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Caldwell, NJ: West Ciba-Geigy, 1981; 165–177
Cardiac Decortication
(Epicardiectomy) for Occult
Constrictive Cardiac
Physiology After Left
Extrapleural Pneumonectomy*
John G. Byrne, MD, FCCP; Alexandros N. Karavas, MD;
Yolonda L. Colson, MD; Raphael Bueno, MD, FCCP;
William G. Richards, PhD; David J. Sugarbaker, MD, FCCP;
and Samuel Z. Goldhaber, MD, FCCP
Constrictive cardiac physiology typically does not
occur in the absence of parietal pericardium. However, we report eight patients who, after left extrapleural pneumonectomy and removal of the parietal pericardium for malignancy, presented with
dyspnea, jugular venous distension, and peripheral
or generalized edema unresponsive to diuretics.
Cardiac decortication (epicardiectomy) was performed whereby a thickened peel encasing the heart
was surgically excised, resulting in vigorous contraction and expansion of the heart. In one patient,
decortication occurred early after pneumonectomy
and was incomplete. Acute signs of inflammation
were present, and recurrence necessitated repeat
decortication. When patients present with dyspnea,
hepatojugular reflux, and peripheral edema refractory to diuretics, constrictive cardiac physiology
should be considered in the differential diagnosis,
even in the absence of parietal pericardium.
(CHEST 2002; 122:2256 –2259)
Key words: cardiac decortication; epicardiectomy; pneumonectomy
Abbreviations: EPP ⫽ extrapleural pneumonectomy; POD ⫽
postoperative day; RV ⫽ right ventricular
xtrapleural pneumonectomy of the left lung includes
E removal
of the lung, parietal pleura, parietal pericar-
dium, and diaphragm.1 Therefore, constrictive cardiac
physiology due to pericarditis would not seem possible
postoperatively. We report eight patients who nonetheless
acquired occult constrictive cardiac physiology due to
epicardial constriction, despite left extrapleural pneumonectomy (EPP) for underlying cancer. In all cases, fibrous
material grew around and encased the heart. These patients required reoperation for epicardial decortication to
alleviate dyspnea and peripheral edema refractory to
diuretics.
Materials and Methods
We undertook a retrospective chart review of the preoperative
presentations, clinical evaluations that revealed constrictive physiology, operative procedures, and patient outcomes.
Results
In the period from February 1997 to January 2000, 133
patients underwent EPP. Seven patients (5%) acquired
constrictive cardiac physiology after left EPP for malignant mesothelioma, and one patient acquired constrictive
cardiac physiology after left intrapericardial pneumonectomy for non-small cell lung carcinoma. The mesothelioma was epithelial in six patients and epithelial/sarcomatoid in one patient. The parietal pericardium was entirely
excised in seven patients and partially excised in one
patient. Pericardial and/or diaphragm reconstruction was
accomplished using polytetrafluoroethylene (Gore-Tex;
W.L. Gore & Associates; Flagstaff, AZ). Adjunct therapy
included preoperative chemotherapy and radiation in one
patient and intraoperative heated chemotherapy in four
patients. No talc was used in any patients.
After a median interval of 3.3 months (range, 1.6 to 18.9
*From the Cardiac Surgery (Drs. Byrne and Karavas), Thoracic
Surgery (Drs. Colson, Bueno, Richards, and Sugarbaker), and
Cardiovascular Divisions (Dr. Goldhaber), Brigham and Women’s Hospital, Boston, MA.
Presented at the American Heart Association Scientific Sessions,
Anaheim, CA, November 11–14, 2001.
Manuscript received November 30, 2001; revision accepted June
6, 2002.
Correspondence to: John G. Byrne, MD, FCCP, Division of
Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St,
Boston, MA; e-mail: [email protected]
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Selected Reports
months) following pneumonectomy, patients were readmitted with symptoms and signs consistent with constrictive cardiac physiology. Symptoms always included dyspnea, jugular venous distension, hepatojugular reflux, and
peripheral leg edema, all unresponsive to diuretics. One
patient required dialysis because of anasarca. In the
absence of parietal pericardium, medical-care providers
did not initially attribute the symptoms to constrictive
cardiac physiology (Fig 1). Details that led to the diagnosis
of constrictive cardiac physiology in these eight patients
are presented in Table 1. CT scan was performed in four
patients, but it was not conclusive and did not help further
in the establishment of the diagnosis. MRI, performed in
one patient, revealed fibrous bands encasing the heart.
