Background: Since constrictive pericarditis is most often idiopathic and the pathophysiology remains largely unknown, both the diagnosis and the treatment can be challenging. However, by definition, inflammatory processes are central to this disease process. Amniotic membrane patches have been shown to possess anti-inflammatory properties and are believed to be immune privileged. Due to these properties, amniotic membrane patches were applied intraoperatively in a complicated patient presenting with constrictive pericarditis. Case presentation: A patient with a history of multiple cardiac surgeries presented with marked fatigue, worsening dyspnea and sinus tachycardia. He was found to have constrictive physiology during cardiac catheterization, with cardiac MRI demonstrating hepatic vein dilatation, atrial enlargement and ventricular narrowing. After amniotic membrane patch treatment and pericardiectomy, post-operative cardiac MRI failed to demonstrate any appreciable pericardial effusion or inflammation, with no increased T2 signal that would suggest edema. Conclusions: Given the positive results seen in this complex patient, we suggest continued research into the beneficial properties of amniotic membrane patches in cardiac surgery.

Constrictive pericarditis arises as a result of the fibrous thickening of the pericardium due to chronic inflammatory changes from various injuries. Increased pulmonary and systemic venous pressures manifest clinical features of left and right heart failure. Idiopathic or post-viral pericarditis is the most common cause followed by postpericardiotomy, radiation-induced causes. Right-sided heart failure symptoms predominate over left-sided heart failure symptoms due to the equalization of pressures. No single diagnostic test can provide a definitive diagnosis or evidence of constrictive pericarditis. Medical management is difficult for constrictive pericarditis. The treatment of choice for constrictive pericarditis is pericardiectomy.

Constrictive pericarditis (CP) is an uncommon disease with multiple causes and discrepant clinical outcome. Till date, there is a scarcity of publications, clearly defining the risk factors of poor outcomes after surgery for CP. Therefore, we retrospectively analysed the results of the surgical treatment for CP at our institution to define the risk factors of poor outcomes. A total of 97 patients (65 male, 67%) undergoing surgery for CP at our institution from 1995 to 2012 were included in this study. CP was diagnosed either preoperatively by cardiac catheterization or at surgery. The mean age was 60±12.5 years and the primary etiology was idiopathic in more than halt the cases, followed by prior cardiac surgery, post-irradiation, and miscellaneous. Preoperative and intraoperative risk factors for 30-day and late mortality were analyzed using stepwise multivariate logistic and Cox regression analysis respectively. Long-term survival was determined by the Kaplan-Meier curve. Mean follow-up was 2.9±3.8 years (range: 0.1-14 years). All patients received either radical (53 patients, 55.2%) or partial (44 patients, 44.8%) pericardiectomy. Concomitant procedures were performed in 38 (39,2%) patients. Overall 30-day, 1-year and 5-year survival were 66.8 %, 58.1% and 52.6% respectively, without significant difference according to the underlying etiology. Univariate analysis showed that preoperative renal dysfunction, liver failure, respiratory insufficiency, emergency surgery and longer operating times were associated with significantly higher 30-day mortality. Multivariate analysis revealed patients with concomitant coronary artery disease to be at higher risk of poor immediate survival, whereas a higher glomerular filtration rate GFR (ml/min/1,73m2) was protective for early mortality. Long-term mortality was independently predicted by the presence of a coronary artery disease, a COPD (chronic obstructive pulmonary disease) and higher absolute creatinine value. To conclude, surgery for constrictive pericarditis is associated with a relatively poor prognosis. Reduced left ventricular ejection fraction and right ventricular dilatation were independent predictors for early mortality, while coronary artery disease, chronic obstructive pulmonary disease, and renal insufficiency were risk factors for late mortality. Thus, indication for surgery needs to be determined on an individual basis and should be justified by an otherwise worse natural prognosis.:1 CONTENTS 1 CONTENTS I 2 ABBREVIATIONS III 3 BIBLIOGRAPHIC DESCRIPTION 1 3.1 REVIEW 1 4 INTRODUCTION 3 4.1 CHRONIC CONSTRICTIVE PERICARDITIS 3 4.2 HISTORY 6 4.3 DEFINITION 8 4.3.1 ACUTE PERICARDITIS 8 4.3.2 RECURRENT PERICARDITIS 9 4.3.3 PERICARDIAL EFFUSION, PERICARDIAL TAMPONADE, EFFUSIVE-CONSTRICTIVE PERICARDITIS 10 4.3.4 CHRONIC PERICARDITIS 12 4.3.5 CHRONIC CONSTRICTIVE PERICARDITIS 14 4.3.6 CLINICAL PRESENTATION 16 4.3.7 DIAGNOSTIC APPROACH 18 4.3.8 TREATMENT OPTIONS 23 4.3.9 PERICARDIECTOMY 24 5 AIM OF THE STUDY 29 6 MATERIAL AND METHODS 30 6.1 DATA COLLECTION 30 6.2 DIAGNOSIS OF CONSTRICTIVE PERICARDITIS 31 6.3 OPERATIVE PROCEDURES 31 6.4 OPERATIVE TECHNIQUE 32 6.5 POSTOPERATIVE COURSE 33 6.6 INCLUSION CRITERIA 34 6.7 EXCLUSION CRITERIA 34 6.8 FOLLOW UP 34 6.9 STATISTICS 35 6.10 STATISTICAL MODEL 37 7 RESULTS 39 7.1 PREOPERATIVE CHARACTERISTICS 39 7.2 ETIOLOGY 42 7.2.1 INDEPENDENT PREDICTORS FOR ALL-CAUSE EARLY MORTALITY 44 7.2.2 INDEPENDENT PREDICTORS FOR ALL-CAUSE LONG-TERM MORTALITY 44 7.3 MORTALITY 46 7.3.1 ALL-CAUSE MORTALITY 46 7.3.2 SURVIVAL ACCORDING TO ETIOLOGY 47 7.3.3 LATE SURVIVAL WITHOUT PERIOPERATIVE DEATHS 48 7.3.4 ISOLATED PERICARDIECTOMY VS. CONCOMITANT SURGERY 49 7.3.5 POSTOPERATIVE OUTCOMES: 50 7.3.6 RECEIVER OPERATING CHARACTERISTIC (ROC) CURVE 51 8 DISCUSSION 54 8.1.1 PERSONAL THOUGHTS AND FUTURE DIRECTIONS 58 9 LIMITATIONS 61 10 CONCLUSION 62 11 SUMMARY 63 12 REFERENCES 65 13 ATTACHMENTS 70 13.1 DIAGNOSTIC APPROACH IN CONSTRICTIVE PERICARDITIS 70 13.2 FOLLOW-UP QUESTIONNAIRE 72 14 NOTE OF THANKS 80 15 DANKSAGUNG 81 16 ERKLÄRUNG ÜBER DIE EIGENSTÄNDIGE ABFASSUNG DER ARBEIT 82 17 CURRICULUM VITAE 83