Radical Pericardiectomy With Bypass Support Delivers the Best Outcomes in Constrictive Pericarditis

A comprehensive new retrospective analysis from Cleveland Clinic reveals that radical pericardiectomy offers significantly better hemodynamic and survival outcomes compared with partial pericardiectomy for patients with constrictive pericarditis. Furthermore, the study clarifies a long-standing surgical debate by demonstrating that routine use of cardiopulmonary bypass (CPB) to facilitate thorough resection is safe and does not negatively impact long-term survival, despite an expected increase in blood product requirements.

“Our experience over more than two decades at Cleveland Clinic indicates that maximizing the extent of pericardial removal, often with the support of cardiopulmonary bypass to ensure stability, results in superior physiological relief and a dramatic reduction in both operative and 10-year mortality rates,” says cardiothoracic surgeon Marijan Koprivanac, MD, MS, first and corresponding author of the study, published in Annals of Thoracic Surgery (2026;121[4]:871-880).

Rationale for radical resection

Pericardiectomy serves as the definitive surgical solution for pericardial constriction, yet the surgical community has lacked consensus about how much tissue to remove. Some advocate for partial, or semi-complete, resection to minimize operative time and complexity, while others argue that leaving diseased tissue behind invites recurrence and inadequate symptom relief.

The role of CPB also has remained controversial. Historically, some surgeons viewed bypass as a risk factor for higher mortality, often because it was reserved for the most unstable patients or as a rescue measure during catastrophic bleeding. “In this study we sought to provide clarity on these questions by comparing radical versus partial approaches and assessing the true impact of bypass support in a large, modern cohort,” says Dr. Koprivanac, Surgical Director of Cleveland Clinic’s Pericardial Diseases Center.

Study design and methodology

He and colleagues examined a registry of 534 consecutive adults who underwent surgery for constrictive pericarditis at Cleveland Clinic between 2000 and 2022. The cohort was divided into those receiving radical pericardiectomy (n = 425) and those receiving partial pericardiectomy (n = 109). Radical resection was defined as removal of the entire pericardial sac including the posterior pericardium and pericardium on phrenic nerves, with the phrenic nerves stripped off the pericardium. Partial resection involved any procedure in which the posterior pericardium or other segments were left in place.

To account for baseline clinical differences between the two groups, the investigators used propensity-score matching, resulting in 89 well-matched pairs. This allowed for direct comparison of postoperative hemodynamics, morbidity and long-term survival. The median follow-up period was 6.2 years, with a quarter of patients monitored for more than 11 years and 10% for more than 17 years.

Key findings: Hemodynamics and survival

The hemodynamic benefits of a radical approach were immediate and pronounced. In the matched pairs, the postoperative cardiac index rose by 1.24 L/min/m² following radical resection, compared with 0.56 L/min/m² after partial resection (P < .001). Similarly, the reduction in central venous pressure (CVP) was more than double with radical pericardiectomy, dropping by 12 mm Hg versus 4.8 mm Hg with partial pericardiectomy (P < .001).

These physiological improvements translated to advantages in survival and reduced complications:

• Operative mortality. The radical resection group experienced a 3.4% mortality rate, significantly lower than the 17% rate in the partial resection group (P = .0029).
• Long-term survival. At the 10-year mark, survival was 61% with radical pericardiectomy compared with 22% with partial pericardiectomy (adjusted hazard ratio = 3.1; 95% CI, 2.1-4.6).
• Morbidity. While major complications like stroke and wound infections were similar between the groups, patients who underwent partial resection had higher rates of respiratory failure and required renal dialysis more frequently.

Practice trends, and safety of cardiopulmonary bypass

Notably, the researchers report that use of radical pericardiectomy at Cleveland Clinic increased throughout the study period, from 60% at the beginning to 95% in the most recent era. This shift occurred alongside a rise in the use of CPB, which reached 100% in the most recent era.

The study showed that, among the overall cohort of patients undergoing radical pericardiectomy, CPB was associated with more frequent blood transfusions (63% vs. 31% for off-pump cases), more reoperations for bleeding (3.4% vs. 0%, respectively) and a higher rate of postoperative atrial fibrillation (29% vs. 15%). Other outcomes, including operative mortality, were similar between the CPB and off-pump groups. After adjusting for propensity scores, there were no significant differences in early or late survival between on-pump and off-pump procedures.

“Cardiopulmonary bypass provides hemodynamic stability during the delicate process of resecting the posterior pericardium and adherent calcific tissue,” Dr. Koprivanac notes. “Our data suggest that for patients with the most severe constriction, as indicated by low preoperative cardiac indices, bypass support may equalize their risk to that of less severe cases.”

Etiology’s role in outcomes

The analysis also showed that the underlying cause of constriction remains a powerful predictor of long-term success, consistent with findings from prior series.

Specifically, results demonstrated that patients with idiopathic and viral etiologies generally have the best prognosis. “These patients are good candidates for early, aggressive surgical intervention,” says study co-author Allan Klein, MD, Medical Director of Cleveland Clinic’s Pericardial Diseases Center. Individuals with postcardiotomy pericarditis had somewhat less favorable early and late outcomes, likely reflecting the presence of mixed pericardial/myocardial disease. The poorest survival outcomes were among patients with postradiotherapy pericarditis, likely due to concurrent radiation-induced damage to the myocardium, heart valves and lungs, which pericardiectomy alone cannot resolve.

The authors also highlight a rare but devastating complication: acute right ventricular over-distension following pericardium removal. “To mitigate this risk, we recommend a strategy of fluid restriction and low-dose inotropic support following resection to control ventricular volumes,” Dr. Klein notes.

Validation of an ‘oncologic mindset’ to treat constriction

“At Cleveland Clinic, we have come to approach constrictive pericarditis with an oncologic mindset, aiming for radical resection to remove as much diseased tissue as possible to prevent recurrence,” Dr. Koprivanac observes. “Our evolution toward favoring radical pericardiectomy whenever possible has been validated by these large-scale data. Using cardiopulmonary bypass to facilitate this approach is a safe, effective strategy that provides the necessary stability to achieve a truly radical excision.”

The investigators note that future studies may assess the role of radical pericardiectomy for patients who don’t have constrictive pericarditis but have intractable recurrent pericarditis that fails to respond to medical management with anti-inflammatory therapy.