pericardiectomy in the setting of ongoing inflammation- a need for caution

7/28/2019 Pericardiectomy in the Setting of Ongoing Inflammation- A Need for Caution

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M. Chadi Alraies MD FACP

Heart and Vascular Institute

Center for the Diagnosis and Treatment of Pericardial DiseaseCleveland Clinic

Cleveland, Ohio, USA

Pericardiectomy in the Setting of Ongoing

Inflammation: a Need for Caution


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ECG


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Laboratory data

WBC 7.37

HB 9.4

HCT 30.7

PLT 382

Troponin normal

BNP 680

WSR39(0 - 15 mm/H)

CRP7.3(0.0 - 1.0 mg/dL)


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Echocardiogram

Parasternal Views


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What is next?


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CMR


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CMR report

Early diastole intraventricular septal bounce

Localized pericardial effusion adjacent to the right

ventricle (left panel). Thickened pericardium at 7 mm

Circumferential late gadolinium enhancement ofpericardium


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RHC

Right and left ventricular pressure tracings showing diastolicequalization of pressures in both ventricles (left panel)

Findings consistent with large pericardial effusion with

constrictive features


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Clinical Management?


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Surgical findingsMine Field

Pericardial window drained only 20 ml

Operation converted to sternotomy

Surgical field showed, intense inflammation of theepicardial/visceral layers.

Pericardial stripping of the right side performed

On attempting left side pericardiectomy, LAD was nicked

Because of intense inflammatory reaction, furtherpericardiectomy of the left side was aborted.


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Histopathology

Histopathology showed Marked fibrosis and granulation tissue with organizing hemorrhage.

Fibrotic with thickened pericardium

Started on prednisone, NSAID and colchicine.

Discharged home


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A month later on anti-inflammatory medications


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Presentation

Shortness of breath

Difficulty doing stairs

Abdominal swelling Chest pain, sharp in nature, increased with exertion


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Physical examination

Vitals were stable

Neck: JVD elevated to angle of jaw

Lungs: Clear to auscultation bilaterally.

Heart: Regular rate and rhythm, pericardial knock

Abdomen: Ascites with shifting dullness.

Extremities: 2+ pitting bilateral leg edema


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Work up

EKG: NSR with LBBB

WSR45(0 - 15 mm/H)

CRP8.1(0.0 - 1.0 mg/dL)

Prednisone was increased to 60 mg daily


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Echocardiogram

Parasternal Views


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Significant respiratory variation ofDoppler flow ( MV 40%)

E/e = 9

Echocardiogram

Apical ViewsTDI


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CMR


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Late Gadolinium Enhancement


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CMR report

Diffuse mild thickening of the left pericardium

Pericardial thickening 4 mm.

Changes in the pericardial space over the RV

Diastolic septal bounce Exaggerated inspiratory flattening and conical deformity of the

ventricles

Mild circumferential enhancement of the pericardium

Right pleural effusion


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Next step

Findings are suggesting ongoing constriction of the leftparicardium

LAD trauma from right pericardiectomy was entertained. LHC was done and normal

Referred for complete pericardiectomy


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Complete pericardiectomy

Through a left anterior thoracotomy

Histopathology showed:

Pericardium is markedly thickened

Organized hemorrhage

Mild chronic inflammation.

Discharged on:

Prednisone 50 mg PO daily Ibuprofen 400 TID

Colchicine 0.6 mg BID

Referred to heart failure clinic and started on diuretics


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5 months later


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5 months later

Patient remained chest pain-free

Remains on diuretics and mild heart failure symptoms

Inflammatory markers normalized

Prednisone was tapered off

Remained on colchicine and NSAID and stopped a year

later.


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Pre Post


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Take home messages


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0

10

20

30

40

myectomy

Right pericardiectomy Total pericardiectomy

Operating on inflamed pericardium has been

associated with adverse outcome

WSR


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Take Home Points

Caution is needed when sending patient for pericardiectomy insetting of inflammation.

Multimodality imaging is useful tool in evaluating effusive

constrictive pericardial disease CMR is an important tool to assess the severity and distribution

of pericardial inflammation

An adequate trial of anti-inflammatories is recommended in thesetting of active inflammation and constrictive findings beforeproceeding to pericardiectomy.


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Thank you


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pericardiectomy in the setting of ongoing inflammation- a need for caution

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