Ann Thorac Surg 2006;81:529-530
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Joseph W. Rubin, MD, CM
22 River Reach Way, Charleston, SC 29407-3372
(Email: jrubin{at}knology.net).
We read in the medical literature that pericardial pathology is now a rare manifestation of tuberculous disease in the industrialized world, and that most often the cause of pericardial constriction is unknown. The uniqueness of this report on pericardiectomy for constrictive pericarditis is the preponderance of tuberculosis as the cause of constriction. The authors emphasize that "tuberculosis continues to be the leading cause of constrictive pericarditis in third world countries." Those of us in the first world should take note. The HIV/AIDS epidemic has already produced a parallel epidemic of tuberculosis often of the chemotherapy-resistant variety. As new treatments for HIV/AIDS come along and those afflicted live longer, practicing thoracic surgeons will discover the wisdom of Chowdhury and colleagues [1]. Their article is an object lesson in surgical choices for the treatment of constrictive pericarditis [1].
The authors have compared two surgical approaches for the treatment of constrictive pericarditis, median sternotomy, and left anterolateral thoracostomy among 395 patients. Their ability to identify a cause in 380 patients (96.2%) of their cohort is an astounding fact. Moreover, in 351 patients the cause was tuberculosis. In the 95 patients who underwent left anterolateral thoracotomy, 57 had chronic constriction and the remainder had effusive or pyogenic disease. Without actually stating that left anterolateral thoracotomy may not be indicated in instances of chronic constrictive pericarditis, the authors leave the reader to conclude that total pericardiectomy through a median sternotomy is the procedure of choice for chronic constriction. For effusive and pyogenic disease, the authors give cogent and respected reasons for left anterolateral thoracotomy. For the preferred median sternotomy for chronic constriction, calcific patches and pericardial masses, they state that "... reports addressing the issue of surgical approach and postoperative hemodynamics are limited and controversial. Our findings contrast markedly with the experiences of others. There was normalization of intracardiac pressures after total pericardiectomy within 24 hours in the great majority of patients of the sternotomy group. The degree of reduction of filling pressure was significantly different between the groups (p < 0.001) ..." with appropriate references to the bibliography appended.
They go on to write, "... in this study, median sternotomy provided good exposure of the right atrium and the venae cavae and enabled excellent clearance of the diseased pericardium. This approach demonstrated enhanced safety, decreased mortality, less postoperative low output syndrome, abbreviated hospitalization, and better long-term survival (log-rank, p = 0.0001) than that obtained via thoracotomy. In the event of inadvertent excessive bleeding (n = 7), the patient could easily be connected to cardiopulmonary bypass ..." The unstated conclusion is that the maximum benefit for constrictive pericarditis, in particular, is expected from total pericardiectomy, which is best achieved through a median sternotomy and is very difficult if not impossible through a left anterior thoracotomy.
Such is the stuff that allows firm conclusions. Chowdhury and colleagues have the data that are supported by excellent statistical comparisons of the two approaches. They can assert that median sternotomy is the approach of choice for chronic constrictive pericarditis, calcific patches, and pericardial masses. They dispel the controversy to which they alluded about the choice of approach for constrictive disease. Also, they can state that left anterolateral thoracotomy should be reserved for the surgery of pyogenic and effusive pericardial disease.
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References
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- Chowdhury UK, Subramaniam GK, Kumar AS, et al. Pericardiectomy for constrictive pericarditisa clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques. Ann Thorac Surg 2006;81:522-530.[Abstract/Free Full Text]
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