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Pericardiectomy in the Setting of Ongoing Inflammation: a Need for Caution

M. Chadi Alraies MD FACP
Heart and Vascular Institute Center for the Diagnosis and Treatment of Pericardial Disease Cleveland Clinic Cleveland, Ohio, USA

History
• A 48-year-old male presented with one week history of chest pain, increased weight, leg edema and progressive dyspnea. • Past history of hypertrophic obstructive cardiomyopathy • Treated with septal myectomy and bilateral pulmonary vein isolation one month before presentation.

Physical examination
• • • • • • • Vitals: 98.6 °F, 146/88, 82, 20, 95% on RA Mild respiratory distress CVS: elevated JVP , regular, no murmurs Lungs: bibasilar diminished breath sounds Abdomen: soft, non-tender Extremity: 2+ bilateral LE pitting edema Skin: midline sternotomy wound, no erythema

ECG

Laboratory data
• WBC 7.37 • HB 9.4 • HCT 30.7 • PLT 382 • Troponin normal • BNP 680

• WSR 39 (0 - 15 mm/H) • CRP 7.3 (0.0 - 1.0 mg/dL)

Echocardiogram Parasternal Views

Echocardiogram Apical Views

What is next?

CMR

Late Gadolinium Enhancement

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 of pericardium

RHC

• Right and left ventricular pressure tracings showing diastolic equalization of pressures in both ventricles (left panel) • Findings consistent with large pericardial effusion with constrictive features

Clinical Management?

Surgical findings…“Mine Field”
• Pericardial window drained only 20 ml • Operation converted to sternotomy • Surgical field showed, intense inflammation of the epicardial/visceral layers. • Pericardial stripping of the right side performed • On attempting left side pericardiectomy, LAD was nicked • Because of intense inflammatory reaction, further pericardiectomy of the left side was aborted.

Histopathology
• Histopathology showed
• • Marked fibrosis and granulation tissue with organizing hemorrhage. Fibrotic with thickened pericardium

• Started on prednisone, NSAID and colchicine. • Discharged home

A month later on antiinflammatory medications…

Presentation
• • • • Shortness of breath Difficulty doing stairs Abdominal swelling Chest pain, sharp in nature, increased with exertion

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

Work up
• EKG: NSR with LBBB • WSR 45 (0 - 15 mm/H) • CRP 8.1 (0.0 - 1.0 mg/dL) • Prednisone was increased to 60 mg daily

Echocardiogram Parasternal Views

Echocardiogram Apical Views

TDI

Significant respiratory variation of Doppler flow ( MV 40%) E/e’ = 9

CMR

Late Gadolinium Enhancement

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

Next step
• Findings are suggesting ongoing constriction of the left paricardium • LAD trauma from right pericardiectomy was entertained. • LHC was done and normal • Referred for complete pericardiectomy

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

5 months later…

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.

Echocardiogram Parasternal Views

Late Gadolinium Enhancement

Late Gadolinium Enhancement

Pre

Post

Take home messages

Operating on inflamed pericardium has been associated with adverse outcome
40

30

WSR

20

10

0
myectomy Total pericardiectomy Right pericardiectomy

Take Home Points
• Caution is needed when sending patient for pericardiectomy in setting 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 the setting of active inflammation and constrictive findings before proceeding to pericardiectomy.

Thank you