**9. Early outcomes and risk factors for early deaths**

#### **9.1 From cardiac centers in Africa**

Yangni-Angate in Cote d'Ivoire [21], in his retrospective study related to 120 patients with CCP who underwent pericardiectomy through a median sternotomy approach (n = 117; 97.5%) found 15 early deaths (12.5%); the cause of hospital deaths was due to a low cardiac output (n = 12) and to a hepatic failure (n = 3). Class III or IV (NYHA) (p = 0.01), mitral regurgitation (p < 0.05), persistent a diastolic syndrome after surgery (p < 0.05) and low cardiac index (p < 0.02) were the important risk factors (**Table 1**). Age, size of cardiac X-ray silhouette, right and left ventricular diastolic pressures, ejection fraction, atrial fibrillation, and pericardial calcifications had no impact on early survival (**Table 2**).

Tettey in Ghana [22] reviewed the surgical management of constructive pericarditis and the post-operative challenges of 11 patients who had pericardiectomy via a median sternotomy in all patients with no early mortality and a significant improvement of functional capacity of all of the patients followed-up.

Mutyaba in South Africa [24] through a retrospective study of 121 patients who had undergone total (n = 105; 88.2%) or partial (n = 14; 11.8%) pericardiectomy for constrictive pericarditis at Groote Schuur Hospital, noted an early mortality of 14% (n = 14) mainly due to a low cardiac output syndrome. In this work, it has been statistically attested that serum sodium and pre-operative New York Heart Association Class IV versus combined Class I–III were independent predictors of early mortality. He also showed that early mortality after pericardiectomy was not influenced by HIV status and that of New York Heart Association Functional Class IV and hyponatremia were predictable factor for early mortality after pericardiectomy.

Ali in Ethiopia [26] has done a retrospective study at the Thoracic Surgical Unit, Tikur Anbessa Hospital, Department of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa on 19 patients who underwent pericardiectomy for CCP by a median sternotomy approach (n = 15; 79%) often. One early post-operative mortality was registered. The author emphasized the benefit of pericardiectomy in terms of physical exercise improvement.

Ondo N'Dong in Gabon [23] has published his series on 18 patients with constrictive pericarditis treated surgically. All of them underwent a partial pericardiectomy via a left anterior thoracic incision in 17 patients and a median sternotomy incision in 1 patient. Four patients died in the early post-operative period due to low cardiac output; this study revealed pre-operative severe heart failure as a principal predictable risk factor for early death after pericardiectomy. This finding has been also noted In Rabat, Morocco by Nzondo [19]; in Fes, Morocco by Hind [18] and in Senegal by Ciss [20].

Nzondo [19] has retrospectively analyzed 11 patients who had undergone partial pericardiectomy via a median sternotomy approach for constrictive pericarditis. Early mortality was of 9.1% related to acute heart and multi-organs failure. Hind in


#### **Table 1.**

*Surgical early results after pericardiectomy for chronic constrictive pericarditis.*

**47**

*Chronic Constrictive Pericarditis (CCP) in Africa: Epidemiology, Etiology, Diagnosis…*

Age (years) 30.4 ± 16.6 10–51 28.4 ± 10.1 8–46 0.09 CTR 0.55 ± 0.05 0.45–0.70 0.53 ± 0.3 0.50–0.59 0.34 RVEDP 20.6 ± 7.8 7–40 16.2 ± 10.3 15–40 0.12 LVEDP 20.1 ± 6.1 10–30 24.6 ± 7.7 16–35 0.07 EF 50.4 ± 16 31–67 54.3 ± 5 49–59 0.24 CI 2.42 ± 0.7 1.3–3.6 1.63 ± 0.2 1.4–2 0.02 WPAP 20.6 ± 9.9 10–40 25 ± 10.4 18–37 0.36 SPAP 27.3 ± 11.1 21–66 38.2 ± 17.9 21–66 0.08 Functional class NYHA III–IV 42/105 15/15 0.01 Atrial fibrillation 18/105 3/15 0.10 Calcifications 54/105 6/15 0.07 Mitral insufficiency 6/105 9/15 0.00

**Alive (n = 105) Deceased (n = 15) P**

9/105 5/15 0.00

**Average Extremes Average Extremes**

Fes, Morocco [18] on a study of 43 patients with constrictive pericarditis focused on 41 who had a partial pericardiectomy through a median sternotomy approach;

*Risk Factors for immediate deaths after pericardiectomy for constrictive chronic pericarditis—from Yangni-*

instability added to a poor NYHA functional class pre-operatively.

