Surgical Management of Pericardial Diseases

doi:10.1016/j.pcad.2017.01.005

Progress in Cardiovascular Diseases

Volume 59, Issue 4, January–February 2017, Pages 407-416

https://doi.org/10.1016/j.pcad.2017.01.005 Get rights and content

Abstract

Disease of the pericardium represents a relatively rare indication for cardiac surgery, and there exist no widely accepted guidelines for surgical management. As such, the surgical approach to the pericardium has relied largely on institutional experience with a slow evolution based on published studies. In particular, management of pericardial constriction has varied widely from surgeon to surgeon and institution to institution, in large part due to a perception of inherent high risk to the procedure. This review covers the current practice of surgery for disease of the pericardium, with particular focus on the evolution of indications for pericardiectomy, new applications in inflammatory or relapsing pericarditis, and the progressive refinement in surgical technique and operative planning which have led to significantly improved outcomes in experienced centers.

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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Indications for pericardial biopsy
2021, Medicine (Spain)
La biopsia pericárdica tiene un papel relevante en la investigación etiológica de la patología pericárdica, siendo en este ámbito superior a la pericardiocentesis. La biopsia pericárdica debe hacerse del epicardio y del pericardio mediante un abordaje quirúrgico o intervencionista; la técnica debe adaptarse al tipo de paciente y patología. Las indicaciones de la biopsia pericárdica incluyen la enfermedad pericárdica con evolución desfavorable, el taponamiento cardíaco recidivante o la presencia de masas intrapericárdicas. La cirugía pericárdica se puede realizar mediante distintos abordajes, incluyendo la pericardioscopia, la ventana pericárdica, y la pericardiectomia. Las indicaciones de la cirugía pericárdica incluyen escenarios de patología congénita y adquirida del pericardio.
Pericardial biopsy has a relevant role in the etiological investigation of pericardial pathology, being in this area superior to pericardiocentesis. The pericardial biopsy should be obtained from the epicardium and pericardium through a surgical or an interventional approach; the technique must be adapted to the patient and pathology. Indications for pericardial biopsy include pericardial disease with unfavorable course, recurrent cardiac tamponade, or the presence of intrapericardial masses. Pericardial surgery can be performed using different approaches including pericardioscopy, a pericardial window, and a pericardiectomy. The indications for pericardial surgery include congenital and acquired pathology scenarios of the pericardium.
Clinical Update in Pericardial Diseases
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Citation 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
Patients with pericardial disease often require interventional therapies or surgery, making it essential for anesthesiologists to understand the altered physiology of these disease states and the resultant impact on perioperative management. The broad spectrum of syndromes involving the pericardium present with varying degrees of clinical significance, from asymptomatic presentations to life-threatening emergencies. Impaired diastolic filling of the heart represents a common theme of pericardial disease, with the rate of onset of pericardial pathology largely determining the extent of this impairment and subsequent severity of presentation. This review highlights recent updates in the literature regarding the diagnostic evaluation, medical therapy, and invasive therapeutic procedures for common pericardial syndromes from the perspective of a perioperative physician.
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Surgical Approaches for Pericardial Diseases: What Is New?
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EXPERIMENTAL PERICARDITIS
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"Turtle cage" method in the cardiac surgical treatment of constrictive pericarditis - our short-term results
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Surgical Management of Pericardial Diseases

Abstract

Section snippets

Surgical Anatomy and Function of the Pericardium

Evolution of Pericardial Surgery

Preoperative Workup

Operative Approach

Mortality

Perspective

Statement of Conflict of Interest

Mayo Clin Proc

Am J Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J AmColl Cardiol

Pericardial Disease

Circulation

Ueber pericardiale Verwachsungen

Med Klin

Decortication of the Heart (Delorme) for Adhesive Pericarditis

Arch Surg

Constrictive pericarditis, still a diagnostic challenge: comprehensive review of clinical management

Eur J Cardiothorac Surg

The incidence and clinical outcome of constrictive physiology after coronary artery bypass graft surgery

J Am Coll Cardiol