Pericardiectomy

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Pericardiectomy
ICD-9-CM 37.31
MeSH D010492

Pericardiectomy is the surgical removal of part or most of the pericardium. [1] [2] This operation is most commonly used to relieve constrictive pericarditis, or to remove a pericardium that is calcified and fibrous. [2] It may also be used for severe or recurrent cases of pericardial effusion. [3] Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat. [4] [5]

Contents

Uses

Pericardiectomy is used to treat constrictive pericarditis, which is caused by a variety of conditions. [2] [3] It is also used to treat recurring cases of pericardial effusion. [3] [4]

Contra-indications

Pericardiectomy should not be used if more minor procedures are more appropriate, such as a pericardial window. [6] Pericardiectomy may not be appropriate for patients who already have a poor prognosis, as its medical benefit is reduced. This is because pericardiectomy has a higher rate of complications and a higher mortality. [6] More conservative treatment may use diuretics, digoxin, steroids, NSAIDs, or antibiotics to change cardiovascular physiology without treating the underlying pathology, which is appropriate for those not suitable for major surgery. [7] Some patients may undergo conservative treatment for a number of months before pericardiectomy is considered truly necessary. [7]

Risks

Pericardiectomy can cause a number of cardiac issues, such as arrhythmia, low cardiac output syndrome, and myocardial infarction (in rare cases). [2] There is some risk of damage to the pleural cavities around the lungs, which can lead to pneumonia, or pleural effusion. [2] It also presents typical surgical risks, such as infection, anaesthesia complications, blood clots, and bleeding. [2] [3] There is a low risk of haemorrhage if the heart is perforated whilst removing the pericardium. [3]

Outcomes after surgery depend significantly on the underlying cause of illness, and the function of the kidneys, left ventricle, and pulmonary arteries. [5] Recovery from pericardial effusion treated with pericardiectomy is typically very good. However, its use for treating constrictive pericarditis has a fairly high mortality rate, initially between 5% and 15%. [3] [4] The 5-year survival rate is around 80%. [3] The most common complication after surgery is reduced cardiac output, which occurs in between 14% and 28% of patients. [4]

Technique

Pericardiectomy takes place by removing the infected, fibrosed, or otherwise damaged pericardium. The procedure begins when the surgeon makes an incision in the skin over the breastbone and divides the breastbone to expose the pericardium, known as a median sternotomy. [3] [6] Alternatively, a larger incision known as a thoracotomy may be used. [6] During the surgery, the surgeon will hold the pericardium, cut the top of this fibrous covering of the heart, drop it into the specimen bag, and re-cover the heart. The breastbone is then wired back together and the incision is closed, completing the procedure. When the portion of pericardium lying between the two phrenic nerves is excised, it is called total pericardiectomy. In cases where total pericardiectomy is not possible, subtotal pericardiectomy is performed or, in extreme cases, a cruciate incision on the pericardium is performed.[ citation needed ]

Recovery

Heart function often recovers very quickly after pericardiectomy is performed, [8] although the surgery itself can cause reduced cardiac output in the short term. [4] After surgery, many patients will have a chest drain to remove pericardial fluid. [2] Hospital recovery takes several days, with surgical suture removed after a week. [2]

After pericardiectomy, the heart takes on a more rounded shape due to the lack of stretch with the diaphragm. [9] This does not appear to cause any cardiac issues, but may be detected with echocardiography. [9]

See also

Related Research Articles

<span class="mw-page-title-main">Pericardium</span> Double-walled sac containing the heart and roots of the great vessels

The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue, and an inner layer made of serous membrane. It encloses the pericardial cavity, which contains pericardial fluid, and defines the middle mediastinum. It separates the heart from interference of other structures, protects it against infection and blunt trauma, and lubricates the heart's movements.

<span class="mw-page-title-main">Cardiac tamponade</span> Buildup of fluid around the heart

Cardiac tamponade, also known as pericardial tamponade, is a compression of the heart due to pericardial effusion. Onset may be rapid or gradual. Symptoms typically include those of obstructive shock including shortness of breath, weakness, lightheadedness, and cough. Other symptoms may relate to the underlying cause.

<span class="mw-page-title-main">Constrictive pericarditis</span> Medical condition

Constrictive pericarditis is a condition characterized by a thickened, fibrotic pericardium, limiting the heart's ability to function normally. In many cases, the condition continues to be difficult to diagnose and therefore benefits from a good understanding of the underlying cause.

<span class="mw-page-title-main">Pericarditis</span> Medical condition

Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sitting up and more severe when lying down or breathing deeply. Other symptoms of pericarditis can include fever, weakness, palpitations, and shortness of breath. The onset of symptoms can occasionally be gradual rather than sudden.

<span class="mw-page-title-main">Pericardiocentesis</span> Procedure where fluid is aspirated from the pericardium

Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium.

Kussmaul's sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction.

Dressler syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium. It consists of fever, pleuritic pain, pericarditis and/or pericardial effusion.

<span class="mw-page-title-main">Mediastinum</span> Central part of the thoracic cavity

The mediastinum is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagus, the trachea, the phrenic and cardiac nerves, the thoracic duct, the thymus and the lymph nodes of the central chest.

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. Pulsus paradoxus is not related to pulse rate or heart rate, and it is not a paradoxical rise in systolic pressure. Normally, blood pressure drops less precipitously than 10 mmHg during inhalation. Pulsus paradoxus is a sign that is indicative of several conditions most commonly pericardial effusion.

