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Contents
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20.2 Tuberculous Pericarditis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
20.2.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
20.2.2 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
20.2.3 Clinical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
20.2.4 Tuberculous Pericardial Effusion . . . . . . . . . . . . . . . . . . . . . 332
20.2.5 Non-calcic and Calcic Constrictive Pericarditis . . . . . . . 332
20.2.6 Effusive-Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . 333
20.2.7 A Systematic Approach to the Diagnosis of
Tuberculous Pericardial Effusion . . . . . . . . . . . . . . . . . . . . . 333
20.2.8 Tuberculous Constrictive Pericarditis . . . . . . . . . . . . . . . . . 335
20.3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
20.3.1 Tuberculous Pericardial Effusion . . . . . . . . . . . . . . . . . . . . . 336
20.3.2 Tuberculous Constrictive Pericarditis . . . . . . . . . . . . . . . . . 336
20.3.3 Effusive-Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . 338
20.3.4 Anti-Tubercular Drugs: Optimal Drug Regimen,
Dosing Frequency and Treatment Duration . . . . . . . . . . . . . 338
20.3.5 Role of Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
20.3.6 Tuberculous Pericarditis with Concomitant HIV . . . . . . . . . 339
20.3.7 Effusive-Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . 340
20.3.8 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
20.3.9 Treatment Based on Aetiology . . . . . . . . . . . . . . . . . . . . . . . 342
20.3.10 Treatment Based on Timing of Presentation and
Response to Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
20.3.11 Specic Surgical Manoeuvers in Effusive-Constrictive
Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
20.3.12 Relapsing / Recurrent Pericarditis . . . . . . . . . . . . . . . . . . . . 343
20.3.13 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
20.3.14 Occult Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . 344
20.3.15 Evolution and Patterns of Constriction According to
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
xxiii
21 Short- and Long-Term Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
21.1 Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
21.2 Perioperative Mortality and Low Cardiac Output Syndrome,
Long-Term Survival Following Pericardiectomy in the
Current Era . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
21.3 Surgical Approach, Extent of Pericardiectomy and Use of
Extracorporeal Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
21.4 Constrictive Pericarditis Following Cardiac Transplantation . . . . . 359
21.5 Calcic Constrictive Pericarditis and Survival . . . . . . . . . . . . . . . . 360
21.6 Re-Operations Following Pericardiectomy . . . . . . . . . . . . . . . . . . . 361
21.7 Part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
21.8 Mayo Clinic Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
21.9 Cleveland Clinic Foundation Series . . . . . . . . . . . . . . . . . . . . . . . . . 362
21.10 Stanford Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
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21.11 German Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
21.12 Spanish Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
21.13 Chinese Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
21.14 All India Institute of Medical Sciences Series . . . . . . . . . . . . . . . . . 364
21.15 Japanese Nationwide Outcome Study . . . . . . . . . . . . . . . . . . . . . . . 368
21.16 German Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
21.17 Emory University, Atlanta, Georgia, USA . . . . . . . . . . . . . . . . . . . . 369
21.18 The Johns Hopkins Medical Institution, Baltimore,
Maryland, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
21.19 US Nationwide Outcomes Study Following Pericardiectomy . . . . . 370
21.20 German Series (Second German Series) . . . . . . . . . . . . . . . . . . . . . 370
21.21 The Johns Hopkins Medical Institutions, Baltimore,
Maryland, USA (Second Johns Hopkins Study) . . . . . . . . . . . . . . . 371
21.22 Swedish Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
21.23 Christian Medical College and Hospital, Vellore Series, India . . . . 372
