title: Risk factors for mortality after pericardiectomy for chronic constrictive pericarditis in a large single-centre cohort.
abstract: OBJECTIVE
  Constrictive pericarditis (CP) is an uncommon disease with multiple causes and unclear clinical outcomes. To date, few publications have clearly defined risk factors of poor outcomes after surgery for CP. We performed a retrospective analysis of almost 100 patients undergoing surgical treatment for CP at a single institution in order to identify risk factors for perioperative and long-term mortality.
  
  
  METHODS
  A total of 97 consecutive patients (67.0% male) undergoing surgery for CP at our institution from 1995 to 2012 were included in the study. CP was diagnosed either preoperatively by cardiac catheterization and appropriate imaging or during surgery. Preoperative and intraoperative risk factors for 30-day and late mortality were analysed using stepwise multivariate logistic and Cox regression analyses. Median follow-up was 1.23 ± 3.96 years (mean 3.08 ± 3.96 years).
  
  
  RESULTS
  The mean patient age was 60.0 ± 12.5 years and the underlying aetiology was idiopathic (50.5%), prior cardiac surgery (15.5%), prior mediastinal radiation (9.3%), and miscellaneous (24.7%). All patients underwent either radical (55.2%) or partial (44.8%) pericardiectomy. Concomitant procedures were performed in 54 (55.7%) patients. The total procedure time was 197.0 ± 105.0 min. Cardiopulmonary bypass (CPB) was used in 62 patients with a corresponding CPB time of 124.8 ± 68.4 min. In those patients who underwent CPB, cardioplegic arrest was performed in 53.2% of patients with a mean cross-clamp time of 74.9 ± 41.9 min. Overall 30-day, 1-year and 5-year survival rates were 81.4, 66.5 and 51.6%, respectively, without significant differences according to the underlying aetiology. Multivariate analysis revealed patients with reduced left ventricular ejection fraction (LVEF) [P = 0.01, odds ratio (OR) 3.6] and preoperative right ventricular dilatation (P = 0.04, OR 3.5) to be at significant risk of early mortality. Long-term mortality was independently predicted by the presence of coronary artery disease (CAD) [P < 0.001, hazard ratio (HR) 6.44], chronic obstructive pulmonary disease (P = 0.001, HR 4.21) and preoperative renal insufficiency (P = 0.012, HR 1.8). Concomitant tricuspid valve repair (TVR) appeared to provide protective effect on the long-term survival (P = 0.07).
  
  
  CONCLUSIONS
  Surgery for CP is associated with a significant risk based on the poor preoperative patient status. Whenever justified, partial over radical pericardiectomy should be preferred and TVR should be indicated liberally. Reduced LVEF and right ventricular dilatation were independent predictors for early mortality, whereas CAD, chronic obstructive pulmonary disease and renal insufficiency were risk factors for late mortality. Thus, an optimal timing for surgery on CP remains crucial to avoid secondary morbidity with an even worse natural prognosis.
authors.affiliation: Department of Cardiology, Diakonissenkrankenhaus Leipzig, Leipzig, Germany.
authors.forename: Christiane
authors.initials: C
authors.lastname: Busch
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA penov@stanford.edu.
authors.forename: Kiril
authors.initials: K
authors.lastname: Penov
authors.affiliation: Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
authors.forename: Paulo A
authors.initials: PA
authors.lastname: Amorim
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Garbade
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.
authors.forename: Piroze
authors.initials: P
authors.lastname: Davierwala
authors.affiliation: Department of Cardiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.
authors.forename: Gerhard C
authors.initials: GC
authors.lastname: Schuler
authors.affiliation: Department of Cardiac Surgery, Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg, Germany.
authors.forename: Ardawan J
authors.initials: AJ
authors.lastname: Rastan
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.
authors.forename: Friedrich-Wilhelm
authors.initials: FW
authors.lastname: Mohr
mesh_terms: D002315:Cardiopulmonary Bypass / Q000401:mortality; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010492:Pericardiectomy / Q000401:mortality*; D010494:Pericarditis, Constrictive / Q000150:complications / Q000401:mortality / Q000601:surgery*; D057234:Preoperative Period; D016016:Proportional Hazards Models; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000401:mortality; D051437:Renal Insufficiency / Q000150:complications / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D018487:Ventricular Dysfunction, Left / Q000401:mortality
keywords: Aetiology; Constrictive pericarditis; Outcomes; Pericardiectomy; Risk factors