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Chapter 12
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Decision-Making ontheTimings
ofPericardiectomy, Selection
oftheOptimal Surgical Approach,
Adequacy ofPericardiectomy
andRequirement ofCardiopulmonary
Bypass
Despite experience spanning more than 300years, there is no fool-proof formula in
the published literature to decide on the timing of pericardiectomy, optimal surgical
approach, extent of decortication, and requirement of cardiopulmonary bypass for a
given patient. The literature is rife with descriptions of pericardiectomy by either
left anterolateral thoracotomy or median sternotomy. Despite the effectiveness of
surgery, there are disparate opinions regarding the role of corticosteroids in treating
tuberculous pericarditis, timing of operation, surgical approach, extent of decortication, and requirement of cardiopulmonary bypass [1–29, 34, 38–40, 50, 51, 57, 59,
62, 66–68, 74–100]. The efcacy of pericardiocentesis in preventing chronic con-
strictive pericarditis in pericardial effusion (serous or hemorrhagic) has been inadequately investigated [57, 58, 74–76]. The terms “total”, “complete”, “extensive”,
“radical”, “partial”, “subtotal” and “near-total” pericardiectomy have been variably
used to describe the procedure, often without precise denition of the limits of pericardial resection [4, 11–23, 38–40, 50, 57–59, 69].
Published reports attest to the unpredictable and variable pattern of clinical presentation of chronic constrictive pericarditis, and lend support to radical decortication [5, 11–27, 74–77, 100]. In 2005, to dene the limit of pericardial resection,
total pericardiectomy was dened as wide excision of the pericardium with the
phrenic nerves dening the posterior extent, the great vessels including the intrapericardial portion of superior caval vein and superior cavoatrial junction dening
the superior extent, and the diaphragmatic surface, including the inferior cavoatrial
junction dening the inferior extent of the pericardial resection [19]. Constricting
layers of the epicardium were removed whenever possible and the atria and caval
veins were decorticated in all cases in this study group. Pericardiectomy was considered partial if both ventricles could not be decorticated completely because of
dense myopericardial adhesions or calcication [27]. Radical pericardiectomy was
dened as removal of the entire pericardium over the anterolateral, diaphragmatic
surfaces of the left ventricle, portion of pericardium posterior to the phrenic nerves
and the left ventricle, and the anterior and diaphragmatic surfaces of right ventricle
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_12
217© The Author(s), under exclusive license to Springer Nature Singapore Pte
218
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until the atrioventricular groove, leaving behind intact left and right phrenic pedicles [19].
“total pericardiectomy” when a patient had a wide pericardial excision over the
anterolateral, diaphragmatic surfaces of both ventricles, the pericardium posterior to
the phrenic nerves with intact phrenic pedicles, and over the great vessels including
the intrapericardial cavoatrial junctions [27]. The term “partial pericardiectomy” is
reserved for anything less than total pericardiectomy [19]. “Radical pericardiectomy” will be more dened in terms of relation to oncological situations where
draining lymphatics/lymph nodes will be removed as well. In addition, “radical
pericardiectomy” is something that is never possible as it requires removal of all
three layers of pericardium, which are “brous” and “serous” with two components:
“parietal and visceral epicardium”, and that is not possible in real life [27].
described by Harrington in 1944; successful pericardiectomy requires removal of
all constricting layers including decortication of the ventricular epicardium [38, 39].
In a study, Kloster and associates demonstrated normalization of the pressure volume loop as an indicator of operative success of pericardiectomy [47].
12 Decision-Making on the Timings of Pericardiectomy, Selection of the Optimal…
Subsequently, in 2020 for the sake of uniformity with other studies, we redened
Secondly, the importance of unrecognized constricting epicardial peel was
12.1 Anatomical Basis oftheAdequacy ofPericardiectomy
In constrictive pericarditis, the diseased, brotic pericardial cavity causes impairment of myocardial function by limiting ventricular diastolic lling resulting in
decreased cardiac output [40, 41]. It stands to reason, therefore, that the aim of
surgery would be to physically release the encased ventricles, thereby facilitating
improvement of cardiac output.
