatory agents.
Topics: Anti-Bacterial Agents; Antistreptolysin; Bacteremia; Blood Culture; C-Reactive Protein; Cardiac Catheterization; Ceftriaxone; Electrocardiography; Hospitalization; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Pericardiectomy; Pericarditis, Constrictive; Piperacillin, Tazobactam Drug Combination; Rheumatic Heart Disease; Streptococcal Infections; Streptococcus pyogenes; Ventricular Pressure
PubMed: 33495174
DOI: 10.1136/bcr-2020-236639 -
Frontiers in Cardiovascular Medicine 2023A 77-year-old man underwent percutaneous coronary intervention (PCI) at the right coronary artery, which was complicated by coronary artery perforation (CAP). After...
A 77-year-old man underwent percutaneous coronary intervention (PCI) at the right coronary artery, which was complicated by coronary artery perforation (CAP). After prolonged balloon tamponade proximal to the CAP there was no more contrast extravasation, and the CAP was thought to have resolved. Computed tomography (CT) and echocardiography the following day did not find evidence of continued bleeding, and the patient was discharged. Echocardiograms and chest CT scans obtained one week and two months after PCI detected no remarkable interval change. The patient complained of progressive dyspnea and abdominal distension seven months after PCI however, and echocardiography found an increased amount of pericardial effusion and constrictive physiology. The patient underwent pericardiectomy due to congestive hepatopathy, and progressive dyspnea. The pericardium was thickened and adhesive, and a dark bloody effusion was found. Pathology was unremarkable except for thick fibrosis. After the operation the patient made full recovery, and is stable three years after surgery.
PubMed: 37346286
DOI: 10.3389/fcvm.2023.1208376 -
Indian Journal of Thoracic and... Jul 2021A 46-year-old male presented with breathlessness for a few months. He had been operated twice for liver hydatid cysts and once for right pulmonary hydatid cysts at other...
A 46-year-old male presented with breathlessness for a few months. He had been operated twice for liver hydatid cysts and once for right pulmonary hydatid cysts at other hospitals. Now he was found to have one hydatid cyst in the upper lobe of the left lung and multiple hydatid cysts adjoining left heart border. On computed tomography (CT) scan chest and echocardiography, it was difficult to ascertain whether these cysts were pulmonary or intrapericardial. Left ventricular ejection fraction (LVEF) was 25%. Enzyme-linked immunosorbent assay (ELISA) was positive for hydatid. Left posterolateral thoracotomy revealed dead hydatid cyst in upper lobe of the lung that was removed. Infected mother hydatid cyst was encountered inside pericardial sac. Scores of daughter hydatid cysts, varying in size from 1 to 30 mm, were scooped out intact from the pericardial cavity. There was significant improvement in cardiac activity, once the tamponade effect of hydatid cyst was removed. Pericardium was about 1 cm thick with lot of purulent and necrotic slough. To prevent future constrictive pericarditis, subtotal pericardiectomy was done. Intrapericardial hydatid cyst should be kept in mind whenever it obscures the heart border and patient has features of cardiac tamponade. Early surgical intervention may be required in these cases.
PubMed: 34220028
DOI: 10.1007/s12055-020-01109-6 -
Indian Journal of Thoracic and... May 2022Tuberculosis (TB) is the commonest cause of chronic constrictive pericarditis (CCP) in India, unlike in the western countries. Pericardiectomy is the treatment of choice...
INTRODUCTION AND PURPOSE
Tuberculosis (TB) is the commonest cause of chronic constrictive pericarditis (CCP) in India, unlike in the western countries. Pericardiectomy is the treatment of choice for CCP. Surgery in TB CCP is considerably more difficult than it is for other etiologies. The role of TB as an independent predictor for adverse surgical outcomes had not been properly evaluated in the Indian scenario. Hence, the aim of this study was to retrospectively analyze our results of surgery for CCP and the pre-operative factors that influenced post-operative outcomes.
METHODS
The data of all adult patients who underwent pericardiectomy for CCP, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analyzed.
RESULTS
There were 124 patients in the study. The average age was 32 years. The male to female ratio was 3:1. TB was the commonest cause of CCP, identified in 64 (51.6%) patients. Complete anterior pericardiectomy (CAP) was possible in 122 (98.3%) patients. All the patients had significant drop in their central venous pressure (CVP) (10.25 ± 3.47 mmHg) after surgery. The operative time ( = 0.008), intra-operative blood loss ( = 0.02), intensive care unit (ICU) stay ( = 0.03), and hospital stay ( = 0.028) were significantly higher in the TB group. Apart from TB, the other pre-operative variables that predicted adverse outcomes were male sex, presence of pleural effusion or ascites, and advanced New York Heart Association (NYHA) class. There were 7 (5.6%) post-operative complications and 3 (2.4%) in-hospital deaths.
CONCLUSION
The high incidence of TB CCP makes a pericardiectomy in developing countries technically more challenging resulting in increased operative time, more blood loss, and prolonged ICU and hospital stay, but did not affect in-hospital mortality or morbidity.
PubMed: 35529004
DOI: 10.1007/s12055-021-01313-y