|Performing a pericardiectomy. That evil looking device is a rib stretcher.|
When I asked about why I got back pain from inflamed tissue around heart arteries, I was told the pain was “referred.”
A study performed in Spain (Departamento de Cardiología y Cirugía Cardiaca, Hospital de la Santa Creu i de Sant Pau, Barcelona, España) found that of those patients who survived the initial procedure (16% did not), 82% were still alive after 9 years, and 64% after 10 years. Pericardiectomy improved or alleviated their symptoms. A study performed in France of long-term survival of pericardiectomy patients was not so positive. It found that pericardiectomy allowed a clear functional improvement, but following pericardiectomy more than 60% of patients died within 10 years of the diagnosis being made.
A Japanese study followed 24 post-pericardiectomy patients for up to 27 years, with surgeries taking place between 1966 and 1990. Survival rates were 85% at 5 years, 67% at 10 years, and 58% at 15 years. As in other studies I reviewed, the causes and complications encountered in the patient population varied considerably, making any definitive conclusions difficult.
A retrospective analysis of the records of 60 patients who underwent pericardiectomy over a 10-year period (1980 to 1990) at Johns Hopkins showed differential operative and long-term survival rates based on the cause of the disease. A history of malignancy, previous pericardial procedure, and preoperative New York Heart Association class IV were found to be predictors of poor survival. The operative mortality rate for pericardial effusion and constriction was 4.2% and 5.6%, respectively. Follow-up (median follow-up, 56.9 ± 38.2 months) was obtained on 56 patients (93.3%). Actuarial survival at 1 year, 5 years, and 10 years for all patients was 82.1% ± 5.1%, 71.7% ± 6.7%, and 59.8% ± 12.2%, respectively. All patients who underwent operation primarily for effusion with associated pain were found to be alive and had improved functional capacity without steroid use. The researchers concluded that pericardiectomy can be performed with low mortality and can result in good long-term survival and improved functional capacity. Patients who are seen primarily with pain refractory to steroid therapy can be relieved of symptoms with operation.
One has to be careful about how to interpret findings that survival rates after pericardiectomy are best when the cause of pericarditis is "idiopathic," i.e., unknown. This isn't a case of, "The less we know, the better your chances." What this means to me is that ruling out known serious illness/injury as an underlying cause of pericarditis, such as tuberculosis, cardiac surgery, cancer, etc., results in a patient population for whom pericardiectomy is more straightforward and less likely to result in follow-on complications, thus improving survival.
It was two or three days before a doctor brought in from the teaching hospital at the University of Illinois at Urbana-Champaign diagnosed my problem as pericarditis by identifying the rubbing sound he heard while listening to my chest as a “friction rub,” the sound of the inner and outer layers of the inflamed pericardium rubbing against each other. This was my first case of pericarditis. I was 24 years old. I would have another 9 episodes of pericarditis before my pericardium was removed at Wiesbaden AFB, Germany, in January of 1965.
I was a 2nd Lt when I first came down with pericarditis at Chanute. I had a second episode while there, was admitted to the hospital again, and after a few days, was permitted to attend class during the day and return to the hospital in the evening. I completed training with the class behind my class and received my assignment to the 36th Tactical Fighter Wing at Bitburg Air Force Base, Germany.
Medical tests failed to reveal the underlying cause of my pericarditis. It was recorded as "idiopathic," and presumed to be viral in nature. An interesting footnote was appended to the medical record, which stated that I had been quartered with Arab officer maintenance training students and one of them, an "Ahmed Gandi," had been hospitalized with "precordial pain." He was in the hospital 2 weeks, and then again a second time for 4 weeks. He did not finish the training course, and nothing more was known about his condition. The doctor at Wiesbaden preparing the clinical record preceding my pericardial window, an F. Steichen, wrote that, "It might be interesting to write to Chanute AFB Hospital to get the diagnosis of Gandi's disease." It's puzzling to me why Dr. Steichen would think this information relevant, since everything I've read indicates that viral pericarditis is not contagious. In any case, to my knowledge, no follow up was done on the matter.
I had my first "overseas attack" of pericarditis on the 15th of February 1963 and this time I told the examining physician at the hospital exactly what the diagnosis was. He had my medical records and gave me no argument. While hospitalized I developed an effusion and was treated with ACTH (prednisone).
|Air Force Hospital, Wiesbaden, Germany|
I was returned to Bitburg to convalesce from surgery and returned to full duty after two weeks. I had another attack of pericarditis on the 24th of April, then on the 19th of November, and the 14th of December. My next attack wasn't until August 3rd, 1964. I married my nurse in September 1964. We were spending so much time together we thought we might as well formalize the arrangement.
