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We would like to thank Dr Jolobe for the valuable comments on our recently published case presentation.1 We agree with the commentator regarding the high expected perioperative mortality and morbidity of pericardiectomy for our patient. In a recently published paper, the outcomes of pericardiectomy in 1071 patients over eight decades in Mayo Clinic has been reviewed.2 Accordingly, in the contemporary era, in multi-variate analysis NYHA functional status IV carried 3.5-fold mortality when compared to patients with preserved function (NYHA of I or II). Although the surgical management of these patients continues to be a challenge, a great majority of patients (87%) did still survive the first 30 days after operation. In another report of a 20-year experience of pericardiectomy on 99 patients, survival at 5 years was around 80% and surgery was able to improve the functional status in the majority of surviving patients.3 The greatest contribution to the improvement of the surgical outcome of patients with constrictive pericarditis is due to relative decreases in the prevalence of tuberculosis which in turn contributes to the most difficult cases of pericardiectomy. Due to a relatively lower incidence of the disease, high-volume centers with more experienced physicians/surgical team who is familiar with both operative and post-operative care of these patients, offer advantages over the less-experienced low-volume centers. The treatment options and realistic predicted outcomes need to be presented to the patient and a multi-disciplinary decision should be made. As such in our case, patient understandably refrained from the high-risk surgery.

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