A 20-year Experience with Isolated A 20-year Experience with Isolated PericardiectomyPericardiectomy

An Analysis of Indications and An Analysis of Indications and OutcomesOutcomes

Gillaspie EA, Stulak JM, Daly RC, Greason KL, Gillaspie EA, Stulak JM, Daly RC, Greason KL, Joyce LD, Oh J, Suri RM, Schaff HV, Dearani JAJoyce LD, Oh J, Suri RM, Schaff HV, Dearani JA

Division of Cardiovascular Surgery and Cardiovascular Division of Cardiovascular Surgery and Cardiovascular DiseasesDiseases

Mayo Clinic Division of Cardiovascular Surgery

Research funding within the past year:

AstraZeneca Jarvik HeartAtricure MedtronicAvant Immunotherapeutics St. Jude Medical Baxter Thoratec CorporationCarbomedics/Sorin Group TransTech PharmaCryoLife W.L. Gore and Associates

No personal equity, patents, licensing, or consulting

agreements with the medical device or pharmaceutical

industry to disclose

Mayo Clinic Division of Cardiovascular Surgery

Research funding within the past year:

AstraZeneca Jarvik HeartAtricure MedtronicAvant Immunotherapeutics St. Jude Medical Baxter Thoratec CorporationCarbomedics/Sorin Group TransTech PharmaCryoLife W.L. Gore and Associates

No personal equity, patents, licensing, or consulting

agreements with the medical device or pharmaceutical

industry to disclose

DisclosureDisclosure

BackgroundBackground

• Management of pericarditis Management of pericarditis challengingchallenging

• Subset may require and benefit from Subset may require and benefit from surgerysurgery

• Lack of clarity on association of Lack of clarity on association of patient variables and outcomespatient variables and outcomes

AimsAims

• Establish a homogeneous cohort Establish a homogeneous cohort undergoing isolated pericardiectomyundergoing isolated pericardiectomy

• Analyze overall outcomes and Analyze overall outcomes and stratified for surgical indicationstratified for surgical indication

• Identify patient variables contributing Identify patient variables contributing to outcometo outcome

MethodsMethods

• Mayo Foundation IRB approvalMayo Foundation IRB approval

• Retrospective reviewRetrospective review

• Patients undergoing isolated Patients undergoing isolated pericardiectomypericardiectomy

• ExclusionExclusion• Concomitant proceduresConcomitant procedures

• Prior mediastinal radiationPrior mediastinal radiation

June 1993 December 2013 June 1993 December 2013

363363 150150

AgeAge 1818 8484

57 yr57 yr

n = 513n = 513

Isolated PericardiectomyIsolated PericardiectomyPatient DataPatient Data

ConstrictionConstriction

n = 355n = 355

Isolated Isolated n = 513n = 513

TotalTotaln = 938n = 938

Pericardiectomy: 1993-2013Pericardiectomy: 1993-2013

EffusiveEffusiven = 158n = 158

Effusion Effusion n = 23n = 23

ConstrictionConstriction n = 54n = 54

Pain Pain n = 81n = 81

EffusiveEffusiven = 158n = 158

Pericardiectomy: 1993-2013Pericardiectomy: 1993-2013

Preoperative DataPreoperative Data

PCPC E/CRE/CRNYHA III/IVNYHA III/IV 332 (94%)332 (94%) 73 (46%)73 (46%)DiabetesDiabetes 78 (22%) 78 (22%) 17 (11%)17 (11%)HypertensionHypertension 151 (43%)151 (43%) 47 (30%)47 (30%)COPDCOPD 24 (7%) 24 (7%) 3 (2%) 3 (2%)PVDPVD 30 (8%) 30 (8%) 5 (3%) 5 (3%)Renal insufficiencyRenal insufficiency 19 (6%) 19 (6%) 5 (3%) 5 (3%)Prior surgeryPrior surgery 105 (30%)105 (30%) 0 (0%) 0 (0%)Prior MIPrior MI 23 (6%) 23 (6%) 7 (4%) 7 (4%)Median LVEFMedian LVEF 60 (30-80)60 (30-80) 60 (24-80)60 (24-80)

Intraoperative DataIntraoperative Data

## %%

Isolated pericardiectomyIsolated pericardiectomy 513513 100100

Median sternotomyMedian sternotomy 415415 81 81

Complete resectionComplete resection 417417 81 81

CPB useCPB use 207207 40 40

Median CPB 60 min (range 7-213)Median CPB 60 min (range 7-213)