Finally, Ciss et al. [20] in their study on 32 patients with constrictive pericarditis undergoing partial pericardiectomy via a median sternotomy approach reported an early mortality of 6.25% in 2 patients out of 32 caused by hemodynamic and severe

Bilateral constriction 61/105 15/15 0.04 *CTR, cardiothoracic ratio; RVEDP, right ventricle end-diastolic pressure; SPAP, systolic pulmonary arterial pressure; WPAP, wedged pulmonary artery pressure; LVEPD, left ventricle end-diastolic pressure; CI, cardiac index; EF,* 

Omboga in Nairobi [25] in his study of 47 patients out of 51 who underwent surgery through median sternotomy (82.9%) and left lateral thoracic (17.1%) approaches has mentioned 8.5% of hospital mortality not due to acute failure as mentioned in previous studies in Africa but attributable to massive hemorrhage in the operative table (n = 1) and pulmonary embolism (n = 3) secondary to deep

None of African teams mentioned above used robotic approach; this minimally invasive modern approach seems to be less painful, more adequate for a complete

Compared to African series, where the most common etiology of CCP is TB, in developed world CCP etiology profile is different with idiopathic as most frequent. However, there is no significant difference among either surgical operative approach and hospital mortality or risk factors for early deaths. This fact is on the same line with McCaughan's consideration cited by Kirklin and Barratt-Boyes [2] who demonstrated in 1985 that most of early deaths are due to acute heart failure

*DOI: http://dx.doi.org/10.5772/intechopen.84887*

**Risk factors for immediate** 

Persistence of post-operative

constriction

*ejection fraction.*

*Angate et al. study [21].*

**Table 2.**

**deaths**

hospital mortality was 4.6% (n = 2).

release of the pericardial constriction [29].

**9.2 From worldwide outside Africa**

venous thrombosis.


*Chronic Constrictive Pericarditis (CCP) in Africa: Epidemiology, Etiology, Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.84887*

*CTR, cardiothoracic ratio; RVEDP, right ventricle end-diastolic pressure; SPAP, systolic pulmonary arterial pressure; WPAP, wedged pulmonary artery pressure; LVEPD, left ventricle end-diastolic pressure; CI, cardiac index; EF, ejection fraction.*

#### **Table 2.**

*Inflammatory Heart Diseases*

**Author Country Study** 

Cote d'Ivoire

South Africa

Omboga et al. [25]

Yangni− Angate et al. [21]

Ondo N'Dong et al. [23]

Mutyaba et al. [24]

Zamani et al. [27]

Ciss et al. [20]

Nzondo et al. [19]

Tettey et al. [22]

Hind et al. [18]

*TB: Tuberculosis.*

**period**

KENYA 1973–1981 51 TB (30%)

Gabon 1986–1999 18 TB (50%)

Morocco 1994–2009 23 TB (43%)

Morocco 1996–2010 11 TB (45.5%)

Morocco 2003–2013 43 TB (58%)

*Surgical early results after pericardiectomy for chronic constrictive pericarditis.*

Ghana 2000–2004 11 TB (63.6%) 0

Ali et al. [26] Ethiopia 1996–2005 19 TB (31.6%)

1990–2012 121 TB (91%)

**Cases (n)**

**Aetiology Early** 

1977–2012 120 TB (99%) 12.5 • Low cardiac

Idiopathic (70%)

Idiopathic (33%) Infection (17%)

Idiopathic (5%) Miscellaneous (4%)

Idiopathic (57%)

Infection (10.5%) Miscellaneous (67.9%)

Senegal 1996–2008 32 TB (63.6%) 6.25 Low cardiac

Idiopathic (54.5%)

Idiopathic (48%)

**deaths (%)**

**Causes of deaths**

embolism (n=3) • Massive haemorrhage (n=1)

output (n=12) • Hepatic failure (n=3)

