A total of 184 patients were included in the study and were divided into a surgical group (pericardiectomy; n=58) and a medical group (isolated medical therapy; n=126). Mean follow-up was 5.5±3.5 years in the surgical group and 5.4±4.4 years in the medical treatment group. Follow-up at 30 days, 90 days, and 1 year was 95%, 93%, and 88%, respectively, for the surgical group and 97%, 95%, and 93%, respectively, for the medical treatment group.
Baseline characteristics are listed in and reveal no significant differences with regard to age, sex, symptoms at presentation, cause of relapsing pericarditis, and comorbid conditions, including coronary artery disease, diabetes mellitus, hypertension, hyperlipidemia, prior stroke, renal failure, neoplasm, or autoimmune disease. However, the surgical group had more mean relapses at the time of the initial index visit (6.9±4.2 vs 5.5±4.1; P=.01), was more likely to be taking colchicine (43.1% [n=25] vs 18.3% [n=23]; P=.002) and corticosteroids (70.7% [n=41] vs 42.1% [n=53]; P<.001), less likely to take NSAIDs (55.2% [n=32] vs 75.4% [n=95]; P=.01), and more likely to have undergone a prior pericardiotomy (27.6% [n=16] vs 11.1% [n=14]; P=.003) than the medical treatment group. Baseline echocardiographic data, including ejection fraction and the presence and size of pericardial effusions, were similar between the 2 groups; however, constrictive physiology was a more prominent feature in the surgical group (13.7% [n=7] vs 4.3% [n=5]; P=.03).
Baseline Characteristics of the Study Populationa,b,c
Comorbid Conditions at Baseline for the Study Populationa
Echocardiographic Characteristics at Baseline for the Study Populationa,b
In the perioperative period, the primary outcome variable for the surgical patients was in-hospital postoperative mortality or major morbidity. Of the 58 patients in the surgical group, 57 had a complete pericardiectomy and 1 patient had a partial pericardiectomy (anterior phrenic to phrenic nerve and partial inferior pericardiectomy). The mean hospital stay was 6.9±2.8 days, with only one hospitalization longer than 14 days. There were no cases of in-hospital perioperative mortality (). Two patients (3.4%) had major complications postoperatively (). One patient had a stroke with residual long-term, left-sided weakness. The other patient had emergent surgery within 10 hours of his pericardiectomy for postoperative bleeding from an arterial vessel posterior to the heart and on the surface of the esophagus.
Perioperative Mortality and Morbidity of Patients Undergoing Pericardiectomy for Relapsing Pericarditis
Pathologic examination of the excised pericardium in the 58 patients who underwent pericardiectomy revealed a total of 5 patients (8.6%) with features consistent with constrictive pericarditis and 53 patients (91.4%) with features consistent with chronic pericarditis. Of the 5 patients with constrictive pericarditis, 2 patients had definite constrictive physiologic features on preoperative echocardiographic examination, 2 other patients had some constrictive physiologic features, and 1 patient had no echocardiographic features of constriction.
In the follow-up period, the primary outcome variables were all-cause death, time to relapse, and medication use for both the surgical and medical groups. In the surgical group, 5 deaths (8.6%) occurred during the follow-up period, with 1 treatment-related death (1.7%) occurring on day 68 after pericardiectomy due to methicillin-resistant Staphylococcus aureus sepsis and multiorgan failure. This patient was discharged from the hospital on day 11 in good condition, with no major morbidity postoperatively. Two patients (3.4%) died approximately 2 years after pericardiectomy: one patient of a newly diagnosed malignant mesothelioma and another patient of an acute myocardial infarction. Two other patients (3.4%) died of unknown causes at 5 and 8 years after pericardiectomy. Nine deaths (7.1%) occurred in the medical treatment group, with 7 patients (5.6%) dying of unknown causes, 1 patient (0.8%) dying of metastatic thyroid cancer 13 years after the index visit, and 1 patient (0.8%) dying of glioblastoma multiforme more than 4 years after the index visit. Overall, no significant difference was found in survival between the 2 groups ().
Kaplan-Meier curves for death in patients who underwent pericardiectomy vs medical management for relapsing pericarditis (P=.26).
However, a marked difference was found in the rate of relapse () between the 2 groups. The Kaplan-Meier curves for relapse separate early in the follow-up period, with the surgical group experiencing far fewer relapses than the medical treatment group (log rank P=.009). Five patients (8.6%) experienced relapse in the pericardiectomy group, and their characteristics are summarized in . Four patients had a history of prior pericardiotomy, and 1 patient had a perforated atrium after atrial fibrillation ablation. These 5 patients were all treated with multidrug therapy for relapsing pericarditis and had at least 9 relapses before proceeding with pericardiectomy. The mean time to relapse after pericardiectomy was 2.1 years, and 4 of 5 patients (80.0%) had notable improvement in symptoms after pericardiectomy.
Kaplan-Meier curves for relapse in patients who underwent pericardiectomy vs medical management for relapsing pericarditis (P=.009).
Characteristics of All Patients With Relapse After Pericardiectomya
When comparing medication use for relapsing pericarditis in follow-up (), although a trend was found toward less medication use in the surgical group compared with the medical group, this finding was not statistically significant (29.6% [n=16] vs 43.4% [n=53]; P=.09). Similarly, a statistically nonsignificant trend was found toward reduced corticosteroid use in the surgical group (7.4% [n=4] vs 18.0% [n=22]; P=.07). When comparing medication use before and after pericardiectomy for the surgical group, the use of NSAIDs, colchicine, and prednisone was notably reduced after pericardiectomy ().
Comparison of Follow-up Medication Use in Patients Who Underwent Pericardiectomy vs Medical Management for Relapsing Pericarditisa,b
Medical Management in Patients With Relapsing Pericarditisa,b
In the medical treatment group, 36 patients (28.6%) had a relapse after their index visit. Interestingly, patients in the medical treatment group also used considerably fewer NSAIDs, colchicine, and prednisone in follow-up (). We had hypothesized that patients with a longer duration of corticosteroid taper would be less likely to experience a relapse; however, our data did not support this hypothesis (). No significant differences were found in the time to relapse for patients who had a short duration of corticosteroid taper (≤3 months) vs patients with a longer duration of taper (>3 months). Multiple other corticosteroid duration time points were analyzed, with no significant differences found (data not shown). Patients who were treated with any duration of corticosteroids were more likely to have a relapse compared with patients who were not treated with corticosteroids (; P=.007). Treatments with NSAIDs, colchicine, and immunosuppressive agents were all analyzed independently for relapse rate, with no significant differences found (data not shown), suggesting that the main determinant for relapse in the medical treatment group was corticosteroid use.
FIGURE 3 Kaplan-Meier curves for relapse in the medical treatment group on the basis of duration of corticosteroid treatment (P=.007). The P value represents the statistical difference in relapse rate of the patients who did not receive corticosteroid (n=79; solid (more ...)