Constrictive pericarditis (CP) represents the end stage of pericardial disease, in which the pericardium becomes rigid and loses its normal elasticity, thereby restricting diastolic filling of the ventricles. The resulting clinical picture is unmistakable: a progressive, right-sided heart failure syndrome that can become severely disabling. Within this scenario, pericardiectomy stands as the only intervention capable of offering a cure.

One key technical question, however, has yet to be settled: how extensive the resection should be. Deciding between a total and a partial pericardiectomy is far from straightforward, since it requires weighing the anticipated haemodynamic gain against the immediate operative risk. In everyday practice, this choice still rests largely on the surgical team’s experience and on the individual patient’s characteristics.

Moawad and colleagues have now added contemporary data to this debate. Their work is an observational, retrospective, single-centre study drawing on a consecutive cohort operated on over a twenty-year span, with the principal aim of examining how the extent of pericardial resection relates to long-term survival.

The analysis encompassed 102 patients who underwent pericardiectomy for CP between 2005 and 2025. Patients were divided into two groups according to the surgical technique used: 89 patients (87.3%) underwent total pericardiectomy, while the remaining 13 (12.7%) underwent partial resection. This uneven distribution between groups is not accidental; rather, it mirrors a growing preference for extensive resection as the preferred approach. At the same time, it introduces an important caveat when interpreting the findings, since the partial-resection patients were not a comparable group from the outset. These patients were, in fact, at higher surgical risk from the start. They were older and scored higher on operative risk indices, including EuroSCORE II (7.2 versus 4.9; p = .010) and logistic EuroSCORE (14.5 versus 5.6; p < .001), and urgent or emergency surgery was more common in this group. This baseline imbalance is critical, as it shapes how the subsequent findings should be read.

The study’s most striking finding was the link between total pericardiectomy and improved long-term survival. In unadjusted analysis, complete resection was associated with a 70% lower risk of death (HR = 0.30; p < .001); after adjustment for age, sex, and surgical risk, this association remained significant (HR = 0.38; p = .011).

Clinically, these results point to a substantial prognostic benefit from wider resection, and the underlying physiology makes sense: fully removing the stiffened pericardium releases the constrictive process more effectively, improves ventricular filling, and promotes functional recovery, particularly of the right ventricle (RV).

Partial resection, conversely, can leave areas of residual constriction that blunt haemodynamic improvement, perpetuate venous congestion, and ultimately affect survival.

COMMENTARY:

Although these results are consistent and clinically plausible, they must be read against the study’s inherent constraints. Being retrospective, the design carries an unavoidable risk of bias: there was no random allocation, and the surgical technique chosen depended on the operating surgeon and the patient’s condition. The partial-pericardiectomy group was also small (n = 13), which restricts statistical power and widens the uncertainty around the estimates. Even with multivariable adjustment for relevant covariates, unmeasured factors, such as the anatomical extent of calcification or associated myocardial involvement, could well be influencing the outcome. The study should therefore be understood as reinforcing a trend already hinted at by earlier series, rather than proving absolute superiority.

The report also offers useful technical detail. Total pericardiectomy is understood here as extensive resection spanning both phrenic nerves, covering the anterior and diaphragmatic surfaces and, wherever feasible, the posterior pericardium as well. Achieving this requires adequate surgical exposure, generally through median sternotomy, and in select cases, particularly where extensive adhesions or concomitant procedures are present, CPB may be needed.

One point worth flagging is postoperative RV dysfunction. Once the constriction is suddenly relieved, the RV must cope with an abrupt rise in preload, which can produce transient functional decline. In this series, mildly impaired postoperative RV function became more common (32.1% versus 11.2%; p = .0049). This should not be read as a surgical failure but as a period of adaptation, one that calls for careful haemodynamic support and fluid management.

Surgical technique is not the only determinant of prognosis after pericardiectomy. Aetiology, baseline ventricular function, and coexisting valve disease all carry significant weight. Postradiation disease in particular tends to carry a worse outlook, likely reflecting concurrent myocardial damage, and preoperative RV dilatation has been flagged as a predictor of early death (OR = 3.5; p = .040). Taken together, these observations underline how much timing matters: operating before advanced myocardial injury sets in may improve outcomes regardless of which technique is ultimately chosen.

Taken as a whole, this work lends further weight to a growing consensus favouring total pericardiectomy in CP. Notwithstanding its limitations, it supports the notion that the extent of resection is not a mere technical nuance but a genuine prognostic factor. That said, the findings come from a retrospective study with inherent constraints and possible selection bias, so while the available evidence favours an extensive surgical approach, it does not remove the need to tailor the decision to each patient. In constrictive pericarditis, then, removing more of the pericardium is not always straightforward — but in many cases, it does appear to be the better choice.

REFERENCE:

Moawad KR, Mohamed MME, Abdelkhalik M, Aljasem H, Kho J, Pousious D, et al. Comparative outcomes of total versus partial pericardiectomy in constrictive pericarditis: a two-decade single-centre experience. Interdiscip Cardiovasc Thorac Surg. 2026;ivag147. doi:10.1093/icvts/ivag147.