21.24 Turkish Series. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
21.25 Series from Tehran, Iran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
21.26 New York Medical Center, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
21.27 South-African Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
22 Total Pericardiectomy via Median Sternotomy Without
Cardiopulmonary Bypass (Holman and Willett): A Video
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
22.1 The Operation (Video 22.1) [1, 2] . . . . . . . . . . . . . . . . . . . . . . . . . 381
22.1.1 Median Sternotomy, Subtotal Thymectomy,
Mobilization of Pleural Reection . . . . . . . . . . . . . . . . . . . 381
22.2 Exposure of Right and Left Phrenic Pedicles . . . . . . . . . . . . . . . . 381
22.3 I-Shaped Midline Incision over the Pericardium . . . . . . . . . . . . . . 382
22.4 Development of a Dissection Plane Between Pericardium
and Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
22.5 Development of Pericardial Flap on Left Side . . . . . . . . . . . . . . . . 382
22.6 Mobilization of Diaphragmatic Pericardium and
Release of Left Ventricular Apex . . . . . . . . . . . . . . . . . . . . . . . . . . 382
22.7 Creation of Pericardial Flap on Right Side . . . . . . . . . . . . . . . . . . 383
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Contents
23 Total Pericardiectomy via Modified Left Anterolateral
Thoracotomy Without Cardiopulmonary Bypass
(UKC’s Modification): A Video Presentation . . . . . . . . . . . . . . . . . . . . 385
23.1 Surgical Steps (Video 23.1) [1–3] . . . . . . . . . . . . . . . . . . . . . . . . . 385
23.1.1 Step I: Patient Positioning and Incision . . . . . . . . . . . . . . . 385
23.1.2 Step II: Dissection of the Thymus and Removal of
Excessive Fat Overlying the Left Phrenovascular
Pedicle and Left Ventricular Apex . . . . . . . . . . . . . . . . . . . 385
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23.1.3 Step III: Developing a New Dissection Plane Between
Anterior Surface of Pericardium and Sternum . . . . . . . . . . 386
23.1.4 Step IV: Extension of Dissection Plane beyond Midsternum
to Right Phrenovascular Pedicle . . . . . . . . . . . . . . . . . . . . 386
23.1.5 Step V: Mobilization and Isolation of Left
Phrenovascular Pedicle . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
23.1.6 Step VI: Dissection of Pericardium Posterior
to Left Phrenovascular Pedicle and Division of the
Posterior Pericardium in Two Halves . . . . . . . . . . . . . . . . 386
23.1.7 Step VII: Developing a Dissection Plane Between the
Diaphragmatic Pericardium and Diaphragm . . . . . . . . . . . 387
23.1.8 Step VIII: Dissection of Pericardium Anterior to
Phrenovascular Pedicle . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
24 Modified Left Anterolateral Thoracotomy Approach
Without Cardiopulmonary Bypass (UKC’s Modification):
A Video Presentation on Total Pericardiectomy for Chronic
Calcific Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
24.1 Surgical Steps (Videos 24.1 and 24.2) [1–6] . . . . . . . . . . . . . . . . . . 389
24.1.1 Patient Position and Surgical Incision . . . . . . . . . . . . . . . . . 389
24.1.2 Removing Excessive Fat Overlying Left
Phrenovascular Pedicle and Left Ventricular Apex . . . . . . . 389
24.1.3 Developing a Dissection Plane Between Anterior
Surface of the Pericardium and Sternum . . . . . . . . . . . . . . . 390
24.1.4 Extending the Dissection Plane Beyond the Sternum . . . . . 390
24.1.5 Developing Dissection Plane Between Diaphragm and
Diaphragmatic Pericardium . . . . . . . . . . . . . . . . . . . . . . . . . 390
24.1.6 Mobilisation and Isolation of the Left Phrenovascular
Pedicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
24.1.7 Dissecting the Pericardium Posterior to the Left
Phrenovascular Pedicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
24.1.8 Dissecting the Pericardium Anterior to the Left
Phrenovascular Pedicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
24.1.9 Developing a Dissection Plane Between Diaphragm
and Diaphragmatic Pericardium . . . . . . . . . . . . . . . . . . . . . 391
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
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25 Total Pericardiectomy for Calcific Constrictive Pericarditis
via Median Sternotomy Without Cardiopulmonary Bypass:
