a)Constrictive Pericarditis
It is usually the end stage of inflammatory process involving pericardium. In developing world, infection with mycobacte'iium tuberculosis is still common.Other causes are bacterial, viral and rarely fungal. Non infective causes for constrictive pericarditis include idiopathic, post irradiation or post surgery,neoplastic, auto immune disease induced, uraemic post traumatic or due to sarcoidosis. Recently a few cases have been reported after insertion of implantable defibrillator patches.
Indications for Surgery
Once diagnosis of constrictive pericarditis is made and confirmed by chest X-ray,ECG, echocardiogram, CT, MRI scan, cardiac catheterisation and angio, surgical treatment should not be deferred. These tests help to differentiate constrictive pericarditis from restrictive cardiomyopathy.
The clinical presentation is dominated by signs and symptoms of right heart fhlure. There is reduced cardiac output due to reduced ventricular filling. In later'stages myocardium may be affected by infiltration and atrophy and surgerycarries very high mortality. Patient should have surgery before myocardium is irreversibly damaged, leading to right heart failure and cardiac cirrhosis.
Types of Surgery
Pericardiectomy is the procedure adopted.
Left Antero Lateral Thoracotomy Approach
Arterial and central venous pressure monitoring lines are placed. A left antero lateral thoracotomy is done through the 5th or 4th space. Left phrenic nerve is isolated as a pedicle and retracted. Pericardium away from calcified area is selected over the left venlricle. An incision is deepened and deepened 'till the myocardium bulges and it is pulsating. By sharp dissection, flaps are raised in the correct plain. Care is taken not to go into the myocardium as well as injure coronary vessels on the epicardium. Dissection is done with a sharp knife and the left ventricle is first released. Dissection is extended posterior to the phrenic nave and the thickened peiicardium is removed. The left ventricle is freed ikst as freeing right ventricle first can lead to pulmonary congestion and oedema.
Similarly the right ventricle and its outflow are released and freed. From a left thoracotomy no attempt is made to free the SVC and IVC as they are inaccessible. When calcific plaques are densely adherent, islands of these can be left on the ventricles. When dissection aild raising of the flaps are completed they are excised along with part of the pericardium over the diaphragm. Haeomostasis is achieved and chest closed with two pleural drains. It is a good idea to monitor arterial, left and right atrial pressures post-operatively.
Median Sternotonzy Approach
The preferred approach these days is through a median sternotomy.Pericardiectoiny proceeds in the same way as done through left thoracotomy, by freeing left ventricle first. Then right ventricle is freed. The excision is from one phrenic nerve to the other. Pulmonary outflow, and right atrium and the cavae also can be cleared through median sternotomy approach. On the left side the ventricle is freed upto the atrioventricular groove superiorly and up to the diaphragm inferiorly. Very rarely pericardiectomy will have to be done on cardiopulmonary bypass. In that case femoral cannulation and median sternotomy will be the best approach.
Results
Pericardiectomy used to have a moi-tality of 10-15 per cent in the earlier era. At present it is around 3 to 5 per cent and does not approach 0 per cent even though it is a closed heart operation.
b)Pericardial Effusion
Indications for Surgery
Pericardial effusion may be the result of peiicarditis due to infection,autoiwune disease or neoplasm. Non-inflammatoly diseases like renal failure,hypo thyroidism, amyloidosis and congestive heart failure can cause effusion. It can also be due to post cardiotomy syndrome. They may present with cardiac tamponade. It depends on the amount of fluid collected and also how rapidly the accumulation occurs. Pericardial effusion can occasionally be localised and then produce regional tamponade. Slow collection of fluid may not produce acute tamponade but present a picture of chronic effusive constrictive pericardial disease.
The diagnosis is confirmed by chest X-ray, ECG echocardiogram and finally by pericardiocentesis. Acule cardiac tamponade is an indication for emergency pericardiocentesis. In patients with renal failure, uraenlic peiicarditis with effusion is a known complikation. If they are on haemodialysis, the effusion may become haemorrhagic. It could be managed with increasing frequency of dialysis and adopting regional heparinisation duting haemodialysis.
