Radical Pericardiectomy and Use of Cardiopulmonary Bypass for Constrictive Pericarditis

Background Pericardiectomy is definitive treatment for constrictive pericarditis. However, extent of resection (radical versus partial) and use of cardiopulmonary bypass (CPB) are debated. Objectives To determine the association of extent of pericardial resection and use of CPB with outcomes. Methods From January 2000 to January 2022, 565 patients with constrictive pericarditis underwent radical (n=445, 314 [71%] on CPB) or partial (n=120, 67 [56%] on CPB) pericardiectomy at Cleveland Clinic. Outcomes stratified by extent of pericardial resection and use of CPB were compared after propensity-score matching. Results Both radical pericardiectomy and CPB use (67% [381/565]) increased over time. Among 88 propensity-matched pairs (73% of possible matches), immediate postoperative cardiac index increased ( P <0.001) in both groups by a median of 1.0 L•min-1•m-2. There were no significant differences between radical versus partial resection groups in occurrence of reoperation for bleeding (2.3%, [2/88] vs. 0, P =.50). Median postoperative hospital length of stay was 10 versus 8.5 days ( P =.02). Operative mortality was 9.1% (8/88) versus 6.8% (6/88) ( P =.58). 10-year survival was 54% versus 41%, with a higher propensity-adjusted hazard ratio after partial resection (1.9, 95% CI 1.2-3.1). Conclusions When surgical intervention is deemed necessary, radical — rather than partial — resection for constrictive pericarditis can be performed with low surgical mortality and morbidity. Radical pericardiectomy can be accomplished on CPB and results in better long-term survival. CLINICAL PERSPECTIVES Patients with constrictive pericarditis require a multidisciplinary approach involving primarily a cardiologist and cardiac surgeon, and other disciplines like gastroenterology since liver cirrhosis from increased central venous pressure and congestion is common, or immunology for evaluation of possible autoimmune etiology. Communication is critical in managing patient expectations after pericardiectomy, especially linking etiology to short- and long-term outcomes in this complex patient population. Radical pericardiectomy should be the gold standard for treating patients with constrictive pericarditis. Routine use of cardiopulmonary bypass is safe and enables the radical pericardiectomy surgery and should be recommended in the guidelines.