All patients were re-explored via a left thoracotomy.
Intraoperative findings in each case included a “leatherlike” scar covering uniformly the entire surface of the
heart and restricting the heart from its normal contraction
and relaxation. Dissection in the plane between the fibrous tissue and the myocardium (epicardiectomy) resulted in decortication of the entire myocardium with
minimal bleeding. Peeling off the fibrous tissue restored
vigorous contraction and expansion of the heart. In one
patient, operated on 47 days after the initial pneumonectomy, the tissue was too adherent to peel off entirely
without risking injury to the left anterior descending
coronary artery. Therefore, the anterior portion of the
fibrous peel was left in situ. Another patient developed
right ventricular (RV) free-wall rupture on coughing in
preparation for extubation in the operating room. She
required immediate re-exploration and institution of cardiopulmonary bypass, with arterial cannulation via the left
ventricular apex advanced through the aortic valve and
venous drainage initially via the rent in the right ventricle
and later through the right atrium after further dissection.
The RV rent was repaired with bovine pericardium, and
the patient had an unremarkable recovery.
Details of histopathology and clinical follow-up are
provided in Table 2. One patient died of cachexia and
heart failure on postoperative day (POD) 14, despite
successful decortication. One patient, who could only
be partially decorticated, acquired a relapsing constrictive epicarditis requiring hospital readmission and reoperative decortication on POD 42 and POD 81 after
the primary decortication. He died 10 days after the last
procedure as a consequence of progressive hemodynamic deterioration. The other six patients recovered
fully from a cardiac aspect. Three patients died of the
primary cancer between 101 days and 132 days after
decortication, and the other three patients are alive 20,
26, and 50 months after decortication.
Discussion
Pericardium consists of two layers: (1) an outer
fibrous parietal layer with collagen fibers interlaced
with extensive elastic fibers, and (2) an inner visceral
serous layer composed of a single layer of mesothelial
cells. In 1913, Sauerbruch2 performed the first decortication for constrictive parietal pericarditis and showed
that the myocardium regained full function after the
thickened pericardial layer was removed.
Nissen and Schweizer3 reported that in almost all
patients with constrictive pericardial disease, both the
parietal and visceral layers of the pericardium thicken.3
They operated on and successfully decorticated the first
patient described with epicardial constriction in the presence of a normal parietal pericardium.
In our series, decortication was performed by creating a
plane between the myocardium and the thickened peel,
Figure 1. Angiographic diastolic pressures in eight patients (in mm Hg). RA a ⫽ right atrium a wave;
RV dia ⫽ right ventricular diastolic pressure; PA dia ⫽ pulmonary artery diastolic pressure; PCWP
mean ⫽ mean pulmonary capillary wedge pressure; LV dia ⫽ left ventricular diastolic pressure.
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Table 1—Clinical Presentations*
Patient
No.
Intervals
Clinical Manifestations
1
568 d after left EPP
Anasarca requiring dialysis
2
103 d after LIPP
Dyspnea, confusion, gait disturbance
3
113 d after left EPP
Edema, dyspnea
4
108 d after left EPP
5
85 d after left EPP
Edema, ascites, dyspnea, nausea and
vomiting, syncope, seizure
Anasarca, dyspnea, hepatic congestion
6
92 d after left EPP
Edema, dyspnea
7
60 d after left EPP
Edema, dyspnea, cardiac decompensation
8
47 d after left EPP
Edema, ascites, dyspnea
Echo Findings Prior to Decortication
Restrictive ventricular motion, abnormal septal
motion, ejection fraction 55%
Lack of myocardial expansion, abnormal septal
motion, ejection fraction 50%
Limited expansion of the heart, abnormal
septal motion, ejection fraction 55%
Abnormal RV dynamics, abnormal septal
motion, ejection fraction 50%
Right ventricle restricted, abnormal septal
motion, ejection fraction 50%
Normal left ventricular/RV function; enlarged
atria, ejection fraction 50%
Mild-to-moderate RV dysfunction, abnormal
septal motion, ejection fraction 50%
*LIPP ⫽ left intrapericardial pneumonectomy.