Non-cardiac procedureNon-cardiac procedure 1414 33

Intraoperative DataIntraoperative Data

PCPC E/CR E/CR p p

SternotomySternotomy 286 (81%)286 (81%) 129 (82%) 129 (82%) 0.450.45

CPB useCPB use 181 (51%) 181 (51%) 26 (16%)26 (16%) <0.01<0.01

CPB timeCPB time 50 min 50 min 60 min60 min 0.220.22

Complete resectionComplete resection 275 (77%) 275 (77%) 142 (90%)142 (90%) <0.01<0.01

Early MorbidityEarly Morbidity

## %%

Atrial arrhythmiasAtrial arrhythmias 6666 1313

Prolonged ventilationProlonged ventilation 5555 1111

Renal failureRenal failure 2626 5 5

PneumoniaPneumonia 1717 3 3

Low cardiac outputLow cardiac output 1313 3 3

Bleeding/reexploreBleeding/reexplore 1515 3 3

Postoperative DataPostoperative Data

• Early mortality Early mortality 12/513 (2.3%)12/513 (2.3%)

• ConstrictionConstriction 9/355 (2.5%)9/355 (2.5%)

• Effusive/CREffusive/CR 3/158 (1.9%)3/158 (1.9%)

• Univariate predictorsUnivariate predictors

• LVEF (per ∆10%) LVEF (per ∆10%) (HR 1.09, p=0.03)(HR 1.09, p=0.03)

• Preop renal failurePreop renal failure (HR 9.9, p<0.001)(HR 9.9, p<0.001)

Follow-upFollow-up

Median 29 mosMedian 29 mos

Max 20.5 yrsMax 20.5 yrs

n = 501n = 501

80% NYHA Functional Class I/II80% NYHA Functional Class I/II

501 167 63 16

Su

rviv

al (

%)

Follow-up time (yr)

Late SurvivalLate Survival

155 59 18 4346 108 45 12

Su

rviv

al (

%)

p<0.001

EffusiveConstriction

Follow-up time (yr)

Late SurvivalLate Survival

79 54 43 38 29 2854 32 26 24 23 2222 15 13 11 10 9

Follow-up time (yr)

Su

rviv

al (

%)

p=0.034

PainConstrictionEffusion

SurvivalSurvivalEffusive group - Indications Effusive group - Indications

94 64 52 46 36 3452 35 28 26 25 24 6 2 2 1 1 1

Follow-up time (yr)Follow-up time (yr)

Su

rviv

al (

%)

p<0.001

NormalConstrictionTamponade

SurvivalSurvivalEffusive group - Physiology Effusive group - Physiology

HRHR CI CI p p

Older age (∆ 10 yr)Older age (∆ 10 yr) 1.051.05 1.03, 1.07 1.03, 1.07 <0.001<0.001

CHFCHF 1.491.49 1.03, 2.2 1.03, 2.2 0.020.02

DiabetesDiabetes 1.831.83 1.2, 2.7 1.2, 2.7 0.0040.004

CompletionCompletion 2.42.4 1.2, 4.7 1.2, 4.7 0.010.01

COPDCOPD 2.452.45 1.5, 3.9 1.5, 3.9 0.0040.004

Multivariable ModelMultivariable ModelEntire CohortEntire Cohort

HRHR CI CI p p

Older age (∆ 10 yr)Older age (∆ 10 yr) 1.041.04 1.02, 1.06 1.02, 1.06 <0.001<0.001

NYHA classNYHA class 1.71.7 1.1, 2.5 1.1, 2.5 0.0140.014

COPDCOPD 22 1.2, 3.5 1.2, 3.5 0.0120.012

DiabetesDiabetes 2.22.2 1.4, 3.4 1.4, 3.4 0.004 0.004

Multivariable ModelMultivariable ModelConstriction CohortConstriction Cohort

ConclusionsConclusions

• Low early mortality and morbidityLow early mortality and morbidity

• Pre-operative renal insufficiency and Pre-operative renal insufficiency and reduced LVEF increased early reduced LVEF increased early mortalitymortality

• Effusive/chronic relapsing had a better Effusive/chronic relapsing had a better late survival except in the setting of late survival except in the setting of tamponadetamponade

ConclusionsConclusions

• Older age, CHF, DM, COPD and Older age, CHF, DM, COPD and completion pericardiectomy decreased completion pericardiectomy decreased late survivallate survival

• Functional status is improved in the Functional status is improved in the majority of patients regardless of majority of patients regardless of indication for operationindication for operation

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