Surgical Pathology of the Parietal Pericardium

8/8/2019 Surgical Pathology of the Parietal Pericardium

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( > 1 month), or unknown. Neoplasms and recurrent peri-

carditis were considered chronic processes.

Each case was assigned to one of five categories, based on

the most prevalent type of pericardial disease: constriction(Group 1), neoplasm or cyst (Group 2), effusion (Group 3),

pericarditis (Group 4), or other (Group 5). A preoperative

diagnosis of constriction was established on the basis of

clinical features of right heart failure and one or more of the

following: cardiac catheterization with hemodynamic stud-

ies, echocardiography, computerized tomography (CT), elec-

tron beam (ultrafast) CT, or magnetic resonance imaging.

Pericardial effusions were classified by duration. Pericarditis

(including acute and recurrent types) was distinguished from

pericardial effusions by the presence of the syndrome of

chest pain, friction rub, fever, shortness of breath, cough,

elevated erythrocytic sedimentation rate, and electrocardio-graphic changes.

Surgical procedures were classified as radical, subtotal,

or partial pericardiectomy or as pericardial window, resec-

tion (for neoplasms), biopsy, or unknown, as recently

reviewed by Ling et al. [2]. Radical pericardiectomy implied

removal of the pericardium anteriorly (between the right and

left phrenic nerves, from the level of the great arteries to the

diaphragmatic surface), left laterally (posterior to the left

phrenic nerve), inferiorly (along the diaphragmatic surface),

and posteriorly (to the atrioventricular junction). In contrast,

a subtotal pericardiectomy indicated resection only of the

pericardium between the two phrenic nerves. A partial pericardiectomy represented any other major removal of

the pericardium, including a completion pericardiectomy,

in which a portion had been previously resected. Pericardial

windows were small resections performed to drain the

pericardial space. All nonpericardial cardiac operations were

Table 1

Demographic features in 344 surgical cases of pericardial disease

Age (year) Gender Cases

Clinical category Mean Range M F M/F No. %

Constriction 57 12 81 109 34 3.2 143 42

Neoplasm or cyst 56 4 80 55 41 1.3 96 28

Effusion 57 3 87 25 15 1.7 40 12Pericarditis 47 11 81 18 15 1.1 33 9

Other 51 1 80 14 18 0.8 32 9

Total 55 1 87 221 123 1.8 344a 100

M = males; F = females.a Among the 341 patients, an 11-year-old boy had two operations for

pericarditis and one operation for pericardial constriction, and a 64-year-

old man had two operations for a pericardial neoplasm, thereby producing

344 cases.

Table 2

Clinical features in 344 surgical cases of pericardial disease

Clinical diagnostic category Total

Clinical feature Constriction Neoplasm or cyst Effusion Pericarditis Other No. %

Duration

Acute 0 0 1 2 0 3 1Subacute 1 0 4 3 0 8 2

Chronic 137 96 30 27 0 290 84

Unknown 5 0 5 1 32a 43 13

Total 143 96 40 33 32 344 100

Etiology

Neoplasm or cyst 0 96 9b 0 7b 112 33

Idiopathic 70 0 11 23 0 104 30

Postpericardiotomy 43 0 9 3 0 55 16

Postirradiation 16 0 3 3 3c 25 7

Autoimmune 9d 0 1e 2f 0 12 3

Infection 1g 0 1h 2i 2j 6 2

Sarcoidosis 2 0 2 0 0 4 1

Other 2k 0 4l 0 20m 26 8

Total 143 96 40 33 32 344 100a Patients had no primary pericardial disease.b Neoplasm was only in adjacent structures, not in the pericardium.c Without pericardial constriction.d Six with rheumatoid arthritis, and three with Dresslers syndrome.e Dresslers syndrome.f One with scleroderma, and one with Dresslers syndrome.g Coxsackie B viral pericarditis.h Mixed bacterial and fungal pericarditis.i One bacterial and one fungal infection.j Two aspergillus infections.k One chest trauma and one pericarditis following atrioventricular nodal ablation with right ventricular perforation.l One chest trauma, one uremia, one ascending aortic dissection, and one right ventricular perforation during pacemaker placement.m Twelve congenital heart disease (including nine Ebsteins anomaly), two valve surgery, one ascending aortic dissection, one ascending aortic aneurysm

in Marfans syndrome, one restrictive cardiomyopathy, one chest trauma, one incidental pericardial inflammatory nodule at operation, and one unknown.