A Video Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
25.1 The Operation (Video 25.1) [1–5] . . . . . . . . . . . . . . . . . . . . . . . . . 393
25.1.1 Median Sternotomy, Subtotal Thymectomy,
Mobilization of Pleural Reection . . . . . . . . . . . . . . . . . . . 393
25.2 I-Shaped Midline Incision over the Pericardium . . . . . . . . . . . . . . 393
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Contents
25.3 Piecemeal Removal of Calcic Pericardium and
Development of a Dissection Plane Between Pericardium
and Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
25.4 Development of a Pericardial Flap on the Left Side . . . . . . . . . . . 394
25.5 Division of the Left-Sided Pericardial Flap in Two Halves . . . . . . 394
25.6 Excision of the Left Superior Half of the Calcic Pericardium
Using a Bone Cutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
25.7 Mobilization of the Diaphragmatic Pericardium and
Excision of the Left Inferior Half of the Calcic Pericardium
Using a Bone Cutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
25.8 Mobilization of Diaphragmatic Pericardium . . . . . . . . . . . . . . . . . 395
25.9 Creation of Pericardial Flap on Right Side . . . . . . . . . . . . . . . . . . 395
25.10 Irrigation of the Middle Mediastinum and Placement
of the Pacing Wires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
26 Unresolved Problems in Chronic Constrictive Pericarditis . . . . . . . . . 397
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
About the Author
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UjjwalKumarChowdhury I, Dr. Ujjwal Kumar Chowdhury, have been a practis-
ing academic cardiothoracic surgeon for over 35 years, presently working as
Professor and Consultant in the Department of Cardiothoracic and Vascular Surgery
at the All India Institute of Medical Sciences, New Delhi, India. AIIMS, New Delhi,
is the India’s top most premier quaternary care institute of medical education, training, and research and one of the busiest cardiothoracic centres of South East Asia
performing around 4000–4500 open heart surgeries annually.
I have performed cardiac surgery from neonatal switches to CABG, Fontan procedures, Bentall procedures, and aortic aneurysm surgeries with equal precision. As
a cardiac surgeon, I have performed about 40,000 operations, out of which about
90% cases were open heart operations. The diseases for which open heart surgeries
were performed included coronary artery disease in 30% of cases, valvular heart
disease in 30% of cases, congenital heart disease including complex lesions in 30%,
and miscellaneous including aortic aneurysm repairs in 10%. I perform all cardiac
surgeries from neonates to adulthood with an equal precision. I have performed
pericardiectomy for chronic constrictive pericarditis in over 300 individuals and
have introduced several technical modications to facilitate surgical resection. I
have performed robotic assisted myocardial revascularization on 12 patients with
coronary artery disease.
After graduating from AFMC, Pune, I have been trained at the very best teaching
hospitals in India, namely IPGMER, Kolkata, and Christian Medical College and
Hospitals, Vellore.
I acquired advanced specialized cardiovascular surgical training at three of
Australian nest teaching institutions (Prince Charles Hospital, Brisbane, Australia;
Royal Alexandra Hospital for Children, Sydney; and Royal Prince Alfred Hospital,
Sydney, Australia).
My relentless insistence on uncompromised quality of theatre practices and surgical skills has steered me to my current leadership position. I have described 15
novel operations and laid down 76 new guidelines and new classication of several
cardiac disease entities.
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About the Author
My ongoing research into methods, technologies, and surgical techniques was
the basis for my 425 research projects including 80 surgical videos and 3506 citations. Five original articles have been selected for journal CME, 1 article has been
awarded as the best journal CME activity for Journal of Thoracic and Cardiovascular
Surgery and 10 articles have received invited commentary by various world leaders.
I am an Editorial Board Member and Guest/Peer reviewer of 278 various indexed
international journals.
