Pericardiectomy is the definitive treatment for constrictive pericarditis, but two technical issues have remained unresolved for decades: the optimal extent of pericardial resection and the role of cardiopulmonary bypass (CPB). The Cleveland Clinic group addresses both questions in this retrospective observational study, published in Annals of Thoracic Surgery, including the largest cohort reported to date.

A total of 534 consecutive patients undergoing surgery between 2000 and 2022 were analyzed; 425 underwent radical pericardiectomy and 109 underwent partial pericardiectomy. The predominant etiology was idiopathic or viral (64%), followed by postcardiotomy (25%), postradiotherapy (6%), and miscellaneous causes (5%). To minimize selection bias, propensity-score matching was performed, resulting in 89 well-balanced pairs on which the main outcome comparisons were based.

Hemodynamic outcomes, morbidity/mortality, and long-term survival consistently favored radical pericardiectomy:

• Hemodynamics: cardiac index increased by 1.24 L/min/m² after radical resection compared with 0.56 L/min/m² after partial resection (p< .001), and central venous pressure decreased by 12 mm Hg versus 4.8 mm Hg (p < .001).
• Operative mortality: 3.4% in the radical group versus 17% in the partial group (p= .003), a clinically and statistically relevant difference.
• Ten-year survival: 62% versus 23% (propensity-adjusted hazard ratio = 3.1; 95% CI = 2.1–4.6), with significant differences in both the early and late phases.

Regarding CPB, its use was associated with a greater need for transfusion and reoperation for bleeding, but without a significant impact on survival. In the comparative analysis of radical pericardiectomy with and without CPB, patients operated on with CPB had worse preoperative hemodynamic status and lower intraoperative lactate levels, suggesting that CPB may provide a safer platform in more complex cases.

The authors adopt an oncologic philosophy in their approach: to remove all diseased pericardium, including calcified and scar tissue, with the aim of preventing recurrent constriction. This strategy, which has progressively gained ground at their institution (increasing from 60% to 95% during the study period), is supported by the data presented. The 3.4% mortality rate in the radical group is lower than that reported in previous meta-analyses (6.9%) and in historical series from referral centers.

From the CPB perspective, the study provides reassuring data: routine use of CPB to facilitate complete posterior resection does not increase mortality and may be particularly beneficial in patients with severe constriction. This position is consistent with the 2025 ACC Expert Consensus Statement, although it partially diverges from the 2025 ESC Guidelines, which do not recommend its routine use.

This study, the largest published to date on this topic, consolidates radical pericardiectomy as the benchmark standard in the surgical treatment of constrictive pericarditis. Its findings are especially relevant for cardiovascular surgeons, as they show that a more aggressive resection strategy, supported by CPB when necessary, is not only safe but also provides substantial hemodynamic and survival advantages over partial resection. Etiology remains the main determinant of long-term prognosis, with postradiotherapy patients representing the highest-risk group and having the poorest prognosis.

COMMENTARY:

Before beginning the critical commentary on the study presented here, I would particularly emphasize, with clear relevance to our routine practice, that radical pericardiectomy should be our standard choice when surgically treating these patients. It consists of complete pericardial excision, including both the diaphragmatic and posterior surfaces, with skeletonization and preservation of both phrenic nerves, and it shows superiority in terms of both mortality and long-term quality of life compared with partial pericardiectomy, traditionally limited to the anterior pericardium between both phrenic nerves.

This study represents one of the largest series available and is supported by a robust methodology, giving it considerable statistical weight. However, it also has relevant limitations that should be considered before extrapolating its conclusions to routine clinical practice.

First, the study uses propensity-score matching to balance preoperative variables and allow an appropriate comparison between both groups. Nevertheless, the survival difference between the radical and partial pericardiectomy groups is strikingly large and could be related to an intraoperative decision, not evaluated in the study, to abandon complete resection in high-risk situations or even in the setting of intraoperative complications. The early mortality data, particularly high in this group, would therefore influence the final results.

Second, the heterogeneity in the definition of radical resection, the use of CPB in patients undergoing concomitant procedures, and the fact that the study was performed at a single high-volume center (with an evident evolution in surgical technique and approach over the study period) somewhat limit its external validity.

Regarding CPB use, the authors acknowledge that it was historically used as a rescue strategy in high-risk situations and is now used routinely; therefore, combining both indications under the same variable limits the conclusions that can be drawn. Finally, follow-up does not include functional status or quality-of-life data in the patients studied, which also limits the clinical interpretation of the results.

As previously discussed in this blog, there are no clearly defined pathways for the surgical management of constrictive pericarditis. Although the evidence more consistently supports the benefit of radical over partial pericardiectomy, controversy remains regarding the use of CPB.

In conclusion, this study represents the strongest observational evidence available to date in favor of radical pericardiectomy supported mechanically by CPB and, despite certain limitations, may contribute to a shift in the traditional mindset within our departments.

REFERENCE:

Koprivanac M, Bauza K, Smedira N, Pettersson G, Unai S, Barrios P, et al. Radical Pericardiectomy and Use of Cardiopulmonary Bypass for Constrictive Pericarditis. Ann Thorac Surg. 2026 Apr;121(4):871-880. doi: 10.1016/j.athoracsur.2025.11.041.