Pericardiectomy: A Functional Anatomical Perspective for the Choice of Left Anterolateral Thoracotomy

Abstract   Although pericardiectomy remains an established method for pericardial resection, the choice of surgical approach is not definitive. Within South Africa, surgical referral for tuberculosis-induced chronic constrictive pericarditis has not declined. Anecdotal reports have indicated good operative results that appear to show an association with choice of surgical technique used. This study aimed to provide a functional anatomical perspective for performance and recovery of the heart during pericardiectomy based on anatomical dissection and surgical notes. En bloc specimens were harvested from 16 fresh cadavers and pericardial segments were measured in terms of percentage cover over surface area of the myocardium. Retrospective analysis of 116 surgical reports of pericardiectomy performed over a period of 20 years was conducted. Surgical notes were compared for median sternotomy and anterolateral left thoracotomy. Results from anatomical study indicated that although the anterior pericardium between the phrenic nerves constitutes about 58% of total selected pericardial area, total pericardium accessible over left ventricle from that approach was only 26%. When orientated in left anterolateral position, total accessible area of left ventricular pericardium was 37%. Standard deviations were found to be comparable. Means were significantly different, indicating that the left anterolateral approach allows wider access to the left ventricle. This paper provides a functional anatomical perspective for the choice of left anterolateral thoracotomy as a surgical approach for pericardiectomy.     

Tricuspid Valve Regurgitation in Patients Undergoing Pericardiectomy for Constrictive Pericarditis

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慢性缩窄性心包炎的围术期处理

目的探讨慢性缩窄性心包炎的围术期处理方法. 方法 96例慢性缩窄性心包炎病人均行心包剥脱术. 结果全组死亡1例(1.04%).82例(85.41%)随访2个月～15年,其中80例心功能得到改善. 结论心包剥离术是治疗慢性缩窄性心包炎的有效方法,而良好的围术期处理至关重要.     

Traumatic Hemopericardium and Chronic Constrictive Pericarditis

Chronic constrictive pericarditis following traumatic hemopericardium has been reported in recent years, but it has not been reproduced experimentally in dogs. The present study attempted to produce posttraumatic constrictive pericarditis in 34 experimental animals.Hemopericardium by means of trauma to the epicardium or pericardium was produced by a sharp instrument or by the injection of autologous blood inside the pericardial sac. All animals were killed at intervals between 3 and 31 months.The animals in which hemopericardium was induced by injecting blood into the pericardial cavity showed no changes. The hemopericardium was completely resolved without noticeable residual trace. Animals having hemopericardium as a result of trauma evidenced a well-developed constrictive pericarditis that was documented clinically, hemo-dynamically, and histologically.These experimental findings indicate that chronic constrictive pericarditis may well be due to traumatic hemopericardium rather than to specific infection.     

慢性缩窄性心包炎的外科治疗

目的 总结慢性缩窄性心包炎的外科治疗经验。方法 78例患者术前均被明确诊断为慢性缩窄性心包炎，均在全身麻醉下经胸部正中切口行心包剥脱术。结果 术后中心静脉压6．5～14．0mmHg（1kPa=7．5mmHg），平均8mmHg。死亡1例，再次开胸止血2例，发生低心排血量综合征3例。术后病理检查：心包纤维结缔组织增生、玻璃样变性60例，呈于酪样结核病变18例（伴结核肉芽肿形成7例）。随访65例，随访时间3个月～10年，心功能（NYHA）均为I级，无心包缩窄复发和死亡。结论 手术是治疗慢性缩窄性心包炎惟一有效的方法，胸部正中切口是较佳的手术径路，心包切除范围应根据具体病情而定，力争将心包彻底松解切除。     

慢性缩窄性心包炎的外科治疗

我院1987年5月至1994年5月对54例慢性缩窄性心包炎患者施行了手术治疗，除1例外均未用胸骨正中劈开入路，53例近期症状明显改善，无手术死亡，本文对54例患者的病因，手术方法及围术期处理进行讨论，我们认为，掌握好手术时机及手术方法，注意围术期处理是疗效满意的关键。     

Pericardiectomy to Treat Constrictive Pericarditis in a Patient with Hyperbilirubinemia: Report of a Case

An 18-year-old man was admitted to our hospital with abdominal distension and edema of both legs. His total serum bilirubin level was 5.2mg/dl. Echocardiography showed impaired left ventricular contraction, and computed tomography showed a thickened pericardium with massive pleural effusion and ascites. Cardiac catheterization showed both a dip and a plateau in the right ventricle pressure curve, based on which we diagnosed constrictive pericarditis. The selected treatment option was a pericardiectomy. We dissected the thickened pericardium, which was about 7–10mm thick, and removed as much as possible through a median sternotomy without cardiopulmonary bypass. Postoperatively, his hemodynamics and renal dysfunction improved, and the serum bilirubin level gradually decreased. We report this case to show how pericardiectomy was effective not only for improving this patients hemodynamics, but also for resolving his hyperbilirubinemia. The relevant literature is reviewed following this case report.     

Needle Embolus Causing Cardiac Puncture and Chronic Constrictive Pericarditis

We present a case in which a needle broke off during intravenous injection and embolized to the right heart. After cardiac perforation, the needle entered the pericardial space and ultimately caused chronic constrictive pericarditis, which presented as congestive heart failure. Pericardectomy and removal of the foreign body via a median sternotomy were successful. Early surgical removal of contaminated intrapericardial foreign bodies remains a safe and effective approach to preventing such complications.