In an attempt to provide a functional anatomical perspective for performance and
recovery of the heart during pericardiectomy, Lachman and colleagues in a necropsy study demonstrated that although the anterior pericardium between the
phrenic nerves constitutes about 58% of total selected pericardial area, the total
pericardium accessible over the left ventricle was only 26%. When oriented in the
left anterolateral position, the total area of the left ventricular pericardium was 37%
[50]. From a physiological perspective, the recovery of the heart through increased
cardiac output is dependent primarily on the release of the left ventricular chamber [50].
In 1946, Sellors TH and colleagues stated that the restraining pericardium should
be removed to allow maximum ventricular expansion. The procedure should be
aimed primarily and possibly only at removal of ventricular pericardium. Sellors
goes on to state that the correct dissection should be carried out posteriorly beyond
the phrenic nerves [78].
As the diastolic volume of the heart is directly related to sarcomere length, it is
reasonable to explain Starling’s law in terms of the ultrastructure of the myocardial
cell. As the sarcomere is progressively stretched to its optimal length, the diastolic
12.2 Criteria for Decision-Making on the Indications and Timings for Pericardiectomy…
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bre lengthens proportionately, and the force of contraction progressively increases.
If the sarcomere is overstretched, less force is generated and effective contractility
is decreased [41, 78, 79, 101, 107]. In cases of incomplete pericardiectomy the
patient goes into a state of severely low cardiac output. It is therefore critical to
release the left ventricle for complete functional recovery and regression of
symptoms.
219
12.2 Criteria forDecision-Making ontheIndications
andTimings forPericardiectomy, Selection
oftheOptimal Surgical Approach, Adequacy
ofSurgical Resection, andTheir Relationship
toMortality andLow Cardiac Output Syndrome
In 2005, we compared two surgical approaches, for pericardiectomy, clinically,
echocardiographically and haemodynamically in 395 patients undergoing pericardiectomy for chronic constrictive pericarditis at All India Institute of Medical
Sciences, New Delhi, India. The approach for pericardiectomy was subjective and
remained uniform during the period of study [19].
We concluded that maximum benet could be achieved following total pericardiectomy which was best achieved through a median sternotomy and was indeed
difcult to achieve through a conventional left anterolateral thoracotomy [24, 27].
Total pericardiectomy was associated with superior short- and long-term outcomes namely, lower perioperative and late mortalities, less postoperative low cardiac output syndrome, early normalization of hemodynamics, shorter hospitalization,
and better long-term survival than partial pericardiectomy [27]. The risk of death
was 4.5 times higher (95% CI 2.05, 9.75) in patients undergoing partial pericardiectomy as compared to total pericardiectomy.
At a mean follow-up of 17.9±0.3years, it was demonstrated that late presentation was associated with advanced functional class, higher right-sided lling pressure, supraventricular dysrhythmias, hepatorenal dysfunction, and pericardial
calcication.
Cox regression analysis identied the following predictors of mortality following pericardiectomy (Hazard ratio, 95% CI, p value): elevated right- sided lling
pressure more than 20–24mmHg: 5.62 (1.25–22.84), p=0.002; hyperbilirubinemia: 7.92 (1.98–64.02), p=0.042; renal dysfunction: 4.95 (1.05–23.42), p=0.044;
atrial brillation: 4.70 (1.76–12.58),p = 0.002; pericardial calcication: 9.49
(3.94–22.90), p < 0.001; and extent of pericardiectomy (partial/total): 4.45
(2.05–9.75), p=0.002 [19, 27]. Reoperations for recurrent pericarditis after partial
pericardiectomy via conventional left anterolateral thoracotomy are common [19,
77, 78].
cavoatrial junctions could be achieved via median sternotomy, these areas are of
,
Although a greater degree of pericardial resection over the right atrium and the
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