Anti-inflammatory properties of amniotic membrane patch following pericardiectomy for constrictive pericarditis
© The Author(s). 2017
Received: 8 July 2016
Accepted: 19 January 2017
Published: 26 January 2017
Since constrictive pericarditis is most often idiopathic and the pathophysiology remains largely unknown, both the diagnosis and the treatment can be challenging. However, by definition, inflammatory processes are central to this disease process. Amniotic membrane patches have been shown to possess anti-inflammatory properties and are believed to be immune privileged. Due to these properties, amniotic membrane patches were applied intraoperatively in a complicated patient presenting with constrictive pericarditis.
A patient with a history of multiple cardiac surgeries presented with marked fatigue, worsening dyspnea and sinus tachycardia. He was found to have constrictive physiology during cardiac catheterization, with cardiac MRI demonstrating hepatic vein dilatation, atrial enlargement and ventricular narrowing. After amniotic membrane patch treatment and pericardiectomy, post-operative cardiac MRI failed to demonstrate any appreciable pericardial effusion or inflammation, with no increased T2 signal that would suggest edema.
Given the positive results seen in this complex patient, we suggest continued research into the beneficial properties of amniotic membrane patches in cardiac surgery.
KeywordsConstrictive pericarditis Amniotic membrane patch Orthotopic heart transplant
Constrictive pericarditis results in a thickened and less-elastic pericardium, which can lead to incomplete diastolic filling and myocardial ischemia . Since it is rare and the presenting symptoms are similar to those of several other disorders, the diagnosis can often be challenging. The diagnosis is usually made using cardiac catheterization or echocardiography as a part of the patient’s initial clinical evaluation. Although there are multiple etiologies of constrictive pericarditis, in most cases, the pathophysiology is idiopathic or may occur following cardiac surgical procedures including orthotopic heart transplant . Constrictive pericarditis is commonly treated with pericardiectomy; however even following surgical intervention, long-term survival decreases over time and further diminishes when patient history includes multiple cardiac re-operations .
It has recently been demonstrated that amniotic stem cell therapy consisting of either stem cells with extracellular matrix or extracellular matrix alone can decrease fibrosis and post operative inflammation in humans [4, 5]. Specifically, extracellular matrix in the form of human amniotic membrane allograft has shown to significantly reduce post-ischemic cardiac dysfunction, improve ischemic heart repair, and increase blood flow recovery in rat and mouse models [6, 7]. This immunoprivileged tissue does not need to be donor-recipient matched to produce positive outcomes, further supporting its convenience of use and value . In the context of these anti-inflammatory properties, and since inflammatory processes are central to the pathophysiology of pericarditis, amniotic membrane patches were applied intraoperatively in a patient presenting with constrictive pericarditis as outlined below.
Constrictive pericarditis is difficult to diagnose given its rare occurence and that the presenting symptoms are similar to those of several other disorders. In our patient, this diagnosis was further complicated by his history of orthotopic heart transplant. While the techniques continue to evolve, imaging patients in order to optimize diagnosis following cardiac transplant is limited . Given our patient’s surgical history and clinical presentation, the constrictive physiology from cardiac catheterization was considered to be a more reliable diagnostic measure than both the MRI and echocardiogram findings. The case discussed serves as a prime example for the need to develop alternate non-invasive imaging techniques or algorithms for improved diagnostic capacity in patients with prior orthotopic heart transplant.
Another confounding variable in diagnosing constrictive pericarditis in our patient was the steep y descent on JVP. Although Freidreich’s sign is suggestive for constrictive pericarditis, our patient was also diagnosed with severe tricuspid regurgitation. However, despite these diagnostic difficulties, the patient was known to have prior Gore-Tex membrane placement during surgery. This iatrogenic component is another factor that may, in part, explain his constrictive physiology.
As discussed previously, pericardiectomy is often performed as a curative procedure for constrictive pericarditis. However there are instances, particularly for patients with advanced constrictive pericarditis or with radiation disease, in which pericardiectomy may not offer a cure or desired long-term result . For these patients with higher risk factors, it may be beneficial to explore additional or alternative treatment options. Current treatment of recurrent pericarditis has focused on targeting inflammation, and has shown overall positive outcomes . Given our patient’s extensive cardiac history of orthotopic heart transplant, reoperation for tricuspid valve repair, and Gore-Tex adhesions, extraordinary care was initiated in an attempt to resolve his constrictive pericarditis. As an emerging anti-inflammatory and anti-fibrotic treatment, the use of human allograft membrane has proven to be both safe and effective in humans thus far and continues to pique interest as an alternative therapy option [7, 8]. The anti-inflammatory properties of this treatment were exemplified, as our patient had no evidence of inflammation notable on T2-weighted MRI five weeks postoperatively (Fig. 3b). Given the positive results, we suggest continued research into the beneficial properties of amniotic membrane patches in cardiac surgery.
Constrictive pericarditis is difficult to treat, and even a pericardiectomy may not offer a cure or desired long-term result. Given the inflammatory processes central to this disease process, amniotic membrane patches were used as anti-inflammatory treatment in a patient with a complicated history. With the amniotic membrane patch treatment and pericardiectomy, our patient had no evidence of inflammation five weeks postoperatively on T2-weighted MRI, highlighting the importance of continued research in this area.
Bis in die (twice a day)
Jugular venous pressure
Magnetic resonance imaging
Pathologic antibody-mediated rejection
The authors would like to thank the patient and family, University of Arizona College of Medicine, Department of Surgery- Division of Cardiothoracic Surgery.
The authors declare no funding for this publication.
Availability of data and materials
All data generated or analyzed during this study are included in this published article [and its Additional file 1].
KM, AF, TP, DS, RA- Participated in data collection and interpretation. Wrote and revised manuscript. AD, MF, IO, CJ- Participated in data collection and interpretation. ZK- Performed described surgery, interpreted data, revised manuscript. All authors approved the final version of the manuscript.
The author (Zain Khalpey) of this publication has (i) received research support from Amnio Technology, LLC, and (ii) served as a paid consultant for Amnio Technology, LLC within the twenty-four month period preceding this publication. The terms of this arrangement have been reviewed and appropriately managed by the University of Arizona in accordance with its conflict of interest policies.
Additionally, author Tia Pilikian receives salary support from Amnio Technology.
Consent for publication
Deceased patient, family could not be reached at time of submission.
Ethics approval and consent to participate
Ethics approval and consent were obtained through a University of Arizona Institutional Review Board approved study (CAPTURED, IRB#1300000194).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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