K.Y. Oh et al. / Cardiovascular Pathology 10 (2001) 157168158


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recorded, as was the presence of coexistent ischemic,

valvular, and congenital heart disease; heart failure; and

pleural effusions.

2.3. Pathologic features

Surgical pathology reports and corresponding micro-scopic slides were reviewed in each case. From the report

or the slide, the maximal pericardial thickness was recorded

to the nearest millimeter. The following, if present, were

also recorded: calcification (gross or microscopic), inflam-

mation (acute or chronic, and graded semiquantitatively as

mild, moderate, or marked), granulomas (caseating or non-

caseating, with the results of special stains for organisms),

and fibrosis, granulation tissue, fibrin deposition, hemosi-

derin, and mesothelial hyperplasia. The presence of neutro-

phils, primarily within small vessels, was considered

surgery-related, whereas prominent extravascular neutro-

philic infiltrates were considered disease-related. If a neoplasm was present, no other microscopic information was

recorded for that case.

3. Results

3.1. General findings

3.1.1. Clinical features

Among the 341 patients, one had two pericardial oper-

ations and another had three, resulting in 344 cases. Ages at

operation ranged from 1 to 87 years (mean, 55), and

children were present in each of the five clinical categories

(Table 1). Males accounted for 221 (64%) of the cases and

were particularly prone to develop constriction.

Pericardial disease was chronic in 84% of the cases. It

was neoplastic in 33%, idiopathic in 30%, iatrogenic in

23%, and of other cause in 14% (Table 2). The most

common surgical procedure was a radical pericardiectomy,

which was performed in 30% of the cases (Table 3).

3.1.2. Pathologic featuresOn average, four pieces of parietal pericardium were

evaluated microscopically from each case (Table 4). Peri-

cardial thickening was due to fibrosis in 67%. It occurred in

all five groups, but was greatest in patients with constriction

or pericarditis. Mild to moderate chronic inflammation was

present in 56% of the cases. Granulomas were observed in

only 3%, and none were due to tuberculosis.

3.1.3. Coexistent heart disease

Among the 341 patients, 83 (24%) had coronary artery

disease, 51 (15%) had valvular disease, and 20 (6%) had

congenital heart disease. Of the 78 patients with heartfailure, none were New York Heart Association (NYHA)

Class I, 4 were Class II, 18 were Class III, and 24 were

Class IV; the NYHA class was not specified in 32 patients,

of whom 7 had right heart failure. At the time of pericardial

resection, 48 patients also had resection of a neoplasm

outside the pericardium, 43 underwent valve repair, 33

had coronary artery bypass grafting, and 20 underwent

repair of congenital cardiac anomalies.

3.2. Pericardial constriction (Group 1)


Patients with symptoms related to pericardial constriction

represented the largest group (143 cases), of which 76%

were male. In addition, another 16 patients with features of

Table 3

Types of surgical procedures for parietal pericardial disease in 341 patientsa

Clinical diagnostic category Total

Surgical procedure Constriction Neoplasm or cyst Effusion Pericarditis Other No. %

Radical 75 0 14 21 0 110 30

Partial 36b 3 7c 4 14 64 18

Resection 0 61 0 0 2d 63 17Biopsy 1 34 7 5 10 57 16

Subtotal 31 0 3 1 1 36 10

Window 0 12 13 3 4 32 9

Unknown 0 0 1 0 1 2 < 1

Total 143 110e 45f 34g 32 364a 100

a One patient had three operations and one patient had two operations (accounting for 344 cases), and 20 patients had two procedures during the same

operation, resulting in 364 procedures. Not included are 64 focal epicardialresections (from 50 patients with constriction, 3 with neoplasms, 6 with effusions, 4

with pericarditis, and 1 with other pericardial disease).b Includes 11 completion pericardiectomies (for six prior resections for constriction, and five prior windows).c Includes two completion pericardiectomies (one prior window, and one prior 40% excision).d Resection of two pericardial masses, found at operation to be non-neoplastic.e Fourteen patients had two pericardial procedures during the same operation.f Five patients had two pericardial procedures during the same operation.g One patient had two pericardial procedures during the same operation.

K.Y. Oh et al. / Cardiovascular Pathology 10 (2001) 157168 159


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pletion pericardiectomy. There were no cases of posttu-

bercular constriction.