Pericardiocentesis
This is usually done by the cardiologist. It is better done with ECG and haemodynamic monitoring. Subxyphoid route is preferred with the patient positioned at 45" angle. In ECG controlled technique the hub of the aspiration needle is connected to an electrode. When the exploring needle touches the epicardiuin it produces an ectopic pattei-n. Better than ECG control,echocardiograpl~ically controlled pericardiocentesis is the procedui-e of choice these days. Here the exact tip of the needle is visible thus avoiding myocardial injury. For diagnostic purpose, needle aspiration is adequate. However for therapeutic purpose, insertion of a pigtail catheter and drainage is a safer method.
Sub Xyphoid Pericardial Window
It could be done under local or general anaesthesia. A small vertical inidline incision is made over the xyphoid process on to the linea alba of abdomen.Xyphoid process is excised or retracted. The diaphragm is dissected away from the under surface or sternum and pe~icardium is incised under vision. Fluid is removed and adhesions are released gently with a ,blunt sucker, Fluid and tissue from pericardium are sent for n~icrobiological and histopathological examination.
A drain is inserted and connected to 10-15 mm or suction. The wound is closed lightly. Drain could be left for a few days till drainage comes down.Pericardinl Window Througlz Left Antero Lateral Tlzoracotorny A small left antero lateral thoracotomy is done through the 5"' intercostal space.A pericardial window is made anterior to the phrenic nerve by exicising a piece of pericardium. This effectively makes a pleuro pericardial window. The chest is closed with a drain in the pleura that will drain the pericardial fluid also.
Partial Pericardiectomy
The approach can be either by a left anterolateral thoracotomy or median sternotomy. For pyogenic peiicarditis with adhesions and loculations a partial peiicardiectomy gives better results than a subxyphoid window or pleuro pericardial window.
It is usually the end stage of inflammatory process involving pericardium. In developing world, infection with mycobacte'iium tuberculosis is still common.Other causes are bacterial, viral and rarely fungal. Non infective causes for constrictive pericarditis include idiopathic, post irradiation or post surgery,neoplastic, auto immune disease induced, uraemic post traumatic or due to sarcoidosis. Recently a few cases have been reported after insertion of implantable defibrillator patches.
Indications for Surgery
Once diagnosis of constrictive pericarditis is made and confirmed by chest X-ray,ECG, echocardiogram, CT, MRI scan, cardiac catheterisation and angio, surgical treatment should not be deferred. These tests help to differentiate constrictive pericarditis from restrictive cardiomyopathy.
The clinical presentation is dominated by signs and symptoms of right heart fhlure. There is reduced cardiac output due to reduced ventricular filling. In later'stages myocardium may be affected by infiltration and atrophy and surgerycarries very high mortality. Patient should have surgery before myocardium is irreversibly damaged, leading to right heart failure and cardiac cirrhosis.
Types of Surgery
Pericardiectomy is the procedure adopted.
Left Antero Lateral Thoracotomy Approach
Arterial and central venous pressure monitoring lines are placed. A left antero lateral thoracotomy is done through the 5th or 4th space. Left phrenic nerve is isolated as a pedicle and retracted. Pericardium away from calcified area is selected over the left venlricle. An incision is deepened and deepened 'till the myocardium bulges and it is pulsating. By sharp dissection, flaps are raised in the correct plain. Care is taken not to go into the myocardium as well as injure coronary vessels on the epicardium. Dissection is done with a sharp knife and the left ventricle is first released. Dissection is extended posterior to the phrenic nave and the thickened peiicardium is removed. The left ventricle is freed ikst as freeing right ventricle first can lead to pulmonary congestion and oedema.
