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Poor Outcome Following Pericardiectomy for Postirradiation Constrictive Pericarditis

Department of Cardiovascular & Thoracic Surgery Sri Venkateswara Institute of Medical Sciences Tirupati, Andhra Pradesh 517507, India Department of Cardiovascular and Thoracic Surgery 1 Department of Cardiology Sanjay Gandhi Postgraduate Institute of Medical  Sciences Raebareli Road Lucknow, Uttar Pradesh 226014, India

A 58-year-old female presented with exertional dyspnea (New York Heart Association functional class II to III) of 8 months duration. Two years earlier, she had undergone mastectomy followed by radiotherapy for infiltrative duct carcinoma of the left breast. A total of 4500 rads was delivered in 30 fractions and the cancer was considered adequately controlled. No chemotherapy was given. Examination showed a small volume paradoxical pulse, jugular venous pressure raised to the angle of mandible with prominent x and y descents, a relatively silent precordium, liver enlarged to 6 cm, and moderate ascites. There was no evidence of a local recurrence or systemic spread of the breast carcinoma.

She was in normal sinus rhythm and her electrocardiogram showed low-voltage complexes. Right pleural effusion was detected on a chest skiagram. Echocardiography revealed pericardial thickening (parietal 3 mm, visceral 2 mm) and minimal loculated effusion. Cardiac catheterization and angiography confirmed a diagnosis of constrictive pericarditis and she was advised surgery. There was no evidence of coronary artery disease.

She was operated through a midsternotomy. The pericardium was thickened (6 to 8 mm). There were loculated areas of hemorrhagic fluid but no malignant nodules or deposits. She had bilateral serous pleural effusion with partial collapse of the right lower lobe. A good plane for pericardiectomy could not be obtained but clearance was achieved over the anterior surface of the heart from the left ventricular apex to the atrioventricular groove and from the acute margin to the right ventricular outflow tract. Up to this stage, the patient remained hemodynamically stable. Her central venous pressure fell from a mean preoperative value of 26 mm Hg to 16 mm Hg. However, during sternotomy closure, she developed bradycardia and hypotension. There was a poor response to atropine and rapid infusion of fluids. Adrenaline was started at 15 µg·kg^–1·min^–1 and epicardial pacing was attempted but there was difficulty in capturing the ventricle. This was followed by a brief period of atrioventricular dissociation not amenable to sequential pacing and then junctional tachycardia with a further fall in blood pressure. She was cardioverted with a direct current shock of 15 Joules and bolus doses of lignocaine to a normal sinus rhythm that immediately changed to sinus tachycardia with right bundle branch block and left anterior hemiblock. Subsequently, her blood pressure stabilized and lignocaine infusion was continued. Serum electrolytes and arterial blood gases at this time were within normal limits. The operation was completed and the patient was transferred to the intensive care unit.

However, after about half an hour, her electrocardiogram revealed atrioventricular dissociation followed by bizarre ventricular complexes. Her blood pressure fell again and remained low despite various resuscitative measures. Death occurred 4 hours after surgery, following repeated cardiac arrests.^1,2 Postmortem myocardial biopsies were taken from different sites. Histopathological examination of the excised pericardium revealed fibrinous pericarditis and fibrosis while the myocardium showed increased interstitial nonspecific dense fibrosis and mural thickening.³

Postirradiation constrictive pericarditis should become less frequent with judicious radiotherapy regimens. When it occurs, it should be treated medically as far as possible until the appearance of incapacitating symptoms. The expected benefit of pericardiectomy should be carefully weighed against the high operative mortality and poor long-term survival.^1,2 Since the operative outcome is known to be poorer in the presence of extensive myocardial fibrosis, as was the situation in our patient, we recommend that surgery should be deferred in such cases. Poor results of surgery can be expected if there is a combination of high-dose radiation, coronary artery disease, evidence of myocardial fibrosis, atrioventricular conduction disturbances, major pulmonary fibrosis, cachexia, and recurrent mediastinal tumors.⁴ In such a setting, surgery should be avoided.

REFERENCES

1. Ni Y, von Segesser LK, Turina M. Futility of pericardiectomy for postirradiation constrictive pericarditis? Ann Thorac Surg 1990; 49:445–8.[Abstract]

2. Karram T, Rinkevitch D, Markiewicz W. Poor outcome in radiation induced constrictive pericarditis. Int J Radiol Oncol Biol Phys 1993;25:329–31.[Medline]

3. Stewart JR, Fajardo LF. Radiation induced heart disease: clinical and experimental aspects. Radiol Clin North Am 1971;9:511–31.[Medline]

4. Stewart JR, Fajardo LF. Radiation-induced heart disease: an update. Prog Cardiovasc Dis 1984;27:173–94.[Medline]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lalit Kapoor Anoop K Ganjoo Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chandra, A. Articles by Bajaj, R. Search for Related Content PubMed Articles by Chandra, A. Articles by Bajaj, R.