Ann Thorac Surg 2000;69:951-953
© 2000 The Society of Thoracic Surgeons
Case Reports
Constrictive pericarditis after bypass leading to internal mammary graft failure
John G. Raheb, DOa,
Henry F. Tripp, MDa
a Department of Cardiothoracic Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
Address reprint request to Dr Tripp, Department of Cardiothoracic Surgery, MCHE-SDC, Building 3600, 3851 Roger Brooke Dr, Fort Sam Houston, TX 78234
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Abstract
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Constrictive pericarditis is an infrequent consequence of cardiac operation. The etiology remains unknown, but the consequences include a restrictive process that leads to congestive failure and diminished cardiac output. In addition, the desmoplastic reaction, associated with fusion of the visceral and parietal pericardial layers, has been implicated in failure of saphenous vein grafts. We report a case of constrictive pericarditis, after coronary bypass operation, with occlusion of an internal mammary graft.
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Introduction
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Constrictive pericarditis after cardiac operation is an uncommon problem that can be difficult to diagnose. We report an unusual complication of this infrequently encountered process, and present some guidelines on how to approach this situation.
A fifty-eight-year old man presented with progressive angina, 3 months after a non Q-wave infarction and angioplasty of the circumflex artery. He was found to have critical left main stenosis, as well as multivessel disease. An intraaortic balloon pump was placed and emergent three vessel coronary artery bypass grafting performed, including the left internal mammary artery (LIMA) to the left anterior descending (LAD). Mild bleeding at the LIMA anastamosis was treated with topical hemostatic agents, and was not felt to be significant. The pericardium was left open. He recovered uneventfully. Seven months after his original event, he again presented with chest pain. Catheterization showed the LIMA to have distal subtotal occlusion (Fig 1). Hemodynamics demonstrated equalization of right and left ventricular diastolic pressures (Fig 2 ), rapid initial descent of the diastolic pressure tracings and constrained diastolic filling, all suggestive of constrictive pericarditis. In addition, venticulography noted anterior and septal hypokinesis. An intraaortic balloon pump was placed and the patient was taken into operation. Extensive decortication of the left ventricle, right atrium, and right ventricle was accomplished. The LAD was opened distal to the anastamosis with the LIMA. The LIMA to LAD anastamosis was probed and found to be patent, however, the distal LIMA, proximal to the anastamosis, was surrounded by the inflammatory process and occluded. A saphenous vein graft was placed at the arteriotomy distal to the prior LIMA to LAD anastomosis. The patient was ultimately discharged after a prolonged postoperative course. He is currently doing well 1 year later.
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Fig 1. Cardiac catheterization showing the left internal mammary artery graft occluded at the level of the epicardium (arrowhead).
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Fig 2. Simultaneous pressure tracings from the right and left ventricles showing equalization of diastolic pressures, the pronounced early diastolic pressure dip (closed arrow), and the flattened pressure tracing throughout the duration of diastole (open arrow).
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Comment
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Constrictive pericarditis associated with open heart operations was first described by Kendall in 1972 [1]. Similarly, Simon described constrictive pericarditis after open heart operations in 1976 [2]. Before this, constrictive pericarditis was known to occur after chest trauma. Simon noted that blood in the pericardial space was common in both trauma and open heart operations. However, he also recognized that "were this the only factor ... chronic constrictive pericarditis would be a frequent occurrence after open heart procedures." He deduced that either several factors are responsible or other cases "less pernicious" go undiagnosed. Since then the incidence has been reported from 0.2% to 0.3% after open cardiac operations [3, 4]. In one series, 95 patients, diagnosed from 1970 to 1985, were reviewed [5]. The incidence of cardiac surgery preceding the diagnosis of constrictive pericarditis increased from none before 1980, to 29% after 1980. The etiology of constrictive pericarditis after cardiac operations is unknown. Several factors have been implicated as possible causes. These include surgical trauma, hemopericardium, infection, antiseptic solutions, postpericardiotomy syndrome, cold injury, direct cardiac massage, air desiccation, previous chest irradiation, and closure of the pericardium. Again, our patient was noted to have perianastamotic bleeding at operation, but this was not felt to be significant. The onset has been reported from 2 weeks to 21 years following operation [3, 4]. In the largest review, Cimino and colleagues found the most common symptoms to be dyspnea, chest pain, and fatigue [4]. Clinical findings may include markedly elevated venous pressures, pleural effusion, ascites, a pericardial friction rub, and peripheral edema. Kussmaul’s sign (inspiratory distention of neck veins) is usually not seen. Chest radiography is usually nondiagnostic, but cardiomegaly, pericardial calcification, and pleural effusion may be seen. Two-dimensional echocardiographic findings include biatrial dilation and normally contracting ventricles, of normal to small size, encased in a thick unyielding pericardial shell. Computed tomography may show localized pericardial thickening, though magnetic resonance imaging may yield better resolution and can determine if a pericardial effusion is serous, exudative, or hemorrhagic. Once there is significant suspicion, cardiac catheterization remains the gold standard. Equalization of diastolic pressures in all four chambers of the heart above twenty millimeters of mercury is pathognomonic. There may be the typical dip and plateau or square root contour of the diastolic pressure tracings of both ventricles (Fig 2). Vein graft occlusion has been previously reported [6], and we report the finding of arterial graftocclusion. In our patient, ischemia from this graft occlusion led to systolic dysfunction, in addition to the constrictive physiology. Once diagnosed, the treatment of constrictive pericarditis is generally surgical. The operation consists primarily of pericardiectomy, although extensive fibrosis may make this difficult. If the epicardium is extensively involved a waffle or turtle cage procedure has been described. If graft occlusion is diagnosed, and is felt to be causing significant ischemia, prompt operation with graft revision, or preferably replacement, is necessary.
Constrictive pericarditis is an unusual sequela of cardiac operation, but should be suspected when the postoperative course deviates from the expected. Hemopericardium may be, at least in part, a contributing factor to its development. The potential for graft involvement leading to occlusion should be appreciated.
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References
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Kendall M.E., Rhodes G.R., Wolfe W. Cardiac constriction following aorta coronary bypass surgery. J Thorac Cardiovasc Surg 1972;64:142-153.[Medline]
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Simon J.S., Pluth J.R. Constrictive pericarditis. Ann Thorac Surg 1976;21:440-441.[Abstract/Free Full Text]
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Kutcher M.A., King S.B., Alimurung B.N., Craver J.M., Logue R.B. Constrictive pericarditis as a complication of cardiac surgery. Am J Cardiol 1982;50:742-748.[Medline]
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Cimino J.J., Kogan A.D. Constrictive pericarditis after cardiac surgery. Am Heart J 1989;118:1292-1301.[Medline]
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Cameron J., Oesterle S.N., Baldwin J.C., Hancock E.W. The etiologic spectrum of constrictive pericarditis. Am Heart J 1987;113:354-360.[Medline]
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Kabbani S.S., Bashour T., Ellertson D.G., Geiger J., Hanna E.S., Cheng T.O. Constrictive pericarditis following myocardial revascularization. Am Heart J 1985;110:493-495.[Medline]
Accepted for publication August 1, 1999.
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February 1, 2013;
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731 - 736.
[Abstract]
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Abstract
Introduction
