<div><b>Institutions</b></div><div>1 – Department of Cardiovascular and Thoracic Surgery, University of
Louisville, Louisville, KY</div><div><b>Word count</b> – 497</div><div><b>Corresponding author</b> – Siddharth Pahwa, MD</div><div>Department of Cardiovascular and Thoracic Surgery</div><div>University of Louisville, Louisville, KY</div><div>Phone – 502-588-7600</div><div>Email –
siddharth.pahwa@uoflhealth.org</div><div>Surgical pericardiectomy has been established as the standard of care
for constrictive pericarditis (CP).<sup>1</sup> Radiation induced
CP presents a unique challenge.<sup>2</sup> The effects of
radiation on other cardiac structures, including the coronary
vasculature and cardiac valves, and the associated myocardial fibrosis
and dense plane of adhesions makes surgery especially challenging in
this subset of patients. Nozohoor, in their recent invited commentary,
rightly mentioned the importance of early surgery with prompt referral
to tertiary centers with the ability to care for these complex
patients.<sup>3</sup> We have three comments to make on their
excellent article.</div><div>Firstly, they mentioned that performing concomitant procedures along
with pericardiectomy for CP may have an adverse effect on
outcomes.<sup>3</sup> While this may be true for other subsets of
CP, Pahwa and colleagues, in their recent study on the outcomes of
pericardiectomy in patients with radiation-associated CP, had shown no
difference in survival between patients that underwent pericardiectomy
with concomitant cardiac procedures and patients that underwent isolated
pericardiectomy.<sup>4</sup> Secondly, Nozohoor pointed out that
the improvement in radiation technology and delivery systems over the
years have led to sparing of adjacent normal tissue.<sup>3</sup>Damage to adjacent myocardium and the pan-cardiac involvement in
radiation-induced CP has added to the increased complexity and poor
outcomes in this population. While Pahwa et al did not show a
statistically significant decrease in mortality over time in their study
spanning 18 years, their data suggested an improvement in survival over
time, that trended towards significance.<sup>4</sup> This may be
attributed to the improved radiation delivery over time as well, as
Nozohoor had discussed.</div><div>Lastly, although pericardiectomy for radiation-associated CP is
associated with poor long-term outcomes in terms of patient
survival<sup>4</sup>, it may be worthwhile to look at the
functional outcomes of patients suffering from the disease. Nozohoor
mentioned that the functional class and quality of life may be greatly
improved by surgical pericardiectomy in radiation-associated
constriction.<sup>3</sup> We strongly endorse this suggestion,
and believe that surgery remains the gold standard in the management of
radiation-associated CP. Further studies are needed to look at
functional outcomes, hospital re-admissions and quality of life
variables in this complex subset of patients, which may further
re-affirm the value of pericardiectomy.</div>