Constrictive Pericarditis Associated with Marlex Mesh: Two Case Reports

Abstract

Two patients were referred to our hospital with constrictive pericarditis approximately 1 year after undergoing mitral valve repair at another institution. Both repairs had included the use of a pericardial substitute, Marlex mesh, to prevent adhesion and to facilitate possible reoperations. Computed tomography and cardiac catheterization were used to establish the diagnosis of constrictive pericarditis.

During surgery, dense, thickened fibrous tissue, the result of a Marlex mesh-related reaction, was found tightly adhered to the epicardium in each of the patients. It appeared that the Marlex mesh, which had been inserted to facilitate reoperation, had contributed to the development of constrictive pericarditis.

Constrictive pericarditis is a chronic fibrous thickening of the pericardium, which restricts normal diastolic filling and cardiac output. Frequently, this disease is idiopathic; but it can occur after radiotherapy, cardiac surgery, infection, or as a result of connective tissue disease. ¹ A postoperative response of the pericardium to irritants (notably povidone-iodine and iced saline slush) or to hemopericardium has also been suggested as a possible cause of constrictive pericarditis. ^2,3 We report the cases of 2 patients with constrictive pericarditis who had previously undergone heart surgery with the insertion of Marlex mesh as a pericardial substitute.

Case Reports

Patient 1

A 45-year-old woman was referred to our hospital with suspected constrictive pericarditis. She had undergone mitral valve repair for symptomatic mitral valve prolapse 10 months earlier. At that time, Marlex mesh was inserted as a pericardial substitute before closure of the sternum, in order to prevent adhesion and to facilitate future reoperation should the need arise. After surgery, the patient's heart function improved from New York Heart Association (NYHA) functional class IV to class II. However, 1 month before she presented at our institution, she began experiencing exertional dyspnea, general fatigue, and peripheral edema, all of which were refractory to diuretics and digitalis.

Physical examination revealed a blood pressure of 130/100 mmHg; pulse rate, 100 beats/min; and body temperature, 37 °C. No pericardial knock was heard. The jugular vein was distended. Her abdomen was also distended, with hepatomegaly and ascites, and she had bilateral leg edema. Computerized tomography showed thickening of the pericardium. Cardiac catheterization revealed elevated diastolic pressure and an early diastolic “dip and plateau” configuration in the right and left ventricular pressures.

Patient 2

A 52-year-old man was referred to our hospital with suspected constrictive pericarditis. Twelve months earlier, he had undergone mitral valve repair for severe mitral regurgitation resulting from mitral valve prolapse; the repair had included the insertion of Marlex mesh as a pericardial substitute. Although the patient's heart function improved from NYHA functional class IV to class II after surgery, general fatigue, leg edema, and anorexia gradually developed, and he began medical therapy 1 month before presenting at our institution. His symptoms were refractory to therapy.

Physical examination revealed a blood pressure of 110/90 mmHg and a pulse rate of 120 beats/min. Hepatomegaly and ascites were present. Computerized tomography and cardiac catheterization showed the classic signs of constrictive pericarditis as described for Patient 1.

Patients 1 and 2

In each patient, the results of the physical examination indicated that a pericardiectomy was necessary. During reoperation, we found that a tissue-free space had formed between the sternum and the pericardial substitute, and this space facilitated opening of the sternum. However, thickened, dense fibrous tissue, clearly a reaction to the Marlex mesh, adhered to the underlying epicardium and penetrated the myocardium; this tissue inhibited diastolic filling of the heart. We removed the Marlex mesh (Fig. 1) and the fibrous tissue that had adhered to the epicardium, and the heart function of the patients improved.

Fig. 1 Gross appearance of the pericardial substitute, Marlex mesh, after removal.

Discussion

Rice and associates ⁴ reported the development of constrictive pericarditis after heart surgery in 1981. Since then, it has been estimated that constrictive pericarditis occurs after 0.2% to 0.33% of all heart operations. ^2,3

Due to improving cardiac surgical results with longer follow-up, more patients are expected to undergo cardiac reoperation in the future. Such patients, however, may be at greater surgical risk because of possible adhesion around the sternum, anterior chest wall, heart, and great vessels. Therefore, certain precautions are frequently taken during the original surgery in order to prevent such adhesions and the consequent tearing of the right ventricle, right atrium, or great vessels that might occur during sternal reentry. One such precaution is the insertion of a pericardial substitute ⁵ after cardiac procedures before the sternum is closed. Although many different materials have been tested to minimize epicardial adhesion and to facilitate reoperation, no material has proved ideal. Meus ⁶ and Heydorn's ⁷ groups achieved relatively good results in dogs with use of a polytetrafluoroethylene pericardial substitute, which caused minimal epicardial tissue reaction. Gallo and colleagues ⁵ used glutaraldehyde-preserved heterologous pericardium in a clinical trial comprising 58 patients. Results showed minimal tissue reaction for up to 6 months after pericardial replacement. Mitchell and coworkers ⁸ found that a hyaluronic acid, bioabsorbable membrane reduced postoperative pericardial adhesion in a canine model.

Both of our patients had undergone mitral valve repair at another institution, and Marlex mesh had been used as a pericardial substitute to prevent adhesion and to facilitate future reoperations. Symptoms of constrictive pericarditis appeared 10 to 12 months after the initial heart procedures.

These 2 cases clearly indicate that Marlex mesh, when used as a pericardial substitute, can provide a space between the sternum and the pericardium, thus facilitating reoperation. Nevertheless, Marlex mesh may also induce an epicardial tissue reaction that results in constrictive pericarditis.