Pericardiectomy vs Medical Management in Patients With Relapsing Pericarditis

Abstract

Objective: To determine whether surgical pericardiectomy is a safe and effective alternative to medical management for chronic relapsing pericarditis. Patients and Methods: Retrospective review of 184 patients presenting to the Mayo Clinic in Rochester, Minnesota, from January 1, 1994, through December 31, 2005, with persistent relapsing pericarditis identified 58 patients who had a pericardiectomy after failed medical management and 126 patients who continued with medical treatment only. The primary outcome variables were in-hospital postoperative mortality or major morbidity, all-cause death, time to relapse, and medication use. Results: Mean Ϯ SD follow-up was 5.5Ϯ3.5 years in the surgical group and 5.4Ϯ4.4 years in the medical treatment group. At baseline, patients in the surgical group had higher mean relapses (6.9 vs 5.5; Pϭ.01), were more likely to be taking colchicine ( than the medical treatment group. Perioperative mortality (0%) and major morbidity (3%; nϭ2) were minimal. Kaplan-Meier analysis revealed no differences in all-cause death at follow-up (Pϭ.26); however, the surgical group had a markedly decreased relapse rate compared with the medical treatment group (Pϭ.009). Medication use was notably reduced after pericardiectomy. Conclusion: In patients with chronic relapsing pericarditis in whom medical management has failed, surgical pericardiectomy is a safe and effective method of relieving symptoms.

Evaluation and Treatment of Pericarditis

“…However, this therapy is only supported by a retrospective series from the Mayo Clinic, which demonstrated that patients with recurrent pericarditis who received surgery experienced fewer relapses than patients with recurrent pericarditis who received medical therapy (level of evidence C). 46 In contrast, a small retrospective study found that few patients (2 of 9 patients) responded to pericardiectomy. 47 Both of these studies are limited by their retrospective design.…”

2015 ESC Guidelines for the diagnosis and management of pericardial diseases

“…anakinra) [20][21][22][23][28][29][30][31][32]. Jak udowodniono, u chorych z nawracającym opornym zapaleniem osierdzia istotną alternatywę dla farmakoterapii stanowi perikardiektomia [33]. Opublikowano też wyniki prospektywnych i retrospektywnych badań klinicznych obejmujących duże grupy pacjentów (> 100 osób), dotyczące rokowania i ryzyka rozwoju powikłań u chorych na ostre lub nawracające zapalenie osierdzia [7,9,[34][35][36][37][38].…”

“…W ostateczności można rozważyć wykonanie perikardiektomii, choć zabieg ten można przeprowadzić tylko w przypadku wielokrotnego niepowodzenia farmakoterapii. W tym celu należy pacjenta skierować do ośrodka, gdzie są doświadczeni w tej dziedzinie chirurdzy [33]. Chorych na nawracające zapalenie osierdzia obowiązują takie same ograniczenia aktywności fizycznej jak pacjentów z zapaleniem ostrym [53,54].…”

“…W przypadku nawracającego zaciskającego zapalenia osierdzia ponowny zabieg należy wykonać tak szybko, jak to możliwe, najlepiej w ciągu roku od pierwszym zabiegu. Perikardiektomię przeprowadza się rzadko w przypadku nawracającego zapalenia osierdzia (bez cech zaciskania), choć u niektórych pacjentów zabieg może przynieść korzyści kliniczne [33].…”

Acute pericarditis

“…Case series studies suggest a clinical benefit. 22 Pericardiectomy is not consistently effective, perhaps because visceral pericardium remains after the procedure, along with remnants of parietal pericardium. 3 Patients with cardiac tamponade should undergo urgent therapeutic pericardiocentesis.…”