All-cause Mortality after Pericardiectomy for Chronic Constrictive Pericarditis in a Single-Center Cohort

Constrictive pericarditis (CP) is an uncommon disease with multiple causes and discrepant clinical outcome. Till date, there is a scarcity of publications, clearly defining the risk factors of poor outcomes after surgery for CP. Therefore, we retrospectively analysed the results of the surgical treatment for CP at our institution to define the risk factors of poor outcomes. A total of 97 patients (65 male, 67%) undergoing surgery for CP at our institution from 1995 to 2012 were included in this study. CP was diagnosed either preoperatively by cardiac catheterization or at surgery. The mean age was 60±12.5 years and the primary etiology was idiopathic in more than halt the cases, followed by prior cardiac surgery, post-irradiation, and miscellaneous. Preoperative and intraoperative risk factors for 30-day and late mortality were analyzed using stepwise multivariate logistic and Cox regression analysis respectively. Long-term survival was determined by the Kaplan-Meier curve. Mean follow-up was 2.9±3.8 years (range: 0.1-14 years). All patients received either radical (53 patients, 55.2%) or partial (44 patients, 44.8%) pericardiectomy. Concomitant procedures were performed in 38 (39,2%) patients. Overall 30-day, 1-year and 5-year survival were 66.8 %, 58.1% and 52.6% respectively, without significant difference according to the underlying etiology. Univariate analysis showed that preoperative renal dysfunction, liver failure, respiratory insufficiency, emergency surgery and longer operating times were associated with significantly higher 30-day mortality. Multivariate analysis revealed patients with concomitant coronary artery disease to be at higher risk of poor immediate survival, whereas a higher glomerular filtration rate GFR (ml/min/1,73m2) was protective for early mortality. Long-term mortality was independently predicted by the presence of a coronary artery disease, a COPD (chronic obstructive pulmonary disease) and higher absolute creatinine value. To conclude, surgery for constrictive pericarditis is associated with a relatively poor prognosis. Reduced left ventricular ejection fraction and right ventricular dilatation were independent predictors for early mortality, while coronary artery disease, chronic obstructive pulmonary disease, and renal insufficiency were risk factors for late mortality. Thus, indication for surgery needs to be determined on an individual basis and should be justified by an otherwise worse natural prognosis.:1 CONTENTS 1 CONTENTS I 2 ABBREVIATIONS III 3 BIBLIOGRAPHIC DESCRIPTION 1 3.1 REVIEW 1 4 INTRODUCTION 3 4.1 CHRONIC CONSTRICTIVE PERICARDITIS 3 4.2 HISTORY 6 4.3 DEFINITION 8 4.3.1 ACUTE PERICARDITIS 8 4.3.2 RECURRENT PERICARDITIS 9 4.3.3 PERICARDIAL EFFUSION, PERICARDIAL TAMPONADE, EFFUSIVE-CONSTRICTIVE PERICARDITIS 10 4.3.4 CHRONIC PERICARDITIS 12 4.3.5 CHRONIC CONSTRICTIVE PERICARDITIS 14 4.3.6 CLINICAL PRESENTATION 16 4.3.7 DIAGNOSTIC APPROACH 18 4.3.8 TREATMENT OPTIONS 23 4.3.9 PERICARDIECTOMY 24 5 AIM OF THE STUDY 29 6 MATERIAL AND METHODS 30 6.1 DATA COLLECTION 30 6.2 DIAGNOSIS OF CONSTRICTIVE PERICARDITIS 31 6.3 OPERATIVE PROCEDURES 31 6.4 OPERATIVE TECHNIQUE 32 6.5 POSTOPERATIVE COURSE 33 6.6 INCLUSION CRITERIA 34 6.7 EXCLUSION CRITERIA 34 6.8 FOLLOW UP 34 6.9 STATISTICS 35 6.10 STATISTICAL MODEL 37 7 RESULTS 39 7.1 PREOPERATIVE CHARACTERISTICS 39 7.2 ETIOLOGY 42 7.2.1 INDEPENDENT PREDICTORS FOR ALL-CAUSE EARLY MORTALITY 44 7.2.2 INDEPENDENT PREDICTORS FOR ALL-CAUSE LONG-TERM MORTALITY 44 7.3 MORTALITY 46 7.3.1 ALL-CAUSE MORTALITY 46 7.3.2 SURVIVAL ACCORDING TO ETIOLOGY 47 7.3.3 LATE SURVIVAL WITHOUT PERIOPERATIVE DEATHS 48 7.3.4 ISOLATED PERICARDIECTOMY VS. CONCOMITANT SURGERY 49 7.3.5 POSTOPERATIVE OUTCOMES: 50 7.3.6 RECEIVER OPERATING CHARACTERISTIC (ROC) CURVE 51 8 DISCUSSION 54 8.1.1 PERSONAL THOUGHTS AND FUTURE DIRECTIONS 58 9 LIMITATIONS 61 10 CONCLUSION 62 11 SUMMARY 63 12 REFERENCES 65 13 ATTACHMENTS 70 13.1 DIAGNOSTIC APPROACH IN CONSTRICTIVE PERICARDITIS 70 13.2 FOLLOW-UP QUESTIONNAIRE 72 14 NOTE OF THANKS 80 15 DANKSAGUNG 81 16 ERKLÄRUNG ÜBER DIE EIGENSTÄNDIGE ABFASSUNG DER ARBEIT 82 17 CURRICULUM VITAE 8