Treating Pericardial Disease

Recurring pericardial disease can be debilitating to patients, and an operation to completely remove the pericardium may be necessary. Thor Sundt, MD, chief of the Division of Cardiac Surgery and co-director of the Corrigan Minehan Heart Center at Massachusetts General Hospital, explains how the center treats relapsing pericarditis and, in some cases, even cures the disease.

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Transcript

I became interested in pericardial disease when I was working at another institution that has a very large pericardial disease clinic, and I've realized that in New England there are not a lot of pericardial disease clinics to care for patients either with acute pericarditis, acute relapsing pericarditis or with pericardial constriction.

Now a single episode of pericarditis is clearly unpleasant, and uncomfortable—nobody wants to go through that. But recurrent relapsing pericarditis actually can be so debilitating to patients and simply by removing all the pericardium we can resolve their acute relapsing pericarditis. Now like all surgical procedures, it has to be done correctly and that means all of the pericardium needs to be removed. So you may have had experience with patients who had recurrent relapsing pericarditis, had a phrenic to phrenic pericardiectomy, and still had pain. That makes sense because there's a huge amount of pericardium behind the left phrenic nerve and on the diaphragm. So the right way to do this operation is to take all the pericardium, leave a little strip on the left phrenic nerve, but all the rest of the pericardium needs to go, and that's the way that you can treat acute recurrent relapsing pericarditis.

In the same way as pericardial constriction, some subset of patients with acute pericarditis will develop constriction. There are lots of causes of this, most often it's idiopathic, and sometimes it's postsurgical. The most problematic group, of course, are the patients who have had previous mediastinal radiation, and the reason they are such a challenge is that they have a combination of pericardial constriction and restrictive cardiomyopathy because of the radiation damage to the heart itself.

So particularly in patients with prior episodes of radiation you need a multidisciplinary team that includes a cardio-oncologist who really understands restrictive cardiomyopathy and can help us sort out how much of the patient's symptoms are constriction versus restriction. Most of the time that we're doing a pericardiectomy it's for constriction due to idiopathic causes, and in this case just like with acute relapsing pericarditis, one needs to be sure to take the entire pericardium in front and behind the phrenic nerve and off of the diaphragm. So you may have seen patients who were sent for pericardiectomy who didn't get relief… well, they may not have had a complete pericardiectomy. But if somebody has really got congestive failure from constriction from my standpoint it's a very gratifying condition to treat because we can actually cure it.

Learn more about the Division of Cardiac Surgery

Refer a patient to the Corrigan Minehan Heart Center