3.3. Neoplasms and cysts (Group 2)


Neoplasms and cysts represented the second largest

group and included 96 cases and 110 specimens (Table 3).

There was no appreciable gender predilection (Table 1). The

two most frequently performed procedures were resection(55%) and biopsy (31%). An additional seven patients had

pericardial procedures to rule out neoplastic disease and are

included in Group 5.

Overall, metastatic disease accounted for 64%, primary

benign tumors and cysts 23%, and mesotheliomas 13%

(Table 5). Carcinomas and lymphomas were the most

prevalent forms of secondary involvement. Among the

18 cases with tumor identified only in adjacent tissues

and not in the pericardium directly, there were no lym-

phomas or mesotheliomas.

Three patients had symptoms of constriction due to

neoplastic encasement of the heart (two pericardial meso-

theliomas, one metastatic adenocarcinoma of the lung).

Seven patients had both pericardial effusions and pericardial

neoplasms. Fifteen patients also had pleural effusions.

3.3.2. Pathologic features

The maximal pericardial thickness ranged from 1 to 5

mm (mean, 3), excluding two cases with oblique tissue

orientation on the slide. Thickening was tumor-related in

all cases, with coexistent fibrosis in 11% (Table 4).

Chronic lymphoplasmacytic inflammation was present inonly 17% and was mild in 81% of these. A noncaseat-

ing granuloma was found in pericardial tissue from a

patient with an unresectable squamous cell carcinoma of

the lung.

3.4. Pericardial effusions (Group 3)


Of the 40 patients with pericardial effusions, 63% were

male (Table 1). Effusions were chronic in 75% (Table 2).

Specific gravity was determined in six cases, and all were

transudative. The two procedures performed most often

Fig. 1. Photomicrographs from patients with constrictive pericarditis. (A C) Low-power views of the pericardium (taken at the same magnification),

showing fibrotic thickening (A), plate-like calcification (B), and normal thickness (C, between arrows). (D,E) Chronic nongranulomatous

lymphoplasmacytic inflammation, of mild degree at the border between the pericardium and adjacent adipose tissue (D), and of moderate degree within

fibrotic pericardium (E).



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were radical pericardiectomy (31%) and pericardial window

(29%) (Table 3).

Eighteen patients had isolated effusions. Of the remain-

ing 22 patients, 9 had both a pericardial effusion and

hemodynamic evidence of constriction due to ventricular

compression by loculated fluid or hematoma. Four patients

had effusive constrictive disease (that is, a pericardial

effusion and constriction by the epicardium rather than

by the parietal pericardium) [3]. The remaining nine cases

(not included in the neoplastic group above) each had both

a pericardial effusion and a neoplasm that did not involve

the pericardium.

3.4.2. Pathologic featuresThe maximal pericardial thickness ranged from 1 to 9

mm (mean, 4), and fibrosis was identified in 83% (Table 4).

Chronic lymphoplasmacytic inflammation was present in

88% (mild to moderate in 97%) (Fig. 2). Acute inflamma-

tion was observed in 25%, and fibrin deposition in 65%.

Old postoperative foreign-body granulomas were found in

two cases.

3.4.3. Causes of effusions

Pericardial effusions were idiopathic in 28%. The two

most common known causes were previous pericardiotomy

and neighboring neoplasms (23% each).

3.5. Pericarditis (Group 4)


The smallest group included 32 patients with pericarditis,

30% of whom also had a pericardial effusion. There was no

gender predilection (Table 1). One patient had two pericar-

dial operations, and another had two pericardial procedures

during the same operation, yielding 33 operations and 34

specimens. Of the 33 operations, 82% were for chronic

recurrent disease (Table 2). A radical pericardiectomy was

performed in 62% (Table 3).

In an 11-year-old boy, a pericardial window was made

to relieve a septic streptococcal effusion, and a subsequent

partial pericardiectomy was performed when sterile peri-

carditis occurred 1 month after the first operation. Within

another month, he developed pericardial constriction and

underwent a completion pericardiectomy (included in

Group 1).


Maximal pericardial thickness ranged from 1 to 13 mm

(mean, 3), and fibrosis was present in 79%. Chronic

lymphoplasmacytic inflammation was observed in 73%

and was mild to moderate in all (Table 4) (Fig. 3). Acute

neutrophilic inflammation, often with edema, occurred in

21%, and acute and chronic inflammation coexisted in four

cases. Both examples of severe acute inflammation were in

the 11-year-old boy.