8.5 • Pulmonary

22.2 Low cardiac

14 Low cardiac

17 Low cardiac

5.3 − −

9.1 Low cardiac

4.6 Low cardiac

output (n=4)

output (n=11) Acute kidney injury (n=6)

output (n=2) Severe dysarythmia (n=1) Haemorrhage (n=1)

output (n=1)

output (n=1)

output (n=2)

**Early risk factors**

• Class III or IV (NYHA) • Low cardiac index • Mitral regurgitation • Persistent diastolic postoperative syndrome

Class IV (NYHA)

Class IV (NYHA)

Class IV (NYHA)

Class IV (NYHA)

Class IV (NYHA)

Class IV (NYHA)

−

**46**

**Table 1.**

*Risk Factors for immediate deaths after pericardiectomy for constrictive chronic pericarditis—from Yangni-Angate et al. study [21].*

Fes, Morocco [18] on a study of 43 patients with constrictive pericarditis focused on 41 who had a partial pericardiectomy through a median sternotomy approach; hospital mortality was 4.6% (n = 2).

Finally, Ciss et al. [20] in their study on 32 patients with constrictive pericarditis undergoing partial pericardiectomy via a median sternotomy approach reported an early mortality of 6.25% in 2 patients out of 32 caused by hemodynamic and severe instability added to a poor NYHA functional class pre-operatively.

Omboga in Nairobi [25] in his study of 47 patients out of 51 who underwent surgery through median sternotomy (82.9%) and left lateral thoracic (17.1%) approaches has mentioned 8.5% of hospital mortality not due to acute failure as mentioned in previous studies in Africa but attributable to massive hemorrhage in the operative table (n = 1) and pulmonary embolism (n = 3) secondary to deep venous thrombosis.

None of African teams mentioned above used robotic approach; this minimally invasive modern approach seems to be less painful, more adequate for a complete release of the pericardial constriction [29].

#### **9.2 From worldwide outside Africa**

Compared to African series, where the most common etiology of CCP is TB, in developed world CCP etiology profile is different with idiopathic as most frequent. However, there is no significant difference among either surgical operative approach and hospital mortality or risk factors for early deaths. This fact is on the same line with McCaughan's consideration cited by Kirklin and Barratt-Boyes [2] who demonstrated in 1985 that most of early deaths are due to acute heart failure

#### *Inflammatory Heart Diseases*

and that of pre-operative NYHA class III and IV are significant risk factor for early death after pericardiectomy as noted in African surgical experiences. Chowdhury et al. [30] in a study including 338 patients (85.6%) who underwent total pericardiectomy (group I), and 57 patients (14.4%) undergoing partial pericardiectomy (group II), has demonstrated better perioperative and late mortality rates after total pericardiectomy; in addition, duration of symptoms, advanced functional class, partial pericardiectomy, pre-operative high right atrial pressure, hyperbilirubinemia, renal dysfunction, atrial fibrillation, pericardial calcification, thoracotomy approach, were significant risk factors for death.

In a recent study from Porta-Sanchez in Spain [31], 140 consecutive patients who underwent pericardiectomy for constrictive pericarditis over a 34-year period in a single center were analyzed. Most frequent etiology found was idiopathic in 76 patients (54%). Median sternotomy was done in all patients. Perioperative mortality was 11%. There was no difference in mortality between etiologies.

Mayo Clinic Experience with pericardiectomy for constrictive pericarditis over eight decades [32] related to 1071 pericardiectomies in 1066 individual patients. Patients were divided into two intervals: an historical (pre-1990) group (n = 259) and a contemporary (1990–2013) group (n = 807). This study showed a significant change in constrictive pericarditis etiology with a similar overall survival over decades and a significant decrease of 30-day mortality from 13.5% in the historical era to 5.2% in the contemporary era (p < 0.001). Another article from North America with no significant disparity is the Montreal Heart Institute Experience over a 20-year period [33]; it involved 99 consecutive patients with constrictive pericarditis; idiopathic was the most frequent etiology (61%) and hospital mortality 7.9% after isolated pericardiectomy.

Busha et al. [34] revealed an higher mortality death of 18.6% after pericardiectomy in 97 consecutive patients with constrictive pericarditis and no different risk factors for early death such as reduced left ventricular ejection fraction (LVEF) (35% < LVEF <55%) and right ventricular dilatation on multivariable analysis. He also found no difference in early mortality between patients with isolated pericardiectomy and those with concomitant surgery (p = 0.62).

