Constrictive cardiac physiology typically does not meet the eye in the absence of parietal pericardium.

Constrictive cardiac physiology typically does not meet the eye in the absence of parietal pericardium. However, we report eight patients who, after left extrapleural pneumonectomy and removal of the parietal pericardium for malignancy, not absented with dyspnea, jugular venous distension, and peripheral or generalized edema unresponsive to diuretics. Cardiac decortication (epicardiectomy) was performed whereby a thickened come off encasing the heart was surgically excised, resulting in vigorous contraction and expansion of the heart. In the same patient, decortication occurred early after pneumonectomy and was incomplete. Acute signs of inflammation were current and recurrence necessitated repeat decortication. When patients current with dyspnea, hepatojugular reflux, and peripheral edema refractory to diuretics, constrictive cardiac physiology should be considered in the differential diagnosis, unruffled in the absence of parietal pericardium.

clew words: cardiac decortication; epicardiectomy; pneumonectomy

Abbreviations: EPP = extrapleural pneumonectomy; legume = postoperative day; RV = right ventricular

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Extrapleural pneumonectomy of the left lung includes removal of the lung parietal pleura, parietal pericardium, and diaphragm. (1) Therefore, constrictive cardiac physiology to be ascribed to pericarditis would not strike one as being possible postoperatively. We report eight patients who nonetheless acquired recondite 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 operations 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 single in kind patient acquired constrictive cardiac physiology after left intrapericardial pneumonectomy for non-small small cavity lung carcinoma. The mesothelioma was epithelial in six patients and epithelial/sarcomatoid in single patient. The parietal pericardium was entirely excised in seven patients and partially excised in individual patient. Pericardial and/or diaphragm reconstruction was accomplished using polytetrafluoroethylene (Gore-Tex; WL Gore & Associates; Flagstaff, AZ). Adjunct therapy included preoperative chemotherapy and radiation in united patient and intraoperative heated chemotherapy in four patients. No talc was used in any patients.

After a median interval of 33 month (range, 16 to 189 months) following pneumonectomy, patients were readmitted with symptoms and signs consistent with constrictive cardiac physiology. Symptoms always included dyspnea, jugular venous distension, hepatojugular ebb and peripheral leg edema, all unresponsive to diuretics. the same 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 l to the diagnosis of constrictive cardiac physiology in these eight patients are at handed in Table 1. CT scan was performed in four patients, if it were not that it was not conclusive and did not help further in the establishment of the diagnosis. MRI, performed in the same patient, revealed fibrous bands encasing the heart.

[FIGURE 1 OMITTED]

All patients were re-explored via a left thoracotomy. Intraoperative findings in each case included a "leather-like" 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) inferenceed in decortication of the entire myocardium with minimal bleeding. Peeling opposite to the fibrous tissue restored vigorous contraction and expansion of the heart. In common patient, operated on 47 days after the initial pneumonectomy, the tissue was too adherent to bark off entirely without risking injury to the left anterior descending coronary artery. Therefore, the anterior portion of the fibrous flay was left in situ. Another patient unraveled right ventricular (RV) free-wall burst on coughing in preparation for extubation in the operating range She required immediate re-exploration and institution of cardiopulmonary bypass, with arterial cannulation via the left ventricular apex advanced by means of the aortic valve and venous drainage initially via the disruption in the right ventricle and later end the right atrium after further dissection. The RV income was repaired with bovine pericardium, and the patient had an unremarkable recovery

Details of histopathology and clinical follow-up are provided in Table 2 single patient died of cachexia and heart failure forward postoperative day (POD) 14, despite prosperous decortication. One patient, who could solitary be partially decorticated, acquired a relapsing constrictive epicarditis requiring hospital readmission and reoperative decortication forward POD 42 and POD 81 after the primary decortication. He died 10 days after the last performance as a consequence of progressive hemodynamic deterioration. The other six patients healed 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 month after decortication.

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