3.5.3. Causes of pericarditis

In most cases (68%), the cause of pericarditis wasunknown (Table 2). Previous pericardiotomy and mediasti-

nal irradiation each accounted for 9%.

3.6. Other pericardial disorders (Group 5)


Thirty-two patients had pericardial resection for causes

unrelated to primary pericardial disease (Table 1). Twelve

patients had surgery to repair congenital cardiac anoma-

lies, during which excessive parietal pericardium was

also removed. For seven patients with clinically suspect-

ed primary pericardial neoplasms, surgery ruled outtheir presence. The other 13 patients are described in

Table 2. A partial pericardiectomy was performed in

44% (Table 3).


The maximal pericardial thickness ranged from 1 to 6 mm

(mean, 3), excluding two cases with oblique tissue orienta-

tion on the slide. For patients with congenital heart disease,

the thickness was only 13 mm (mean, 2). Chronic lym-

phoplasmacytic inflammation was present in 66% and

included six cases with coexistent acute neutrophilic inflam-

mation (Table 4). A pericardial caseating granuloma without

Table 5

Neoplasms or cysts in 96 patients with pericardial resection

Total

Neoplasms or cysts No. %

Secondary (n = 61)

Carcinoma 23a 15b 38 40

Lymphoma 9c 0 9 9Other 11d 3e 14 15

Primary (n = 22)

Cyst 20 0 20 21

Lymphangioma 1 0 1 1

Lipoma 1 0 1 1

Mesothelioma (n = 13)

Pleural 11 0 11 11

Pericardial 2 0 2 2

Total 78 18 96 100

a Twenty-one adenocarcinomas (15 lung, 4 breast, 1 esophagus, 1

colon) and two squamous cell carcinomas (one lung, one esophagus).b Seven adenocarcinomas (five lung, two esophagus), four squamous

cell carcinomas (three lung, one esophagus), three non-small cell

carcinomas of lung, and one mediastinal embryonal carcinoma.c Six B-cell lymphomas, two T-cell lymphomas, and one nodular

sclerosing Hodgkins disease.d Five malignant thymomas (four Type I, one Type II) and six others

(osteosarcoma, liposarcoma, synovial sarcoma, peripheral nerve sheath

tumor, endometrial mixed mullerian tumor, and mediastinal mixed germ

cell tumor with yolk sac and mature teratoma components).e Three others (Type I thymoma, synovial sarcoma, and mediastinal

germ cell tumor).

In the

pericardium

In adjacent

tissues



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identifiable organisms was observed in a patient with

invasive pulmonary aspergillosis.

4. Discussion

Much has been written about the clinical features,

causes, treatment, and operative results of pericardial

diseases [3 8]. However, little has been published con-

cerning the pathology of surgically resected tissues [915],and only one consecutive series of all pericardial resections

(35 patients) has been reported [1]. The current investiga-

tion uniquely reviewed the pathology of the parietal

pericardium in a large number (344 specimens) of recent

cases from a single institution.

As in other studies, pericardial operations in the present

study were performed for constriction, neoplasms, effusions,

pericarditis, or other disorders, and the surgical procedures

included radical, subtotal, or partial pericardiectomy and

pericardial window, resection (of neoplasms), or biopsy.

Patients ranged in age from 1 to 87 years (mean, 55), and

each of the clinical categories included children. The most

commonly performed procedure was a radical pericardiec-

tomy for constriction or effusion. For the microscopic

evaluation of non-neoplastic pericardial disorders, four or

more representative pieces were usually obtained, decal-

cified if necessary, embedded and cut on edge, and stained

with hematoxylineosin.

4.1. Pericardial constriction

4.1.1. Clinical featuresPericardial constriction comprised the largest group

(42%) in the present investigation. Similarly, in other

studies from North America and Europe, constric-

tion represented 25 44% of all pericardial operations

[1, 16 18]. Constriction accounted for 79% of the peri-

cardial excisions in Turkey, where tuberculosis is still

prevalent [4].

Although pericardial constriction usually affects adults,

the age range is broad and includes children. There is a

notable male preponderance, as reflected by a male-to-

female ratio of 3:1 in the current study and 2:1 3:1 in

other reports [2,9,1923].