<span class="mw-page-title-main">Pericardial effusion</span> Medical condition

A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of the serous membrane enclose the pericardial cavity between them. This pericardial space contains a small amount of pericardial fluid, normally 15-50 mL in volume. The pericardium, specifically the pericardial fluid provides lubrication, maintains the anatomic position of the heart in the chest, and also serves as a barrier to protect the heart from infection and inflammation in adjacent tissues and organs.

<span class="mw-page-title-main">Pericardial fluid</span>

Pericardial fluid is the serous fluid secreted by the serous layer of the pericardium into the pericardial cavity. The pericardium consists of two layers, an outer fibrous layer and the inner serous layer. This serous layer has two membranes which enclose the pericardial cavity into which is secreted the pericardial fluid. The fluid is similar to the cerebrospinal fluid of the brain which also serves to cushion and allow some movement of the organ.

<span class="mw-page-title-main">Pericardial sinus</span>

The pericardial sinuses are impressions in the pericardial sac formed between the points where great vessels enter it.

<span class="mw-page-title-main">Acute pericarditis</span> Medical condition

Acute pericarditis is a type of pericarditis usually lasting less than 6 weeks. It is the most common condition affecting the pericardium.

Autoimmune heart diseases are the effects of the body's own immune defense system mistaking cardiac antigens as foreign and attacking them leading to inflammation of the heart as a whole, or in parts. The commonest form of autoimmune heart disease is rheumatic heart disease or rheumatic fever.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

Tuberculous pericarditis is a form of pericarditis. It is a condition in which the pericardium surrounding the heart is infected by the bacterial species Mycobacterium tuberculosis. Tuberculous pericarditis accounts for a significant percentage of presentations of tuberculosis worldwide. The condition has four stages of disease which manifests with clinical presentations ranging from acute pericarditis to overt heart failure. Tuberculous pericarditis is an under-diagnosed condition. Diagnosis often requires a range of diagnostic tools, including pericardiocentesis, biochemical tests, and imaging. Treatment of this disease is similar to treatment of pulmonary tuberculosis. Alternative treatment options to reduce cardiac complications are also available.

A pericardial window is a cardiac surgical procedure to create a fistula – or "window" – from the pericardial space to the pleural cavity. The purpose of the window is to allow a pericardial effusion or cardiac tamponade to drain from the space surrounding the heart into the chest cavity.

<span class="mw-page-title-main">Postpericardiotomy syndrome</span> Medical condition

Postpericardiotomy syndrome (PPS) is a medical syndrome referring to an immune phenomenon that occurs days to months after surgical incision of the pericardium. PPS can also be caused after a trauma, a puncture of the cardiac or pleural structures, after percutaneous coronary intervention, or due to pacemaker or pacemaker wire placement.

<span class="mw-page-title-main">Purulent pericarditis</span> Inflammation of the sac surrounding the heart due to bacterial infection.

Purulent pericarditis refers to localized inflammation in the setting of infection of the pericardial sac surrounding the heart. In contrast to other causes of pericarditis which may have a viral etiology, purulent pericarditis refers specifically to bacterial or fungal infection of the pericardial sac. Clinical etiologies of purulent pericarditis may include recent surgery, adjacent infection, trauma, or even primary infection. The onset of purulent pericarditis is usually acute, with most individuals presenting to a medical facility approximately 3 days following the onset of symptoms.

References

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  4. 1 2 3 4 5 Fox, Jonathan F.; Smith, Mark M.; Nuttall, Gregory A.; Oliver, William C. (2018-01-01), Kaplan, Joel A. (ed.), "Chapter 18 - Uncommon Cardiac Diseases", Kaplan's Essentials of Cardiac Anesthesia (Second Edition), Philadelphia: Elsevier, pp. 426–472, doi:10.1016/b978-0-323-49798-5.00018-8, ISBN   978-0-323-49798-5, archived from the original on 2021-02-10, retrieved 2020-12-03
  5. 1 2 Trindade, Pedro T.; Meijboom, Folkert J. (2018-01-01), Gatzoulis, Michael A.; Webb, Gary D.; Daubeney, Piers E. F. (eds.), "62 - Constrictive Pericarditis and Restrictive Cardiomyopathy", Diagnosis and Management of Adult Congenital Heart Disease (Third Edition), Elsevier, pp. 622–630, doi:10.1016/b978-0-7020-6929-1.00062-9, ISBN   978-0-7020-6929-1 , retrieved 2020-12-03
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  7. 1 2 Hoit, Brian D. (2010-01-01), Levine, Glenn N. (ed.), "Chapter 53 - Pericarditis, Pericardial Constriction, and Pericardial Tamponade", Cardiology Secrets (Third Edition), Philadelphia: Mosby, pp. 341–347, ISBN   978-0-323-04525-4 , retrieved 2020-12-03
  8. ↑ Rabie, Rania; Wong, Florence S. (2012-01-01), Friedman, Lawrence S.; Keeffe, Emmet B. (eds.), "Chapter 20 - The liver in heart failure", Handbook of Liver Disease (Third Edition), Philadelphia: W.B. Saunders, pp. 268–281, doi:10.1016/b978-1-4377-1725-9.10020-6, ISBN   978-1-4377-1725-9, archived from the original on 2021-02-10, retrieved 2020-12-03
  9. 1 2 Klick, John C.; Ali, Jafer; Avery, Edwin G. (2014-01-01), Reich, David L.; Fischer, Gregory W. (eds.), "23 - Echocardiographic Evaluation of Pericardial Disease", Perioperative Transesophageal Echocardiography, Philadelphia: W.B. Saunders, pp. 253–264, doi:10.1016/b978-1-4557-0761-4.00023-2, ISBN   978-1-4557-0761-4, archived from the original on 2021-02-10, retrieved 2020-12-03
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