Operation for chronic constrictive pericarditis: Do the surgical approach and degree of pericardial resection influence the outcome significantly?

Our experience with 27 patients undergoing pericardiectomy at New York University Medical Center over the past 13 years has evolved a radical pericardiectomy operation suggesting that two traditional concepts are erroneous: (1) pericardiectomy limited to the anterior and lateral surfaces of the ventricles is an adequate operation and (2) delayed recovery is due to myocardial "atrophy" and not to inadequate operation. Radical pericardiectomy entails removal of virtually the entire parietal pericardium from all cardiac surfaces including that of both ventricles, the right atrium, and the venae cavae. Performed in 22 patients by dissecting a cleavage plane between the thickened parietal pericardium and underlying epicardium, all procedures were done through a sternotomy. Intraoperative monitoring of arterial pressure, cardiac output, and wedge pressure is essential because of displacement of the left ventricle. The left ventricle can be completely mobilized so that at the end of the operation the entire heart can be lifted upward and the course of the coronary sinus fully visualized. Intraoperative pressure measurements demonstrate that this radical resection immediately corrects hemodynamic abnormalities (elevated right atrial and ventricular end-diastolic pressures), as demonstrated in 10 patients. Most patients undergo massive diuresis (7 to 16 kg) within two weeks, with an uneventful recovery. These findings contrast markedly with early experiences using a conventional limited pericardiectomy.