Fig. 2. Photomicrographs from a patient with pericardial effusion. (A) Low-power view of moderately thickened and fibrotic pericardium, with fibrin along the

inner surface and inflammatory infiltrates near the outer surface. (B D) Inflammation along the outer border of the pericardium (B), showing both a chronic

lymphoplasmacytic infiltrate with a germinal center (C) and an acute neutrophilic infiltrate (D).



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In the current study, the pericardial thickness ranged from

1 to 17 mm (mean, 4). Thickening was due primarily to

fibrosis, and calcification was grossly visible in only 28% of

the cases. Inflammation, when present, was mild and of

chronic lymphoplasmacytic type in 79%. These general

morphologic findings are similar to those described in other

studies of pericardial constriction [1,911,13,24]. Pericar-

dial neovascularization and mesothelial pseudocysts havealso been described; both were identified in the current

study, but were not quantitated.

Agarwal and Chopra [9] described two microscopic

patterns. One was characterized by dense fibrosis, lympho-

plasmacytic infiltrates, neovascularization, mesothelial

pseudocysts, and calcium or bone formation, and the other

consisted primarily of dense fibrosis with prominent gran-

ulomas and neovascularization. The granulomatous pattern

was often associated with tuberculosis. Only the lympho-

plasmacytic pattern was encountered in the current study.

Interestingly, 4% of the cases in the present study showed

no fibrosis, calcification, or thickening an observation

also reported by others [7]. Thus, symptomatic pericardial

constriction can occur in the setting of a noncalcified and

nonthickened pericardium, a fact that should be borne in

mind when evaluating patients preoperatively. Conversely,

since patients with pericardial neoplasms, pericardial effu-

sions, or pericarditis also commonly have appreciable

thickening, not all patients with a thickened pericardium

will have features of constriction.

4.1.3. Causes of constriction

In most cases, the cause of chronic constriction cannot be

determined. Idiopathic disease accounted for 49% of the

cases in the present study and 3383% of the cases in other

series [2,15,19,22]. Though speculative, viral pericarditis is

considered the most likely cause of idiopathic constriction.

Iatrogenic disease is currently the most common known

cause of pericardial constriction and is usually the result of

prior cardiac surgery or mediastinal irradiation. It develops in

0.3% of all patients undergoing cardiac surgery [25]. Con-

striction was the result of previous pericardiotomy in 30% of

the current patients. It accounted for 18% of the cases

Fig. 3. Photomicrographs from patients with chronic or recurrent pericarditis. (A) Pericardium thickened by edema and neovascularization, with minimal

inflammation, from a patient treated with corticosteroids. (B) Granulation tissue with clumps of residual compact fibrin. (C,D) Chronic lymphoplasmacytic

infiltrates within fibrotic pericardium (C) and within edematous pericardium (D).



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reviewed by Ling et al. [2] and for 11% of those reported by

Cameron et al. [22] including 29% of their patients who

presented after 1980. The reported time interval between

cardiac surgery and a diagnosis of postoperative pericardial

constriction has ranged from 2 weeks to 21 years (mean,

2 years) [19,25]. Multiple pathogenetic theories have been

proposed, including the formation of adhesions due to organ-ization of fibrinous exudates or pericardial blood, the use of

povidone or other antiseptic solutions in the pericardial space,

or simply pericardial trauma during the operation [26]. Of the

52 patients in the current study with constriction and a history

of prior cardiac surgery, 14 also had symptoms of the

postpericardiotomy syndrome, another condition that may

predispose patients to develop constriction [25,27,28].

Acute pericarditis with an effusion is often a precursor to

constriction [7]. In contrast, recurrent pericarditis occurs less

frequently and rarely proceeds to constriction, although

cases have been observed. Among patients with constric-

tion, a previous history of acute pericarditis was docu-mented in 6% of the cases reported by Cameron et al.

[22], 16% of those by Ling et al. [2], and 17% of those in

the current investigation. It should be emphasized, however,

that the majority of patients in each study had not had

pericarditis. Other causes of pericardial constriction include

infections (tuberculosis, bacteria, fungi, viruses, and para-

sites), autoimmune diseases (systemic lupus erythematosus,

rheumatoid arthritis, and Dresslers syndrome), neoplasms

(especially lymphomas, carcinomas of the lung and breast,

and mesotheliomas), drugs (such as the ergot alkaloids), and

miscellaneous disorders (uremia, sarcoidosis, amyloidosis,

asbestosis, trauma, and chylopericardium) [2,3,19,22].

