1. A 20-year Experience with Isolated Pericardiectomy An Analysis of Indications and Outcomes Gillaspie EA, Stulak JM, Daly RC, Greason KL, Joyce LD, Oh J, Suri RM, Schaff HV, Dearani JA Division of Cardiovascular Surgery and Cardiovascular Diseases

2. Mayo Clinic Division of Cardiovascular Surgery Research funding within the past year: AstraZenecaJarvik Heart AtricureMedtronic Avant ImmunotherapeuticsSt. Jude Medical BaxterThoratec Corporation Carbomedics/Sorin GroupTransTech Pharma CryoLifeW.L. Gore and Associates No personal equity, patents, licensing, or consulting agreements with the medical device or pharmaceutical industry to disclose Mayo Clinic Division of Cardiovascular Surgery Research funding within the past year: AstraZenecaJarvik Heart AtricureMedtronic Avant ImmunotherapeuticsSt. Jude Medical BaxterThoratec Corporation Carbomedics/Sorin GroupTransTech Pharma CryoLifeW.L. Gore and Associates No personal equity, patents, licensing, or consulting agreements with the medical device or pharmaceutical industry to disclose Disclosure

3. Background Management of pericarditis challenging Management of pericarditis challenging Subset may require and benefit from surgery Subset may require and benefit from surgery Lack of clarity on association of patient variables and outcomes Lack of clarity on association of patient variables and outcomes

4. Aims Establish a homogeneous cohort undergoing isolated pericardiectomy Establish a homogeneous cohort undergoing isolated pericardiectomy Analyze overall outcomes and stratified for surgical indication Analyze overall outcomes and stratified for surgical indication Identify patient variables contributing to outcome Identify patient variables contributing to outcome

5. Methods Mayo Foundation IRB approval Mayo Foundation IRB approval Retrospective review Retrospective review Patients undergoing isolated pericardiectomy Patients undergoing isolated pericardiectomy Exclusion Exclusion Concomitant procedures Concomitant procedures Prior mediastinal radiation Prior mediastinal radiation

6. June 1993 December 2013 June 1993 December 2013 363150 Age 18 18 84 57 yr n = 513 Isolated Pericardiectomy Patient Data

7. Constriction n = 355 Isolated n = 513 Total n = 938 Pericardiectomy: 1993-2013 Effusive n = 158

8. Effusion n = 23 Constriction n = 54 Pain n = 81 Effusive n = 158 Pericardiectomy: 1993-2013

9. Preoperative Data PCE/CR NYHA III/IV332 (94%)73 (46%) Diabetes 78 (22%)17 (11%) Hypertension151 (43%)47 (30%) COPD 24 (7%) 3 (2%) PVD 30 (8%) 5 (3%) Renal insufficiency 19 (6%) 5 (3%) Prior surgery105 (30%) 0 (0%) Prior MI 23 (6%) 7 (4%) Median LVEF60 (30-80)60 (24-80)

10. Intraoperative Data #% Isolated pericardiectomy513100 Median sternotomy415 81 Complete resection417 81 CPB use207 40 Median CPB 60 min (range 7-213) Non-cardiac procedure143

11. Intraoperative Data PC E/CR p PC E/CR p Sternotomy286 (81%)129 (82%) 0.45 CPB use 181 (51%) 26 (16%)<0.01 CPB time 50 min 60 min0.22 Complete resection275 (77%) 142 (90%)<0.01

12. Early Morbidity #% Atrial arrhythmias6613 Prolonged ventilation5511 Renal failure26 5 Pneumonia17 3 Low cardiac output13 3 Bleeding/reexplore15 3

13. Postoperative Data Early mortality 12/513 (2.3%) Early mortality 12/513 (2.3%) Constriction9/355 (2.5%) Constriction9/355 (2.5%) Effusive/CR3/158 (1.9%) Effusive/CR3/158 (1.9%) Univariate predictors Univariate predictors LVEF (per ∆10%) (HR 1.09, p=0.03) LVEF (per ∆10%) (HR 1.09, p=0.03) Preop renal failure(HR 9.9, p<0.001) Preop renal failure(HR 9.9, p<0.001)

14. Follow-up Median 29 mos Max 20.5 yrs Max 20.5 yrs n = 501 80% NYHA Functional Class I/II

15. 5011676316 Survival (%) Follow-up time (yr) Late Survival

16. 1555918 4 3461084512 Survival (%) p<0.001 Effusive Constriction Follow-up time (yr) Late Survival

17. 795443382928 543226242322 2215131110 9 Follow-up time (yr) Survival (%) p=0.034 Pain Constriction Effusion Survival Effusive group - Indications

18. 946452463634 523528262524 6 2 2 1 1 1 Follow-up time (yr) Survival (%) p<0.001 Normal Constriction Tamponade Survival Effusive group - Physiology

19. HR CI p Older age (∆ 10 yr)1.05 1.03, 1.07<0.001 CHF1.49 1.03, 2.20.02 Diabetes1.83 1.2, 2.70.004 Completion2.4 1.2, 4.70.01 COPD2.45 1.5, 3.90.004 Multivariable Model Entire Cohort

20. HR CI p Older age (∆ 10 yr)1.04 1.02, 1.06<0.001 NYHA class1.7 1.1, 2.50.014 COPD2 1.2, 3.50.012 Diabetes2.2 1.4, 3.40.004 Multivariable Model Constriction Cohort

21. Conclusions Low early mortality and morbidity Low early mortality and morbidity Pre-operative renal insufficiency and reduced LVEF increased early mortality Pre-operative renal insufficiency and reduced LVEF increased early mortality Effusive/chronic relapsing had a better late survival except in the setting of tamponade Effusive/chronic relapsing had a better late survival except in the setting of tamponade

22. Conclusions Older age, CHF, DM, COPD and completion pericardiectomy decreased late survival Older age, CHF, DM, COPD and completion pericardiectomy decreased late survival Functional status is improved in the majority of patients regardless of indication for operation Functional status is improved in the majority of patients regardless of indication for operation

23. Thank you