2023 FSA Podium and Poster Abstracts

P031: PERICARDIAL WAFFLE, IT'S WHAT'S FOR BREAKFAST!
Muna Oli; Patrick Millan, MD; Nikolaus Gravenstein, MD; University of Florida

The pericardium is a double walled sac that encases the heart and is filled with pericardial fluid. The role of the pericardium is to protect the heart and provide lubrication. When there is inflammation of the pericardium, it is referred to as pericarditis. Pericarditis can be separated into constrictive and restrictive pericarditis. Constrictive pericarditis is often caused by radiation, chronic inflammation, or infection. It causes the pericardium to become thick, rigid, and calcified. This can restrict the heart’s ability to have effective cardiac output. Restrictive pericarditis is often due to scarring of the pericardium from pathology such as cancer, tuberculosis, or autoimmune disease. Initial treatment usually consists of NSAIDS and colchicine but pericardial drainage or pericardiectomy may be necessary.

A 65-year-old male presented to an outside hospital for shortness of breath, chest pain, paroxysmal nocturnal dyspnea, and lower extremity edema a month after developing fevers and a viral infection. The patient’s past medical history included hypertension, prostate cancer, and COVID-19 infection. Heart catheterization and cardiac MRI confirmed constrictive cardiomyopathy and pericarditis. The patient was started on torsemide, apixaban and colchicine, but symptoms worsened, and he was transferred to our hospital for further workup and treatment.

Presurgical TTE showed mild concentric LV hypertrophy, low-normal LV systolic dysfunction, enlarged RA, moderately dilated LA, pericardial effusion and thickening/calcification of pericardium. In the operating room, an arterial line was started and patient was induced with fentanyl, ketamine, versed, propofol, and rocuronium. Anesthesia was maintained with sevoflurane. Patient was on an epinephrine infusion throughout the case to improve cardiac function.

The surgeon reported densely adhered pericardium with calcifications. He was unable to remove pericardium and so instead performed a pericardial waffle procedure with a cross-hatch pattern to alleviate the pericardial constriction. CVP pre-op was noted to be 25-30 and decreased to 14-16 post-op. The patient was transported to the ICU in stable condition. He remained in the hospital for a week and was discharged home on colchicine.

It can be difficult to differentiate restrictive versus constrictive pericarditis as symptoms can be similar. On echocardiography, constrictive pericarditis may demonstrate reduced motion of atrial/ventricular walls due to tethering of the walls to the pericardium, while restrictive pericarditis more often has no wall motion abnormalities.

Anesthetic considerations are very important for these cases. Severe cases of pericarditis can demonstrate a tamponade physiology, compressing the heart and causing impaired venous return to the heart and decreased cardiac output. General anesthesia is often used for these cases, especially when sternotomy is required. An arterial line is often done to allow close monitoring of blood pressure. Induction of anesthesia in these patients can be fatal, and it is important to be extremely careful. Adequate IV access, attention to fluid status and access to emergency medications are all essential for these cases as well. Lastly both versions of pericarditis cause an elevated CVP and when this is relieved may result in pulmonary edema from release of all the backed up venous blood into the central circulation- referred to as pericardial decompression syndrome.