Pericardiectomy
Bryan A. Whitson, MD, PhD1 and Sara J. Shumway, MD2
1 The Ohio State University Wexner Medical Center Department of Surgery Division of Cardiac Surgery N-813 Doan Hall, 410 W. 10th Ave., Columbus, OH 43210 bryanwhitson@gmail.com; bryan.whitson@osumc.edu
2 The University of Minnesota Department of Surgery Division of Cardiovascular and Thoracic Surgery MMC 207, 420 Delaware St. SE, Minneapolis, MN 55455

​Procedure
Pericardiectomy

Indications/contra-indications
Pericardiectomy is typically indicated for constrictive pericarditis.  It is subsequent to an inflammatory process of the pericardium which leads to a scarring and constriction of the fibrous pericardium surrounding the heart.  The inciting events may be ultimately unknown, but factors that have been attributed to constrictive pericarditis are: idiopathic, viral, tuberculosis, chronic renal insufficiency, previous cardiac surgery, previous intrapercardial blood, external beam radiation to the mediastinum, and trauma.
A hallmark of this diagnosis is impaired diastolic function causing systemic signs of right-sided heart failure.  There is a suggestion of right-sided failure and pulmonary congestion.  It is important to exclude restrictive cardiomyopathy, severe isolated tricuspid regurgitation, pulmonary embolism, etc.

Pre-op
Special diagnostic or imaging tests
Preoperatively, an electrocardiogram, echocardiogram and right and left heart catheterization should be performed.  There may be a role for cardiac CT or cardiac MRI to evaluate for restrictive cardiomyopathies.

Relevant anatomy (if any)
The pericardium should be resected from phrenic nerve to phrenic nerve and from the pericardial reflection at the innominate vein to the diaphragmatic surface, inferior-posteriorly to the inlet of the inferior vena cava into the mediastinum.  Both pleura are entered in order to adequately visualize the phrenic nerves.
 
Anesthesia
General endotracheal anesthesia is used.  If there is a pericardial effusion and/or tamponade, care on induction must occur to watch for and treat hemodynamic collapse.  Volume expansion should be considered.  During the dissection, there may be a need for vasopressor support to maintain adequate blood pressure during resection of highly adherent calcified pericardium.
 
Monitoring lines
Arterial line, and large bore, central venous catheter access are needed.  Typically a pulmonary artery catheter is utilized as well, but not required.  A Foley catheter is needed as well.  If the case is a redo-sternotomy, a femoral arterial line is often placed in the event that rapid femoral cannulation is needed.
 
TEE
Trans-esophageal echocardiogram is not mandatory.  Its use, however, can provide adjunctive information in the post-cardiotomy setting or when there is a concern about the need for concomitant procedures.
 
Antibiotics
Typical surgical antibiotics prophylaxis is utilized.  Cefazolin is often adequate.  In the setting of a patient with colonization with methicillin resistant S. Aureus, vancomycin is the agent of choice.  In the setting of penicillin or cephalosporin allergy, vancomycin or carbapenem is used.  Antibiotics added into warm saline irrigation is also typically used, per routine.
 
Prep
Typical surgical preparation solution is used from the angle of the jaw to at least the knee and from “bed-to-bed” laterally.
 
Positioning
The patient is positioned supine, with a shoulder roll.  The arms are securely “tucked” at the patient’s side.
 
Incision
From the sternal notch to xyphoid. Sternotomy is made in the standard fashion with bone wax and electrocautery used to facilitate hemostasis
 
Retractor
A traditional sternal retractor can be utilized, per the surgeon’s preference.
 