Similarly the right ventricle and its outflow are released and freed. From a left thoracotomy no attempt is made to free the SVC and IVC as they are inaccessible. When calcific plaques are densely adherent, islands of these can be left on the ventricles. When dissection aild raising of the flaps are completed they are excised along with part of the pericardium over the diaphragm. Haeomostasis is achieved and chest closed with two pleural drains. It is a good idea to monitor arterial, left and right atrial pressures post-operatively.
Median Sternotonzy Approach
The preferred approach these days is through a median sternotomy.Pericardiectoiny proceeds in the same way as done through left thoracotomy, by freeing left ventricle first. Then right ventricle is freed. The excision is from one phrenic nerve to the other. Pulmonary outflow, and right atrium and the cavae also can be cleared through median sternotomy approach. On the left side the ventricle is freed upto the atrioventricular groove superiorly and up to the diaphragm inferiorly. Very rarely pericardiectomy will have to be done on cardiopulmonary bypass. In that case femoral cannulation and median sternotomy will be the best approach.
Results
Pericardiectomy used to have a moi-tality of 10-15 per cent in the earlier era. At present it is around 3 to 5 per cent and does not approach 0 per cent even though it is a closed heart operation.
b)Pericardial Effusion
Indications for Surgery
Pericardial effusion may be the result of peiicarditis due to infection,autoiwune disease or neoplasm. Non-inflammatoly diseases like renal failure,hypo thyroidism, amyloidosis and congestive heart failure can cause effusion. It can also be due to post cardiotomy syndrome. They may present with cardiac tamponade. It depends on the amount of fluid collected and also how rapidly the accumulation occurs. Pericardial effusion can occasionally be localised and then produce regional tamponade. Slow collection of fluid may not produce acute tamponade but present a picture of chronic effusive constrictive pericardial disease.
The diagnosis is confirmed by chest X-ray, ECG echocardiogram and finally by pericardiocentesis. Acule cardiac tamponade is an indication for emergency pericardiocentesis. In patients with renal failure, uraenlic peiicarditis with effusion is a known complikation. If they are on haemodialysis, the effusion may become haemorrhagic. It could be managed with increasing frequency of dialysis and adopting regional heparinisation duting haemodialysis.
Pericardiocentesis
This is usually done by the cardiologist. It is better done with ECG and haemodynamic monitoring. Subxyphoid route is preferred with the patient positioned at 45" angle. In ECG controlled technique the hub of the aspiration needle is connected to an electrode. When the exploring needle touches the epicardiuin it produces an ectopic pattei-n. Better than ECG control,echocardiograpl~ically controlled pericardiocentesis is the procedui-e of choice these days. Here the exact tip of the needle is visible thus avoiding myocardial injury. For diagnostic purpose, needle aspiration is adequate. However for therapeutic purpose, insertion of a pigtail catheter and drainage is a safer method.
Sub Xyphoid Pericardial Window
It could be done under local or general anaesthesia. A small vertical inidline incision is made over the xyphoid process on to the linea alba of abdomen.Xyphoid process is excised or retracted. The diaphragm is dissected away from the under surface or sternum and pe~icardium is incised under vision. Fluid is removed and adhesions are released gently with a ,blunt sucker, Fluid and tissue from pericardium are sent for n~icrobiological and histopathological examination.
A drain is inserted and connected to 10-15 mm or suction. The wound is closed lightly. Drain could be left for a few days till drainage comes down.Pericardinl Window Througlz Left Antero Lateral Tlzoracotorny A small left antero lateral thoracotomy is done through the 5"' intercostal space.A pericardial window is made anterior to the phrenic nerve by exicising a piece of pericardium. This effectively makes a pleuro pericardial window. The chest is closed with a drain in the pleura that will drain the pericardial fluid also.
Partial Pericardiectomy
The approach can be either by a left anterolateral thoracotomy or median sternotomy. For pyogenic peiicarditis with adhesions and loculations a partial peiicardiectomy gives better results than a subxyphoid window or pleuro pericardial window.
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