essentially performing an epicardiectomy. This procedure
was accomplished with minimal bleeding. In one patient
only, decorticated only 47 days after pneumonectomy (the
earliest time interval in our series), we could not safely
separate the fibrous tissue from the heart without causing
bleeding, so decortication was limited to the inferolateral
region of the myocardium. This inability to safely dissect
the rind is most likely attributed to the time interval
between pneumonectomy and decortication. We believe
that inflammation was still active, because the tissue was
highly vascularized and fibrin organization had not been
completed. The patient subsequently relapsed and required reoperative decortication. All other patients were
operated after a period of 2 months, usually between 2 to
4 months after pneumonectomy. This seems to be the
appropriate timing, late enough to allow the inflammation
to subside but also early enough to detect possible local
metastasis. In the patient who experienced RV free-wall
rupture, we believe that the RV decortication was likely
too aggressive, and this, in addition to the absence of the
epicardium (after decortication), weakened the RV free
wall, making it susceptible to tearing. Therefore, on the
right ventricle in particular, we suggest that decortication
should be conservative.
In our effort to detect precipitating factors for this
unusual clinical manifestation, we could not identify any
component of the adjunct therapy or intraoperative approach at the time of the EPP that would differentiate
patients who acquired epicardial scarring from those who
did not. Some received chemotherapy and all patients had
reconstruction of the diaphragm using polytetrafluoroethylene.
Patients with mesothelioma or lung cancer are seen
postoperatively at 2 weeks, 6 weeks, 3 months, and then
every 3 months for 2 years. At each visit, they undergo
physical examination, chest radiography and, if abnormal-
Table 2—Histologic Findings and Outcomes
Patient
No.
Histopathologic Findings
1
Dense fibroconnective tissue, tumor positive
2
Extensive fibrosis, chronic inflammation, tumor
negative
Dense fibroconnective tissue, focal hemosiderin,
tumor negative
Dense fibrous tissue with erosion, granulation,
fibrinous exudate, tumor negative
Dense fibrous tissue, chronic inflammation,
hemosiderin, tumor negative
Fibrous tissue with chronic inflammation, tumor
positive
Metastatic malignant mesothelioma, tumor positive
(Report from repeat decortication) fibrous tissue
with acute and chronic inflammation, fibrin,
deposition, granulation tissue
3
4
5
6
7
8
Follow-up
Status as of
August 5, 2001
Required reoperation right atrial thrombectomy
on POD 13
No further hemodynamic compromise
Death on POD 157
No further hemodynamic compromise
Alive on POD 534
No further hemodynamic compromise
Alive on POD 1439
No follow-up
Alive on POD 782
No further hemodynamic compromise
Death on POD 132
Death due to cachexia and heart failure
Required two repeat decortications
Death on POD 14
Death on POD 89
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Death on POD 101
Selected Reports
ities are identified, echocardiography and chest CT. We
now pay particular attention to the signs and symptoms of
right heart failure and have adopted a low threshold to
perform echocardiography. Since this is the first report of
this clinical manifestation, we do not recommend echocardiography unless clinical signs and symptoms of right
heart failure are present. Echocardiography is very sensitive in detecting constrictive physiology, but findings
should be confirmed by cardiac catheterization, which will
show the typical pressure equalization and also establish
the indication for operation. CT scan was insensitive in
detecting morphologic abnormalities, while MRI, in the
one occasion used, revealed clearly the fibrous bands
encasing the heart. CT scan is used primarily for the
detection of metastatic disease.
Conclusion
Constrictive cardiac physiology can occur even in the
absence of the parietal pericardium. Constrictive epicarditis evolves from an early phase with highly vascularized tissue that is difficult to dissect to a late phase in
which the tissue is less vascularized and easy to excise.
When patients present with dyspnea, hepatojugular
reflux, and peripheral edema refractory to diuretics,
constrictive cardiac physiology should be considered in
the differential diagnosis, even in the absence of parietal pericardium.