Intra-op
Intraoperatively, there is no special imaging needed.  A standard median sternotomy is performed.  If the operation is a reoperative cardiac surgery, accessing the femoral vessels with an arterial line and a wire in the femoral vein in case of a need for rapid conversion to cardiopulmonary bypass is prudent.  The pericardium is typically densely adherent to the epicardial surface and calcified.  The dissection is performed with meticulous technique.  Care is taken to avoid injury to epicardial vessels.  As the dissection proceeds, it may be advisable to perform the pericardial resection from the left ventricle initially.  This is to prevent the theoretical concern for liberating the right ventricle, it becoming distended, and having subsequent overload due to a continued left side constriction.  The dissection is performed from the phrenic nerve to phrenic nerve and from the great vessels to diaphragm and IVC origin.  The dissection can typically be performed without the need for cardiopulmonary bypass.  At the conclusion of the operation, a complete check for hemostasis is required with topical adjuncts used as needed.  Adequate mediastinal and pleural drainage is performed with bilateral pleural chest tubes as well as 2 or 3 mediastinal chest tubes.
 
Special Instruments
No special instruments are needed
 
Heparin + Adjuncts
The anticipated conduct of the operation would be to perform the complete dissection without cardiopulmonary bypass.  However, if bypass is needed, either for hemodynamic support or to repair an epicardial injury inherent to the dissection of the densely adherent pericardium, full dose systemic heparinization anticoagulation is utilized with reversal of the anticoagulation with protamine sulfate at the conclusion of the bypass run.
 
Arterial cannulation-----cannula, sutures
In the event that cardiopulmonary bypass is needed, the patient may be placed on cardiopulmonary bypass either centrally or through femoral cannulation.  If direct central cannulation is used, the cannula is secured with 2 concentrically pledgeted 2-0 or 3-0.  If femoral cannulation is used, the authors typically repair the femoral artery directly at the time of removal of the cannula. 
 
Venous cannulation-----cannula, sutures
If cardiopulmonary bypass is needed, venous cannulation can be achieved either centrally via the right atrium (typical right atrial cannulation) or via the femoral vein.  For the right atrial cannulation, suture is a 2-0 or 3-0 non-absorbable monofilament or braided per surgeon preference.  Femoral vein cannulation can be achieved either percutaneously or via direct cut-down and exposure of the femoral vessels.
 
Cardioplegia
Cardioplegia is not typically needed.
 
Temperature
Every attempt should be made to keep the patient normothermic in order to minimize coagulopathy.  A sterile air-heating mattress can be helpful.
 
Prosthetic material
Typically no prosthetic material is needed.
 
Pacing wires-----atrial, ventricular
Atrial and ventricular epicardial pacing wires are sometimes felt to be an advantage depending on the cardiac function, the heart rate, the need for cardiopulmonary bypass and any other concomitant procedure.
 
Drains
The pericardial well is drained with 2 or 3 large bore chest tubes.  Ideally one tube is placed along the diaphragmatic/posterior surface.  Since the pleural space(s) are entered, they require drainage with a large bore chest tube on each side.
 
Hemostatic agents
Per surgeon preference and/or need to ensure hemostasis on the epicardial there often is a degree of coagulopathy and topical hemostatic agents can be of benefit.  These adjuncts can be either topical powder, sheet based hemostatic agents, or spray applied agents.
 
Closure
If the patient is hemodynamically stable and hemostatic to attempt sternal closure, it is performed in the standard fashion (e.g., 6-8 interrupted sternal wires; consider plating if a redo sternotomy, obese patient, diabetic and prior bilateral mammary use).  The suprasternal fascia and subcutaneous tissue are closed in 3 layers with absorbable suture with a sternal dermal glue dressing over the top.
 
Post-op management
Postoperatively, hemodynamic support and hemostasis are the paramount concerns.  The epicardial surface will be raw and prone to bleeding yet without the pericardium present to provide physiologic pressure.  As both pleural spaces will be entered widely, there is the potential for hemothorax development.  A low threshold for repeat chest x-ray imaging is needed.  When the risk of perioperative bleeding has subsided non-steroidal anti-inflammatory medications may be restarted.  If the patient was on preoperative steroids, perioperative stress-dose steroids should be considered.  There is the potential for systolic dysfunction in the postoperative period and vasoactive medications as well as volume expansion may be needed.