Perioperative outcomes and predictors of mortality after pericardiectomy for constrictive pericarditis in Africa: a systematic review and meta-analysis

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Abstract Background Constrictive pericarditis remains a significant cause of heart failure in Africa, predominantly due to tuberculosis; however, pericardiectomy outcomes across African settings have not been systematically synthesised. This review aimed to determine the pooled perioperative mortality following pericardiectomy for constrictive pericarditis in the African population and identify predictors of early death. Methods We searched PubMed, Scopus, African Journals Online, Cochrane Library, and Web of Science from inception to May 2026, supplemented by Google Scholar and citation tracking. Two reviewers independently screened the records and extracted the data, with a third reviewer resolving any disagreements. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Case Series. Perioperative mortality and aetiology were pooled using a random-effects model with Freeman-Tukey double arcsine transformation. The certainty of evidence was rated using GRADE. This systematic review and meta-analysis was conducted in accordance with the PRISMA 2020 statement. Results Of the 2148 records identified, 16 studies met the eligibility criteria and were included in the narrative synthesis, spanning South Africa, Côte d’Ivoire, Ethiopia, Ghana, Senegal, Gabon, and Nigeria. Eleven studies (604 patients) contributed to the pooled mortality analyses. The pooled perioperative mortality was 10.0% (95% confidence interval 6.5–14.0%), with substantial heterogeneity (I² = 51.5%) and evidence of funnel plot asymmetry on Egger’s test ( p = 0.004). Mortality was numerically highest in the East African cohorts (12.9%) and lowest in the Southern African cohorts (8.5%) in the subgroup analysis. In eleven studies with extractable presumed or clinically diagnosed aetiological data, the pooled proportion attributed to tuberculous or infectious aetiology was 72.5% (95% confidence interval 51.4 to 89.3%; I² = 96.4%), whereas in the nine studies reporting histology- or culture-confirmed (‘definite’) tuberculous aetiology as a distinct category, the pooled proportion was 32.5% (95% confidence interval 26.1 to 39.2%; I² = 60.9%), indicating that diagnostic certainty was a major driver of the heterogeneity in the broader aetiological estimate. Preoperative New York Heart Association functional class IV was the most consistently reported predictor of early mortality across studies. The certainty of evidence for the pooled mortality estimate was rated as very low. Conclusion Pericardiectomy for constrictive pericarditis in Africa carries a pooled perioperative mortality of approximately 10%. Tuberculous aetiology was common but highly heterogeneous in how it was diagnosed across studies, and advanced preoperative NYHA functional class IV was consistently associated with higher perioperative mortality, although this association was derived predominantly from retrospective, unadjusted, or single-study analyses. Given the very low certainty of the underlying evidence, these findings should be regarded as hypothesis-generating associations rather than established causal predictors; standardised, prospectively collected outcome data across African surgical centres are needed to determine whether earlier referral or other interventions could reduce this mortality burden. Clinical trial number Not applicable.