Interestingly, the most prevalent causes of constriction

have changed appreciably during the past century. Tuber-

culosis, though once a common cause in Asia, Europe, and

North America, has steadily decreased in frequency (Table 6)

[2,9,11,16,17,1923,2932]. There were no cases of tuber-

culosis in the current study, from 1993 to 1999. On a

worldwide basis, however, tuberculosis is still a relatively

frequent cause of pericarditis and constriction [33].

4.2. Pericardial neoplasms and cysts

4.2.1. Clinical and pathologic features

Among various large studies, the pericardium has shown

diverse neoplastic involvement. Nonetheless, carcinomas of

the lung and breast and lymphomas were the three most

commonly encountered tumors in our investigation and in

others (Table 7) [3441]. Although melanoma frequently

metastasizes to the heart, most patients also have wide-

spread extracardiac metastases that preclude cardiac surgery.

Thus, there were no examples of pericardial melanoma in

the current surgical study.Effusions occurred in 7 of our 96 patients, but the 3 who

underwent pericardiocentesis preoperatively had no malig-

nancy identified cytologically. This is somewhat unusual, as

the reported specificity of cytologic analysis has ranged

from 73% to 93% [42,43].

Pericardial mesotheliomas represent fewer than 1% of all

malignant mesotheliomas and may produce arrhythmias,

compression syndromes, or pericardial constriction [34].

Both cases in the current study produced symptoms of cardiac

tamponade. One was diagnosed as effusive constrictive

disease by echocardiography, and the other as possible

constrictive pericarditis.

It is important to emphasize that patients with underlying

malignancies may have pericardial disease due to non-

Table 6

Frequency of pericardial constriction due to tuberculosis (TB) by region and year in 15 surgical studies

Reference (study, by continent) Country Time span Pt. no. % TB

Asia

[21] India 1954 1985 118 61

[9] India 1960 1976 86 38

[4] Turkey 1983 1993 105 38

[30] Japan 1952 1976 57 14

Europe

[20] Denmark 1953 1983 34 79[31] France 1979 1989 84 12

[29] Ireland 1958 1983 32 9

[19] Germany 1970 1990 71 4

North America

[16] USA (TN) 1930 1971 45 62

[11] USA (OH) 1930 1950 61 28

[32] USA (CA) 1955 1982 31 19

[17] USA (GA) 1974 1980 26 8

[23] USA (MN) 1936 1982 231 6

[22] USA (CA) 1970 1985 95 2

[2] USA (MN) 1985 1995 133 1

Current study USA (MN) 1993 1999 143 0

Pt. no.= number of patients; CA = California; GA= Georgia; MN= Minnesota; OH= Ohio; TN = Tennessee; USA = United States of America.



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neoplastic causes. Pericardial effusions or constriction may

be a consequence of mediastinal irradiation, infections,

drugs, or idiopathic pericarditis [37]. They may cause

symptoms alone or in various combinations, with or without pericardial metastases.

4.3. Pericardial effusion


This complex category includes isolated effusions, con-

striction or neoplasms with an effusion, and effusive

constrictive disease. Constriction with an effusion, affecting

23% of the patients in the current study, results from

loculated fluid that produces constrictive hemodynamics

[7]. In contrast, effusiveconstrictive pericarditis, involving

10% of the current patients with an effusion, is characterized

by constriction by the epicardium and by a tense pericardial

effusion. Its diagnosis relies on both hemodynamic and

clinical findings [3].


Other than for patients with malignancy, irradiation, or

uremia, there are few descriptions of the pericardial histol-

ogy associated with effusions. In an older study from the

Mayo Clinic, Wychulis et al. [44] described the microscopy

from 26 patients who had undergone surgery for effusions

or recurrent pericarditis; the pericardium was normal or only

mildly fibrotic in 18 and showed pericarditis with chronic

lymphoplasmacytic inflammation in 8, among whom 2 hadtuberculosis. Olsen et al. [40] found acute and chronic

inflammation in 76% of patients with benign effusions

and in 77% of those with idiopathic effusions. In the present

study, specimens showed acute or chronic inflammation in

90%, fibrosis in 83%, and fibrin deposition in 65%. It is not

surprising that fibrosis is associated with both effusions and

constriction, since effusion may represent a stage in the

development of constriction [44].

4.3.3. Causes of effusions

Idiopathic disease accounted for 30% of the cases in the

present study and 13 39% in other large surgical series

[40,45 47]. The most common known cause was neoplastic

disease, affecting 23% of the 40 patients in the current

investigation and 33 50% in other series [40,45 47].