References
1 Sugarbaker DJ, Flores RM, Jaklitsch MT, et al. Resection
margins, extrapleural nodal status, and cell type determine
postoperative long-term survival in trimodality therapy of
malignant pleural mesothelioma: results in 183 patients.
Thorac Cardiovasc Surg 1999; 117:54 – 63
2 Sauerbruch F. Die Chirurgie des Herzens und seines Beutels. In: Sauerbruch F, ed. Die Chirurgie der Brustorgane.
2nd ed. Berlin, Germany: J Springer, 1920; 141–308
3 Nissen R, Schweizer W. Constrictive epicarditis [in German].
Thoraxchir Vask Chir 1968; 16:296 –300
Bacterial Endocarditis and
Functional Mitral Stenosis*
A Report of Two Cases and Brief
Literature Review
Irving Y. Tiong, MD; Gian M. Novaro, MD;
Brian Jefferson, MD; Michael Monson, MD;
Nicholas Smedira, MD, FCCP; and Marc S. Penn, MD, PhD
Mitral valve endocarditis typically results in mitral
regurgitation. However, endocarditis leading to
functional mitral stenosis is uncommon and, when
present, fungal organisms are typically implicated.
Thus, obstructive-type bacterial endocarditis due to
large vegetations blocking the mitral valve orifice is
www.chestjournal.org
a rare occurrence, with approximately 20 reported
cases in the literature. We report on two patients
with bacterial endocarditis and severe functional
mitral stenosis requiring emergent surgery. Additionally, this is the first report of vancomycin-resistant enterococcus causing endocarditis and functional mitral stenosis. The discussion emphasizes the
hemodynamic instability of these patients and need
for early surgical intervention.
(CHEST 2002; 122:2259 –2262)
Key words: bacterial endocarditis; echocardiography; enterococcal infection; mitral valve stenosis; vegetations
Abbreviations: MRSA ⫽ methicillin-resistant Staphylococcus
aureus; TEE ⫽ transesophageal echocardiography; VRE ⫽
vancomycin-resistant enterococcus
alvular dysfunction in infective endocarditis implies
V the
development of a new regurgitant lesion. The
occurrence of an obstructive or “functionally” stenotic
valvular condition in the setting of endocarditis is rare and
often goes clinically unsuspected until late in the course of
the disease.1– 8 Moreover, suspicion of this condition usually surfaces only in cases of fungal endocarditis.9,10 Importantly, when present, the management of such a scenario is medically challenging and uniformly warrants
emergent surgery. We describe two cases of bacterial
endocarditis presenting with functional mitral stenosis due
to obstructive vegetations at the mitral valve orifice. Novel
to our report are the microorganisms involved in this
“obstructive-type” of endocarditis, namely methicillinresistant Staphylococcus aureus (MRSA) and vancomycinresistant enterococcus (VRE). A discussion on the management of these patients and a brief review of the
literature is provided.
Case Reports
Case 1
A 54-year-old African-American woman presented with fevers,
respiratory distress, and mental status changes. Her medical
history was significant for end-stage renal disease with secondary
hyperparathyroidism, long-standing hypertension, and IV drug
abuse. The week prior to hospital admission, she missed several
sessions of hemodialysis, becoming progressively lethargic, and
was brought by her family to the emergency department. On
presentation, her temperature was 39.3°C, BP was 97/65 mm Hg,
and heart rate was 120 beats/min. Physical examination was
remarkable for jugular venous distension, an apical holosystolic
murmur that radiated to the axilla, a short apical diastolic
murmur, and bilateral pulmonary crackles up to the mid-lung
fields.
*From the Department of Cardiovascular Medicine (Drs. Novaro, Jefferson, Monson, and Penn), Internal Medicine (Dr.
Tiong), and Cardiothoracic Surgery (Dr. Smedira), The Cleveland Clinic Foundation, Cleveland, OH.
Manuscript received March 21, 2002; revision accepted June 21,
2002.
Correspondence to: Marc S. Penn, MD, PhD, Departments of
Cardiovascular Medicine and Cell Biology, NC10, Cleveland
Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195;
e-mail: [email protected]
CHEST / 122 / 6 / DECEMBER, 2002
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