#### **10. Late outcomes**

In African context, lack of substantial late outcomes after pericardiectomy is observed due to a significant number of patients lost to follow-up in general; however, in his series from Cote d'ivoire, Yangni-Angate [21], after an average follow-up of 4 years (extremes: 1–10 years), no late death was observed. A functional class I or II (NYHA) was mentioned in all survivors. Among them, those who underwent cardiac catheterization late post-operatively, a significant reduction even a normalization of the right and/or the left ventricular end-diastolic pressures, of the pulmonary capillary wedge pressure (p < 0.05) and of the right atrial pressure (p < 0.05) and absence of the dip-and-plateau after pericardiectomy were certified (**Table 3**).

Significant reduction of right atrial mean pressure from 17 ± 6 mmHg preoperatively to 7.1 ± 4.2 mmHg after pericardiectomy for CCP has been also shown by an African team work published by Zamani in Rabat, Morrocco [27].

A similar experience as African teams series has been published by Bicer et al. [35] with a predominance of tuberculous constrictive pericarditis (48.8%); other etiologies were: idiopathic (31.9%), malignancy (6.4%), prior cardiac surgery (4.3%), non-tuberculosis bacterial infections (4.3%), radiotherapy (2.1%), uremia (2.1%), and post-traumatic (2.1%). They had performed pericardiectomy in all patients via a sternotomy approach with a very low early mortality of 2.1%, while

**49**

12 years.

literature results.

**Table 3.**

*Chronic Constrictive Pericarditis (CCP) in Africa: Epidemiology, Etiology, Diagnosis…*

**Hemodynamic measurements Average Extremes P**

RAP 16 7.4 10–36 5–10 0.04 RVEDP 21 10 7–40 5–15 0.02 SPAP 29 23 8–66 17–30 0.09 WPAP 21 14 10–40 9–19 0.00 LVEDP 21 13 10–35 4.5–20 0.02 CI 2.3 2.7 1.2–36 1.92–3.5 0.15 *Significant (P < 0.05); Non-significant (P* ≥ *0.05); Preop., Pre-operative; Postop., Post-operative; RAP, right atrial pressure; RVEDP, right ventricle end-diastolic pressure; SPAP, systolic pulmonary arterial pressure; WPAP, wedged* 

**Preop. Postop. Preop. Postop.**

late mortality was 23.4%, and actuarial survival rates at 1, 5, 10 years were 91, 85, and 81%, respectively. Those rates are closed to the Montreal Heart Institute experience [33] characterized by tolerable long-term clinical outcome: 79% of patients were in NYHA class I or II post-operatively with an overall survival rate of 87% at 5 years and 78% at 10 years. At 10 years survival, Bicer et al. [35] estimated rate was worse (64%) because of poor prognosis of pericardiectomy after constrictive

*Comparison of hemodynamic measurements: pre-operative versus post-operative in patients who underwent* 

*pulmonary artery pressure; LVEPD, left ventricle end-diastolic pressure; CI, cardiac index.*

*pericardiectomy for chronic constrictive pericarditis—from Yangni-Angate et al. study [21].*

In a 24-year experience on pericardiectomy in patients with constrictive pericarditis, based on Kaplan-Meier survival curves demonstration, Szaboa et al. [36] have confirmed poor prognosis of post-irradiation constrictive pericardiectomy and shown better and comparable long-term survival after in other etiologies as idiopathic tuberculosis myocardial infarction, and uremia; the author noted no survival after 5 years with post-radiation constrictive pericarditis; it is widely accepted radiation etiology is a negative factor affecting long-term survival results as well indicated by Nishimura in Japanese population [37] and Avgerinos et al. [38]. On his study related to 46 patients with a mean age of 59 years and various classic etiologies, Nishumuna et al. [37] have described the very high severity of radiation etiology with death within only 1 year after pericardiectomy confirming overall

