Completion pericardiectomy for recurrent constrictive pericarditis: importance of timing of recurrence on late clinical outcome of operation

Abstract

Background: Recurrent right-side heart failure after operation for constrictive pericarditis (CP) may be caused by incomplete pericardiectomy, recurrent constriction due to exuberant scar tissue, or diastolic dysfunction. Because the risks and benefits of reoperation are not well defined, we reviewed the outcome of completion pericardiectomy.

Methods: From 1993 to December 2010, 41 patients underwent redo pericardiectomy. Thirty-eight patients had the initial operation elsewhere, and 3 had first pericardiectomy at our clinic. All patients had the diagnosis of CP at initial operation. We divided patients into two groups according to the interval between the first and second pericardiectomies: group A, 1 year or less, n = 20; group B, more than 1 year, n = 21.

Results: The mean age was 57.6 ± 12.7 years, and there were 34 males (83%). Twenty-six patients (63%) were in New York Heart Association class II, 10 (24%) were in class III, and 5 (12%) were in class IV. Etiologies were idiopathic in 20 (49%), prior cardiac surgery in 13 (32%), radiation in 6 (15%), and trauma in 2 (5%). There was no significant difference in patient characteristics between group A and group B. The 30-day and in-hospital mortalities were 7% (n = 3) and 12% (n = 5), respectively. Overall 5-year survival was 49%, and was significantly better in group A than group B (73% versus 29%, p = 0.032). In multivariate analysis, New York Heart Association class III or IV and the interval between operations longer than 1 year were significant risk factors for death (p = 0.010 and p = 0.027, respectively).

Conclusions: The significant early mortality of repeat pericardiectomy emphasizes the importance of complete pericardial resection at first operation and accurate diagnosis of recurrent constriction. The poor clinical outcome of late (more than 1 year) reoperation suggests that many of these patients may have unrecognized diastolic dysfunction or recurrent mediastinal scarring as the cause of right-side heart failure rather than incomplete initial pericardiectomy.