When I wasn't in the Bitburg Air Base hospital, I was working in my specialty as an aircraft maintenance officer, first on the flight line, then as Chief of Maintenance, then as an assistant maintenance control officer. I worked 12-hour days regularly, and we were subject to frequent alerts, when the horn would sound at 0300 hours and we'd sprint to the flight line, not knowing whether it was another drill, or whether the Russians were charging across the Fulda Gap.
My frequent bouts with pericarditis effected me in three ways. First, I was less physically fit than I had been going into the Air Force. I'd been active in sports and was in excellent physical condition. I enjoyed running, but after several episodes of pericarditis, I found I had no "umph" in my legs. I remember starting to run on the air base track and staggering to a stop, bent over, hands on my knees. It was a very discouraging experience.
Second, my officer evaluations had been downgraded from outstanding to excellent by the reviewing officer, and my recommendation for a Regular Air Force Commission had been refused by the reviewing officer, on both counts because of my frequent attacks of pericarditis. I'd been hospitalized or confined to quarters a third of the time I'd been at Bitburg. I couldn't blame the reviewing officer for thinking that my boss was inflating my evaluation.
|Bitburg AFB Hospital|
The surgeon performing the procedure was Dr. Dale E. Dominy, a 39 year-old Air Force major. In his operation report he wrote, "the left pleural space was entered through a left anterior chest incision [Dr. Dominy noted that I already had a previous right thoracotomy] with finding of considerable adhesion of lung to pericardium." Dr. Dominy went on to describe the surgery as, "excision of the pericardium to the region of the right phrenic nerve, the aorta and pulmonary artery..." Dr. Dominy stated that, "the left phrenic vessels and nerve were preserved."
Dr. Dominy wrote that I tolerated the procedure satisfactorily and was taken to recovery in excellent condition. My wife, who saw me leave surgery after what she thought was 4 to 6 hours, said I looked, "gray."
I returned to Bitburg to convalese, and then returned to duty. Unfortunately, my struggle with pericarditis was not over.
I had another episode of pericardial pain in October 1965, and was treated as an outpatient.
In May of '66 I was notified that I had again been disqualified medically for a regular commission. Also in May of that year I was granted a waiver by the flight surgeon and given medical clearance for an altitude chamber flight.
In June of 1966, 3 months prior to my reassignment date, I experienced pain in my right shoulder, across my chest, and into my rib cage. Deep breathing exacerbated the pain, as did lying flat. This was all very similar to my experience before the pericardiectomy. Serial EKGs revealed "evolutionary changes of acute pericarditis with minimal improvement noted in later tracings." Not a good sign.
I had been receiving outstanding performance evaluations (this time not overturned by the reviewing officer), I had been promoted to 1st Lt, and then captain, and I had been selected to attend the Air Force Institute of Technology (AFIT) to study for an advanced degree in human factors engineering at Texas Tech starting at the beginning of the school year, September 1966. My wife was pregnant with our second child and was expecting in October.
Thinking myself fit for world wide duty, I had also volunteered for Vietnam, something I had yet to tell my wife. It didn't seem that this was going to be a problem.
My wife and I decided that she and our 18-month old son should return to the States ahead of me and stay with her parents while I underwent the medical board at Wiesbaden. It was a very difficult trip for her. For me, it was a month of examinations, consultations, waiting, and wondering what the doctors at Wiesbaden would determine about my future in the Air Force.
The Wiesbaden medical staff decided that I was fit for worldwide duty, so informed my commander, and my permanent change of station (PCS) orders were cut, and was on a flight to McQuire Air Force Base, where I'd shipped my Volkswagen Beetle 2 months earlier.
Amazingly, the VW started right up, and I drove immediately to Florida to see my wife and son, and then on to Lubbock, Texas, to start school at Texas Tech, leaving my wife in Florida with her parents and under the care of her brother, who was a doctor.
I kept in virtually constant touch with my wife and was troubled to learn that she'd had some bleeding and had been put on bed rest awaiting delivery. She was bored, but otherwise seemed okay, or at least she made me believe that was the case.
My Air Force sponsor helped me locate a modest, three bedroom house in a quiet neighborhood and I located my household goods and had them shipped. In the meantime, I started attending classes. Our second son was born 5 weeks prematurely on September 19, 1966. He was being kept in the hospital for observation. My wife was okay.
On October 25, 1966, I was required to report to the local AFIT commander, who handed me a letter from the Air Force Surgeon General disapproving the recommendation of the Wiesbaden medical board and requiring that I undergo another medical evaluation board. My fight to continue my Air Force career without my pericardium was not yet over.
Continued -- click here.