Avgerinos et al. [38] reported his 36 patients study who underwent pericardiectomy for constrictive pericarditis over 15 years; he has no hospital mortality and 1-, 5-, 10-, and 15-year survival rates were 97.2, 94.6, 86.5, and 78.3%, respectively; he fund risk factors for increased long-term mortality such as: pre-operative heart failure, elevated pre-operative total bilirubin (>2.7mg/dl, hazard ratio 6.8, p = 0.02), and elevated creatinine (>1.4mg/dl, hazard ratio 3.1, p = 0.05). Subsequently, he demonstrated from Kaplan-Meier survival analysis a significant decrease in survival of all the patients with post-radiation etiology associated (p = 0.05) or with

According to Porta-Sanchez et al. [31], from a Cox-regression analysis in his study, age at surgery, advanced New York Heart Association Functional Class (III–IV) and previous acute idiopathic pericarditis were associated with increased mortality during follow-up ranging from 0.1 to 33.0 years with a mean follow-up of

Predictor factors of prognosis and mortality after pericardiectomy have been largely documented by many studies; one of them from Kang [39] has even stipulated that an echocardiographical measurement of higher early diastolic mitral

*DOI: http://dx.doi.org/10.5772/intechopen.84887*

pericarditis post-mediastinal irradiation.

impaired cardiac, hepatic or renal dysfunction.

*Chronic Constrictive Pericarditis (CCP) in Africa: Epidemiology, Etiology, Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.84887*


*Significant (P < 0.05); Non-significant (P* ≥ *0.05); Preop., Pre-operative; Postop., Post-operative; RAP, right atrial pressure; RVEDP, right ventricle end-diastolic pressure; SPAP, systolic pulmonary arterial pressure; WPAP, wedged pulmonary artery pressure; LVEPD, left ventricle end-diastolic pressure; CI, cardiac index.*

#### **Table 3.**

*Inflammatory Heart Diseases*

approach, were significant risk factors for death.

7.9% after isolated pericardiectomy.

**10. Late outcomes**

ectomy and those with concomitant surgery (p = 0.62).

and that of pre-operative NYHA class III and IV are significant risk factor for early death after pericardiectomy as noted in African surgical experiences. Chowdhury et al. [30] in a study including 338 patients (85.6%) who underwent total pericardiectomy (group I), and 57 patients (14.4%) undergoing partial pericardiectomy (group II), has demonstrated better perioperative and late mortality rates after total pericardiectomy; in addition, duration of symptoms, advanced functional class, partial pericardiectomy, pre-operative high right atrial pressure, hyperbilirubinemia, renal dysfunction, atrial fibrillation, pericardial calcification, thoracotomy

In a recent study from Porta-Sanchez in Spain [31], 140 consecutive patients who underwent pericardiectomy for constrictive pericarditis over a 34-year period in a single center were analyzed. Most frequent etiology found was idiopathic in 76 patients (54%). Median sternotomy was done in all patients. Perioperative mortality

Mayo Clinic Experience with pericardiectomy for constrictive pericarditis over eight decades [32] related to 1071 pericardiectomies in 1066 individual patients. Patients were divided into two intervals: an historical (pre-1990) group (n = 259) and a contemporary (1990–2013) group (n = 807). This study showed a significant change in constrictive pericarditis etiology with a similar overall survival over decades and a significant decrease of 30-day mortality from 13.5% in the historical era to 5.2% in the contemporary era (p < 0.001). Another article from North America with no significant disparity is the Montreal Heart Institute Experience over a 20-year period [33]; it involved 99 consecutive patients with constrictive pericarditis; idiopathic was the most frequent etiology (61%) and hospital mortality

Busha et al. [34] revealed an higher mortality death of 18.6% after pericardiectomy in 97 consecutive patients with constrictive pericarditis and no different risk factors for early death such as reduced left ventricular ejection fraction (LVEF) (35% < LVEF <55%) and right ventricular dilatation on multivariable analysis. He also found no difference in early mortality between patients with isolated pericardi-

In African context, lack of substantial late outcomes after pericardiectomy is observed due to a significant number of patients lost to follow-up in general; however, in his series from Cote d'ivoire, Yangni-Angate [21], after an average follow-up of 4 years (extremes: 1–10 years), no late death was observed. A functional class I or II (NYHA) was mentioned in all survivors. Among them, those who underwent cardiac catheterization late post-operatively, a significant reduction even a normalization of the right and/or the left ventricular end-diastolic pressures, of the pulmonary capillary wedge pressure (p < 0.05) and of the right atrial pressure (p < 0.05) and absence of the dip-and-plateau after pericardiectomy were certified (**Table 3**). Significant reduction of right atrial mean pressure from 17 ± 6 mmHg preoperatively to 7.1 ± 4.2 mmHg after pericardiectomy for CCP has been also shown by

