Pericardial Disease

Question 1

Indications for surgical referral and expected outcomes for purulent pericarditis

Answer 1

Subxiphoid pericardiotomy – Subxiphoid pericardiotomy usually allows more complete and permanent drainage than pericardiocentesis because a pericardial “window” is established during the procedure and because manual lysis of adhesions and loculations is easily accomplished with the finger of the operating surgeon. This procedure is usually performed in an operating room, but, when necessary, can be performed at the bedside using local anesthesia [27]. This approach was recommended as the preferable course of management by the 2015 ESC guidelines [6].

Postoperative constrictive pericarditis can occur following this procedure, but is uncommon.

Pericardiectomy – Pericardiectomy has a higher morbidity and mortality than subxiphoid pericardiotomy. However, pericardiectomy usually achieves complete drainage, and is frequently required in patients with dense adhesions, loculated and thick purulent effusion, recurrent tamponade, persistent infection, and progression to constriction. A full discussion of pericardiectomy is presented separately.

Question 2

Effusive Constrictive Pericarditis

Answer 2

Effusive CP is defined as persistent elevation in right atrial pressure and constrictive pathophysiology despite pericardiocentesis in patients with pericardial tamponade (right atrial pressure fails to decrease by 50% or remains >10 mm Hg). Epicarditis, or inflammation of the visceral layer of the pericardium, is the characteristic pathology in effusive CP. Because tuberculosis is the leading cause, effusive CP is more common in the developing world. After pericardiocentesis, effusive CP has been reported in 2-16% of patients. Therefore, routine surveillance for effusive CP with measurement of postpericardiocentesis intrapericardial pressure, right heart pressures, and arterial pressures is recommended. Similar to transient CP, effusive CP is often reversible and patients may benefit from anti-inflammatory therapy. In persistent cases, pericardiectomy, with removal of as much of the visceral pericardium as possible, is recommended.