Indications, results, and pitfalls in the surgery of constrictive pericarditis

Constrictive pericarditis is a rare disease with an often unclear etiology. There may be a long delay between the onset of the underlying disease and the onset of clinical symptoms, which are fatigue, abdominal swelling, peripheral edema and breathlessness. However, if clinically apparent, these symptoms may progress rapidly and severely disable the affected patient. Diagnosis is achieved by the clinical presentation, echocardiography and/or MRI and right heart catheterization. The standard therapy is an extended pericardiectomy to restore an unlimited inflow and outflow as well as an unrestricted diastolic function of both ventricles. The risks of this procedure are related to dense adhesions between the 2 pericardial layers and severe calcifications especially of the epicardium. Incomplete removal results in persistent diastolic restriction while lacerations of the underlying myocardium may lead to diffuse and extensive bleeding and finally to myocardial dysfunction. Also, the postoperative course may be complicated by persistent low output syndrome or acute ventricular dilatation. However, early surgical intervention in the hands of experienced surgeons offers the best prognosis.