Echocardiographic parameters in clinical responders to surgical pericardiectomy – A single center experience with chronic constrictive pericarditis

Abstract

Background: Chronic constrictive pericarditis (CCP) is the end result of chronic inflammation of the pericardium. Developing countries continue to face a significant burden of CCP secondary to tuberculous pericarditis. Surgical pericardiectomy offers potential cure. However, there is paucity of echocardiography data in post-pericardiectomy patients vis-a-vis their clinical status. We studied the changes in multiple echocardiographic parameters in these patients before and after pericardiectomy. Methods: Twenty-three patients (14 men, 9 women) who underwent pericardiectomy for CCP in the last 5 years (from January 2009 to December 2014) were subjected to detailed clinical and echocardiographic evaluation during the study period (between June 2013 and December 2014). Patients with residual symptoms of NYHA class II and below were considered as ‘responders’. The data thus obtained were compared to the pre-operative parameters. Results: After pericardiectomy, the incidence of vena caval congestion decreased from 100% to 15% (p < 0.001). There was significant reduction in the mean left atrial size from 39.33 ± 10.52 mm to 34.45 ± 10.08 mm (p < 0.001) and also the ratio of left atrium to aortic annulus from 1.93 to 1.69 (p < 0.001) among ‘responders’ to pericardiectomy. Septal bounce was observed to persist in 5 (25%) patients after pericardiectomy. There was significant respiratory variation of 39.23 ± 15.11% in the mitral E velocity before pericardiectomy. After pericardiectomy, this variation reduced to 14.43 ± 7.76% (p < 0.001). There was also significant reduction in the respiratory variation in tricuspid E velocities from 31.33 ± 18.81% to 17.35 ± 16.26% (p < 0.001). After pericardiectomy, the mean ratio of mitral annular velocities, medial e′: lateral e′, reduced from 1.08 to 0.87 (p < 0.03). The phenomenon of ‘annulus reversus’ was found to persist in 6 ‘responders’, thereby reflecting a 50% reduction in its incidence after pericardiectomy (p < 0.001). The ratio of mitral E to medial e′ (E/e′) increased from 4.21 ± 1.35 before pericardiectomy to 6.91 ± 2.62 after pericardiectomy (p = 0.001). Conclusion: Among clinical responders to surgical pericardiectomy, echocardiographic assessment revealed a significant reduction in vena caval congestion, LA size, ratio of LA to aortic annulus, septal bounce, respiratory variation in mitral and tricuspid E velocities, mitral annular medial e′ and the phenomenon of annulus reversus. Also, there was a significant rise in minimum tricuspid and mitral E velocities and the E/e′ ratio.

Keywords

• Constrictive pericarditis
• Percardiectomy
• Echocardiography
• Annulus paradoxus
• Annulus reversus