The definitive treatment of constrictive pericarditis is pericardiectomy with complete surgical removal of the parietal, and when possible, the visceral pericardium.
When constrictive pericarditis is diagnosed, diuretics are used to reduce preload, dyspnea and edema. Long term, this is usually unsuccessful, as severe edema results and the decreased cardiac output progresses.
The mortality risk of pericardiectomy is approximately 10%, and is increased when there is heavy calcification. Pericardiectomy in patients with prior coronary artery bypass surgery carries the added risk of disruption of the grafts during the operation.
Pericardiectomy
The following surgery is presented through the courtesy of Dr. Harold Snyder, and was carried out at the Mayo Clinic, Jacksonville, Florida.
The patient is a 34-year-old woman who presented with ascites and dyspnea and was found to have constrictive pericarditis. The pathology report indicated only chronic fibrosis, thickening and calcification, presumably due to prior fungal, viral or bacterial infection.
The skin on the chest was incised, the sternum exposed and split and retractors placed exposing the mediastinum.
Although the patient was hemodynamically stable and in normal sinus rhythm, very little cardiac contractile activity is evident. In most cardiac surgeries, the heart would be contracting very vigorously at this point.
Initial dissection of the anterior pericardium reveals a whitish rind of thickened and calcified pericardium that was very adherent and entirely surrounding the heart. The cheesy looking calcified pericardium is difficult to dissect off.
After 25 minutes of dissection, the pericardium over the anterior right ventricle has been removed and the heart is contracting well. Following the institution of partial cardiopulmonary bypass in order to allow the heart to be manipulated without hypotension, a piece of thickened, diseased, calcified pericardium is being dissected off the right atrium. A second piece of thick pericardium is dissected from the posterolateral wall of the left ventricle. When all of the thick, cheesy pericardium was removed, and the vigorous contraction of the heart muscle was freed from the pericardial constriction, the sternum was reapproximated and the fascia and the skin closed.