Surgical Management of Pericardial Diseases
Section snippets
Surgical Anatomy and Function of the Pericardium
The pericardium surrounds the heart with a thin flexible membrane, which has often been described as providing a “protective layer” around the heart, although this teleological explanation is debatable.1 The pericardium is composed of multiple layers, including a serosal layer and a fibrous layer. The serosal component is composed of single layer of mesothelium that forms the parietal and visceral layers; the parietal layer lines the fibrous pericardium and together they compose the parietal
Evolution of Pericardial Surgery
Morgagni described pericardial constriction in 1761 as “A heart so constricted and confined that it could not receive a proper quantity of blood to pass through it.” Surgery to relieve pericardial constriction was suggested in 1828 by De Lome, and the relationship between pericardial constriction and liver dysfunction was identified as early as 1896 by Pick. However the first documented pericardial resection for constriction was performed by Rehn in 1913 via a left anterolateral thoracotomy,2
Preoperative Workup
An understanding of symptomatology and the progression of manifestations is critical to appropriate decision making regarding timing and appropriateness of surgery for pericardial disease. Preoperative workup is tailored to the etiology physiology of the disease. For congenital pericardial disease, a diagnosis may be made with echocardiography, CT, or MRI, and preparation for operation requires only routine pre-operative clearance studies. In contrast, patients with pericardial constriction
Operative Approach
Pericardiectomy can be performed via median sternotomy, clamshell incision, or bilateral thoracotomy incisions and with or without the use of cardiopulmonary bypass. Controversy exists as to the desired approach and extent of resection.21
A number of reports have suggested a minimalist approach to pericardial resection for constrictive disease, based on the perceived risk of operation in this patient population, and the idea that more extensive resection, in particular with the use of
Mortality
Pericardiectomy has been considered to be a high risk intervention based on early studies suggesting a mortality of as much as 15% in patients with pericardial constriction.28 Acute mortality after pericardiectomy is related to era of surgery, and in particular to the indication for pericardiectomy. More recent series have demonstrated significantly lower mortality. The reasons for this are likely multifactorial. One factor which is not well described in the existing literature is the severity
Perspective
Pericardial disease presents an uncommon, heterogeneous, and difficult to diagnose complex of surgical conditions with widely varying published outcomes. Pericardial constriction in particular is underdiagnosed and likely undertreated secondary to a perception that pericardiectomy is a high risk procedure. Because of this perception, a minimalist approach to surgery has often been advocated. With expanding experience with pericardiectomy for indications such as relapsing pericarditis, it has
Statement of Conflict of Interest
The author declares no conflict of interest.
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Cited by (12)
Indications for pericardial biopsy
2021, Medicine (Spain)Clinical Update in Pericardial Diseases
2019, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Not only must the parietal pericardium be resected, but the visceral pericardium also is a source of constrictive physiology and must be addressed. If the epicardium is densely adherent to the cardiac chambers, then small incisions in a checkerboard pattern may be made in the epicardium to alleviate the constrictive effect.51,52 Additionally, calcifications may be embedded within the walls of the atria and ventricles, and attempts to remove the calcification may lead to tearing of the chamber walls.51
Advances in Echocardiography
2018, Progress in Cardiovascular DiseasesSurgical Approaches for Pericardial Diseases: What Is New?
2023, Current Cardiology ReportsEXPERIMENTAL PERICARDITIS
2023, Avicenna Bulletin