Among our nine patients with effusions and a neoplasm inadjacent structures, neither biopsy nor pericardiectomy had

revealed the malignancy in pericardial tissues, and only two

patients had malignant effusions by pericardiocentesis. Sim-

ilar discrepancies between biopsy and cytology have been

reported in 3058% of such cases [45,48,49].

Radiation-induced effusions should be distinguished

from malignant effusions. Radiation injury is thought to

progress from acute pericarditis to effusion and then to

constriction, often with many intervening asymptomatic

years [14,50,51]. Of the 15 patients undergoing operation

for pericardial effusions reported by Piehler et al. [47],

features of constriction were present in only 40% overall

but in all 3 patients with a history of mediastinal irradiation.

Uremia caused an effusion in 2% of the current cases and

in 820% in three series of pericardial windows for effu-

sions [45,46,49]. Other causes of effusions for which surgery

may be performed include infections, autoimmune connec-

tive tissue diseases, trauma, sarcoidosis, iatrogenic perfora-

tion during pacemaker placement, and other rare disorders.

4.4. Pericarditis


This category includes both acute pericarditis and relaps-

ing or recurrent pericarditis. An episode of acute pericarditiswill become recurrent in 1532% of cases [7,12]. Patients

with pericarditis are frequently treated with nonsteroidal

anti-inflammatory agents, with some relief of symptoms, but

often require long-term treatment with corticosteroids. In the

current study, 18 of the 23 patients with idiopathic recurrent

pericarditis were steroid-dependent. Indications for pericar-

diectomy include unresponsiveness to therapy and intract-

able or disabling pain [12].

Pericarditis tends to affect adults, but may occur in

children and adolescents, and has a male predilection.

Among 215 patients in two large series, ages ranged from

3 to 81 years (mean, 42), and 66% were male [6,44,52].

Table 7

Three most common sites of primary malignancies among 798 cases of metastatic involvement of the pericardium from seven autopsy or surgical series

Reference Carcinoma of lung Carcinoma of breast Lymphoma Other primary site Total

[35] 8 7 2 5 22

[41] 52 35 38 64 189

[39] 10 6 3 9 28

[36] 66 34 24 93 217[38] 32 8 2 41 83

[34] 80 61 13 62 216

Current studya 16 4 9 14 43

Total

Number 264 155 91 288 798

Percentage 33 19 11 36 100

a Includes only the 43 cases with pericardial involvement (see Table 5).



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Similarly, in the current study, ages ranged from 11 to 81

years (mean, 47), and 55% were male.


Although histopathologic descriptions of hemorrhagic

and purulent pericarditis are plentiful, those of acute or

recurrent noninfectious pericarditis are sparse. Kluge and

Hall [13] described smoldering pericarditis with irregular

mesothelial destruction, and Mambo [1] reported nonspe-

cific chronic fibrous pericarditis with layers of fibrosis and

inflammation and a denuded mesothelium. In 11 patients

with recurrent pericarditis reported by Fowler [12], 5

showed fibrosis with adhesions, 3 had only mild fibrosis,

2 exhibited fibrinous exudates, and 1 had inflammation

without fibrosis. Radiation-induced acute fibrinous pericar-

ditis may also later become fibrotic [51].

In the current study, although all patients had acute or

recurrent pericarditis clinically, inflammation was absent

microscopically in 18% (and in 25% when the two casesof infectious pericarditis were excluded) and was of only

mild degree in 72% of the noninfected cases. This was

attributed to the effects of preoperative treatment with

steroids. The relative paucity of fibrin, hemosiderin, and

granulation tissue is also understandable. Thus, it should be

emphasized that previous therapy may appreciably affect the

microscopic appearance.

4.4.3. Causes of pericarditis

The disease was idiopathic in 68% of the current cases

and in 3886% of patients in other series [5254]. Prior

pericardiotomy and mediastinal irradiation each accountedfor 9% of the current cases. Epidemics of Coxsackie B and

other viruses have been responsible for episodic increases in

the incidence of pericarditis. Tuberculosis may also cause

acute pericarditis [33], although the current study contained

no such cases. Additional causes of pericarditis that may

lead to surgical intervention include other infections, auto-

immune connective tissue diseases, uremia, neoplasms, and

other rare disorders [6,52,55].

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Surgical Pathology of the Parietal Pericardium

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