A similar experience as African teams series has been published by Bicer et al. [35] with a predominance of tuberculous constrictive pericarditis (48.8%); other etiologies were: idiopathic (31.9%), malignancy (6.4%), prior cardiac surgery (4.3%), non-tuberculosis bacterial infections (4.3%), radiotherapy (2.1%), uremia (2.1%), and post-traumatic (2.1%). They had performed pericardiectomy in all patients via a sternotomy approach with a very low early mortality of 2.1%, while

an African team work published by Zamani in Rabat, Morrocco [27].

was 11%. There was no difference in mortality between etiologies.

**48**

*Comparison of hemodynamic measurements: pre-operative versus post-operative in patients who underwent pericardiectomy for chronic constrictive pericarditis—from Yangni-Angate et al. study [21].*

late mortality was 23.4%, and actuarial survival rates at 1, 5, 10 years were 91, 85, and 81%, respectively. Those rates are closed to the Montreal Heart Institute experience [33] characterized by tolerable long-term clinical outcome: 79% of patients were in NYHA class I or II post-operatively with an overall survival rate of 87% at 5 years and 78% at 10 years. At 10 years survival, Bicer et al. [35] estimated rate was worse (64%) because of poor prognosis of pericardiectomy after constrictive pericarditis post-mediastinal irradiation.

In a 24-year experience on pericardiectomy in patients with constrictive pericarditis, based on Kaplan-Meier survival curves demonstration, Szaboa et al. [36] have confirmed poor prognosis of post-irradiation constrictive pericardiectomy and shown better and comparable long-term survival after in other etiologies as idiopathic tuberculosis myocardial infarction, and uremia; the author noted no survival after 5 years with post-radiation constrictive pericarditis; it is widely accepted radiation etiology is a negative factor affecting long-term survival results as well indicated by Nishimura in Japanese population [37] and Avgerinos et al. [38]. On his study related to 46 patients with a mean age of 59 years and various classic etiologies, Nishumuna et al. [37] have described the very high severity of radiation etiology with death within only 1 year after pericardiectomy confirming overall literature results.

Avgerinos et al. [38] reported his 36 patients study who underwent pericardiectomy for constrictive pericarditis over 15 years; he has no hospital mortality and 1-, 5-, 10-, and 15-year survival rates were 97.2, 94.6, 86.5, and 78.3%, respectively; he fund risk factors for increased long-term mortality such as: pre-operative heart failure, elevated pre-operative total bilirubin (>2.7mg/dl, hazard ratio 6.8, p = 0.02), and elevated creatinine (>1.4mg/dl, hazard ratio 3.1, p = 0.05). Subsequently, he demonstrated from Kaplan-Meier survival analysis a significant decrease in survival of all the patients with post-radiation etiology associated (p = 0.05) or with impaired cardiac, hepatic or renal dysfunction.

According to Porta-Sanchez et al. [31], from a Cox-regression analysis in his study, age at surgery, advanced New York Heart Association Functional Class (III–IV) and previous acute idiopathic pericarditis were associated with increased mortality during follow-up ranging from 0.1 to 33.0 years with a mean follow-up of 12 years.

Predictor factors of prognosis and mortality after pericardiectomy have been largely documented by many studies; one of them from Kang [39] has even stipulated that an echocardiographical measurement of higher early diastolic mitral

#### *Inflammatory Heart Diseases*

inflow velocity in predicting mortality after pericardiectomy was 71 cm/s (sensitivity of 84.6% and specificity of 52.2%); that value may also be useful in predicting late survival (p = 0.029).

Because of satisfactory long-term results, pericardiectomy can be considered as a safe and efficient technical procedure [40]; it can be achieved in most cases with minimal hospital mortality, post-operative functional class significant improvement and substantial reduction of heart diastolic pressures and absence of any recurrence if completely performed.
