European Journal of Cardio-Thoracic Surgery Advance Access published September 15, 2015
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2015) 1–7 doi:10.1093/ejcts/ezv322
Risk factors for mortality after pericardiectomy for chronic constrictive pericarditis in a large single-centre cohort Christiane Buscha,†, Kiril Penovb,c,*†, Paulo A. Amorimd, Jens Garbadeb, Piroze Davierwalab, Gerhard C. Schulere, Ardawan J. Rastanf and Friedrich-Wilhelm Mohrb a b c d e f
Department of Cardiology, Diakonissenkrankenhaus Leipzig, Leipzig, Germany Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany Department of Cardiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany Department of Cardiac Surgery, Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg, Germany
* Corresponding author: Cardiothoracic Surgery Research Lab, Stanford University, 300 Pasteur Drive (Falk CVRB), Stanford, CA 94305, USA. Fax: +1-650-7256356; e-mail:
[email protected] (K. Penov). Received 21 April 2015; received in revised form 11 August 2015; accepted 17 August 2015
Abstract OBJECTIVES: Constrictive pericarditis (CP) is an uncommon disease with multiple causes and unclear clinical outcomes. To date, few publications have clearly defined risk factors of poor outcomes after surgery for CP. We performed a retrospective analysis of almost 100 patients undergoing surgical treatment for CP at a single institution in order to identify risk factors for perioperative and long-term mortality. METHODS: A total of 97 consecutive patients (67.0% male) undergoing surgery for CP at our institution from 1995 to 2012 were included in the study. CP was diagnosed either preoperatively by cardiac catheterization and appropriate imaging or during surgery. Preoperative and intraoperative risk factors for 30-day and late mortality were analysed using stepwise multivariate logistic and Cox regression analyses. Median follow-up was 1.23 ± 3.96 years (mean 3.08 ± 3.96 years). RESULTS: The mean patient age was 60.0 ± 12.5 years and the underlying aetiology was idiopathic (50.5%), prior cardiac surgery (15.5%), prior mediastinal radiation (9.3%), and miscellaneous (24.7%). All patients underwent either radical (55.2%) or partial (44.8%) pericardiectomy. Concomitant procedures were performed in 54 (55.7%) patients. The total procedure time was 197.0 ± 105.0 min. Cardiopulmonary bypass (CPB) was used in 62 patients with a corresponding CPB time of 124.8 ± 68.4 min. In those patients who underwent CPB, cardioplegic arrest was performed in 53.2% of patients with a mean cross-clamp time of 74.9 ± 41.9 min. Overall 30-day, 1-year and 5-year survival rates were 81.4, 66.5 and 51.6%, respectively, without significant differences according to the underlying aetiology. Multivariate analysis revealed patients with reduced left ventricular ejection fraction (LVEF) [P = 0.01, odds ratio (OR) 3.6] and preoperative right ventricular dilatation (P = 0.04, OR 3.5) to be at significant risk of early mortality. Long-term mortality was independently predicted by the presence of coronary artery disease (CAD) [P < 0.001, hazard ratio (HR) 6.44], chronic obstructive pulmonary disease (P = 0.001, HR 4.21) and preoperative renal insufficiency (P = 0.012, HR 1.8). Concomitant tricuspid valve repair (TVR) appeared to provide protective effect on the long-term survival (P = 0.07). CONCLUSIONS: Surgery for CP is associated with a significant risk based on the poor preoperative patient status. Whenever justified, partial over radical pericardiectomy should be preferred and TVR should be indicated liberally. Reduced LVEF and right ventricular dilatation were independent predictors for early mortality, whereas CAD, chronic obstructive pulmonary disease and renal insufficiency were risk factors for late mortality. Thus, an optimal timing for surgery on CP remains crucial to avoid secondary morbidity with an even worse natural prognosis. Keywords: Constrictive pericarditis • Pericardiectomy • Aetiology • Outcomes • Risk factors
INTRODUCTION Constrictive pericarditis (CP) is an uncommon disease with multiple causes and discrepant clinical outcomes. The loss of pericardial elasticity—considered as the primary pathophysiological pattern [1]—leads to the characteristic haemodynamics of the †
Christiane Busch and Kiril Penov contributed equally to this study.
disease with abnormal ventricular filling and subsequently forming of the so-called square-root sign. During disease progression, patients develop signs and symptoms of systemic venous congestion [2] including lower limb oedema, ascites and liver congestion as a result of restrictive right ventricle (RV) filling. Pericardiectomy remains the only causal treatment for patients with symptomatic CP. However, relatively high rates of morbidity and mortality have been reported for this procedure [3, 4]. In
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ADULT CARDIAC
Cite this article as: Busch C, Penov K, Amorim PA, Garbade J, Davierwala P, Schuler GC et al. Risk factors for mortality after pericardiectomy for chronic constrictive pericarditis in a large single-centre cohort. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezv322.
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C. Busch et al. / European Journal of Cardio-Thoracic Surgery
general, pericardiectomy is performed on patients with significant comorbidities, making interpretation of the results difficult [3]. Only few publications have clearly defined risk factors for poor outcomes after surgery for CP so far [5–7]. These studies tend to identify end-organ dysfunction—notably that of the liver, kidney and lungs—as independent risk factors for mortality [3, 5, 6]. In addition, some investigators have reported that the pathology and operative risk factors have changed over time [5]. The aim of this study was to retrospectively analyse the results of surgical treatment for CP in single-centre experience from almost 100 patients, in order to identify risk factors for perioperative and long-term mortality.
MATERIALS AND METHODS Using our prospectively managed cardiac surgery database, we performed a retrospective analysis on 97 consecutive CP patients operated between October 1995 and May 2012. CP patients who were not operated were not included in the study. The following variables were recorded: age, gender, BMI, diabetes, arterial and pulmonary arterial hypertension, coronary artery disease (CAD), symptoms duration, symptoms classified with New York Heart Association (NYHA), ascites, oedema. Preoperative laboratory tests included creatinine, albumin and parameters of the Child-Pugh classification. Moreover, the aetiology of pericarditis, left ventricular ejection fraction (LVEF), haemodynamic results from the right and left heart catheterization (systemic pressure, diastolic blood pressure and wedge pressure) and operative data [need for cardiopulmonary bypass (CPB), additional coronary artery bypass surgery and concomitant valve procedures] were documented.
Diagnosis of constrictive pericarditis The standardized preoperative work-up for every patient includes clinical examination, blood laboratory data, electrocardiogram, transthoracic echocardiogram, coronary angiography and chest X-ray. According to the clinical symptoms, an additional cardiac catheterization for haemodynamic measurements of all four chambers was performed. When indicated, a computed tomography scan of the chest was additionally obtained for visualization of the extent of pericardial thickening and calcifications or to see the proximity of the heart or coronary artery bypass grafts to the sternum. Intraoperatively, all patients were monitored by transoesophageal echocardiography and Swan–Ganz right-heart catheterization.
Follow-up Patients were contacted via telephone or questionnaire, and family members were contacted if patients could not be contacted or died.
Preoperative characteristics. Of the 97 patients, 65 were male and 32 female. Mean age was 60.0 ± 12.5 years. Main clinical symptom was severe dyspnoea (NYHA III–IV) in 79.8%. During physical examination, 54.6% of patients had peripheral oedema, 59.8% pleural effusion and 35.1% ascites. In 56.7% of patients, symptoms increased significantly within the last 6 months prior to surgery.
The systolic left ventricular function was normal in 72.2%, with a mean LVEF of 58.6 ± 10.5% (range: 27.0–80.0%). Only 3 patients had an LVEF of 56% 31–55%
