Cardiac Decompression by Pericardiectomy for Constrictive Pericarditis: Multimodality Imaging to Identify Patients at Risk for Prolonged Inotropic Support

Abstract

BACKGROUND: Right ventricular (RV) failure post-pericardiectomy for constrictive pericarditis (CP) has been reported but it remains not well-studied. To investigate imaging parameters that could predict RV function and the outcome of patients post-pericardiectomy. METHODS: We analysed data from a total of 53 CP patients undergoing pericardiectomy. Preoperative, early and at 6 months postoperative echocardiographic (echo) imaging datasets were analysed and correlated with preoperative cardiac magnetic resonance (CMR), cardiac computed tomography scans and histology. The primary endpoint of the study was RV functional status early postoperatively and at 6 months. Secondary endpoint was the need for prolonged inotropic support. RESULTS: A cause of CP was identified in 26 patients (49%). Inotropic support ≥ 48 hours was required in n = 28 (53%) of patients and was correlated with lower preoperative RV areas by echo or RV volumes by CMR (p < 0.05 for all). A pericardial score based on pericardial thickness/calcification and epicardial fat thickness had good diagnostic accuracy to identify patients requiring prolonged use of inotropes (area under the curve, 0.825; 95% confidence interval, 0.674-0.976). Pericardiectomy resulted in RV decompression and impaired RV function early postoperatively (fractional area change: 40.5% ± 8.8% preoperatively vs. 31.4% ± 10.4% early postoperatively vs. 42.5% ± 10.2% at 6 months, p < 0.001). CONCLUSIONS:We show that a smaller RV cavity size and a pericardial scoring system are associated with prolonged inotropic support in CP patients undergoing pericardiectomy. RV systolic impairment post decompression is present in most patients, but it is only transient.

Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts

“…Azzu et al [ 77 ] attempted to create a “pericardial score” using pre-operative multimodality imaging to identify the patients at risk for prolonged inotropic support with an assumption that there is an association between pericardial anatomy and difficulty of surgical dissection of the pericardium. High pericardial “score” (score of 2–3) calculated by epicardial fat thickness < 5 mm, thickened pericardium > 5 mm, and pericardial calcification by CT (1 point each) was strongly associated with in-hospital use of inotropes.…”

“…High pericardial “score” (score of 2–3) calculated by epicardial fat thickness < 5 mm, thickened pericardium > 5 mm, and pericardial calcification by CT (1 point each) was strongly associated with in-hospital use of inotropes. Moreover, a smaller RV cavity size calculated either by CMR or echocardiography also predicted prolonged inotropic support in the early post-operative period [ 77 ]. Thus, the use of imaging not only plays an indispensable role in surgical planning and identification of patients with myocardial dysfunction/mixed disease but may also help predict worse outcomes post-operatively thereby aiding in risk stratification of patients with CP.…”

Novel Imaging Parameters for Right Ventricular Dysfunction after Pericardiectomy in Constrictive Pericarditis

“…In conclusion, Azzu et al 8) found that RV dysfunction is prevalent and transient during the early period of post-pericardiectomy, and predictors for prolonged inotropic support include a smaller preoperative RV cavity size and a novel pericardial score based on epicardial fat thickness, pericardial calcification, and pericardial thickness.…”

“…In this issue of Journal of Cardiovascular Imaging , Azzu et al 8) devised a “pericardial score” system using multimodality imaging parameters that could predict RV function and the clinical course of patients post-pericardiectomy. The combined “pericardial score” system consisted of epicardial fat thickness < 5 mm (1 point), thickened pericardium > 5 mm (1 point), and pericardial calcification on computed tomography (1 point).…”