• MBBS, Armed Forces Medical College, Poona, Maharashtra, India, 1979
• MS in General Surgery with 1st class, Inst. Postgraduate Medical Education and
Research, Kolkata, 1984
• MCh, Christian Medical College, Vellore, Tamil Nadu, India, 1991
• Diplomate National Board Examinations, New Delhi, 1990
• Professor, Department of Cardiac Surgery, All India Institute of Medical
Sciences, New Delhi, 1996–2022
• Director Professor, Department of Cardiothoracic and Vascular Surgery, National
Institute of Medical Sciences and Research, Jaipur, Rajasthan 2022—
continuing
• Senior Cardiac Surgical Fellow, active member, allograft team, special training
in implantation of left ventricular assist devices, Prince Charles Hospital,
Brisbane, Australia, 1991–93
• Senior Cardiac Surgical Fellow, Royal Alexandra Hospital for Children, Sydney,
1993–94, Royal Prince Alfred Hospital, Sydney, 1994
• Trained in robotic cardiac surgery, Intuitive Surgical® Da Vinci Surgical System
Training Workshop, Sunnyvale, California, 2003. To date
• Contributed 475 original articles and 80 surgical videos to numerous indexed
cardiac surgical journals
• Fellow of Australasian Society of Cardiac and Thoracic Surgeons (Sydney),
Indian Association of Cardiothoracic Surgeons (New Delhi), Indian Association
of Cardiovascular and Thoracic Surgeons (Life member)
• International Member—Society of Thoracic Surgeons (USA)
• Biography Who’s who in Medicine and Health Care, 2009–2010, Iconic
Achiever
• Editorial Board Member/Guest/Peer Reviewer in 278 indexed scientic journals
Teaching/Research Experience
Institution Post Held From To
1. SSKM Hospital
and IPGMER,
Calcutta
2. SSKM Hospital
and IPGMER,
Calcutta
Postgraduate Trainee MS
(General Surgery)
Honorary Resident House
Ofcer, Dept. of
Cardiothoracic Surgery
15.9.1981 31.12.1983
1.1.1984 31.12.1984
About the Author
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xxix
3. Medical College
Hospitals, Calcutta
Research Ofcer and Medical
Ofcer Incharge, Cardiac Cath
Lab, Dept of Cardiothoracic
Surgery (Teaching post)
4. Christian Medical
College, Vellore
5. Christian Medical
Non-PG Registrar (Teaching
post)
MCh trainee (CTVS) 16.1.1989 15.1.1991
College, Vellore
After Diplomate National Board CTVS
6. Christian Medical
MCh Trainee 16.5.1990 15.1.1991
College, Vellore
7. The Prince Charles
Hospital, Brisbane,
Fellow Cardiac Surgery
(Teaching post)
Australia
8. The Royal
Alexandra Hospital
Fellow Cardiac Surgery
(Teaching post)
for Children,
Sydney, Australia
9. Royal Prince Alfred
Hospital, Sydney,
Fellow Cardiac Surgery
(Teaching post)
Australia
10. All India Institute
of Medical
Assistant Professor (Teaching
post), Dept of CTVS
Sciences, New
Delhi
11. All India Institute
of Medical
Associate Professor (Teaching
post), Dept of CTVS
Sciences, New
Delhi
12. All India Institute
of Medical
Sciences, New
Additional Professor
(Teaching post), Dept of
CTVS
Delhi
13. All India Institute
of Medical
Professor (Teaching post),
Dept of CTVS
Sciences, New
Delhi
14. National Institute
of Medical
Sciences, Jaipur
(Rajasthan)
Director, Professor (Teaching
post), Dept of CTVS
(Including Perfusion
Technology)
15.1.1985 15.1.1988
16.1.1988 15.1.1989
1.2.1991 3.1.1993
12.7.1993 10.1.1994
10.1.1994 10.8.1994
17.10.1996 30.06.2003
01.07.2003 23.09.2005
23.09.2005 30.06.2010
01.07.2010 11.11.2022
12.11.2022 Continuing
Chapter 1
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Anatomy, Histology, Applied Anatomy,
andPhysiology oftheHuman Pericardium
1.1 Anatomy
Pericardium is a broserous ask-shaped sac that encases the heart and great arteries and veins as they leave or enter the heart [1, 8, 9, 64, 71, 74, 75, 107–109, 114–
116]. The pericardial sac separates the heart from the surrounding mediastinal
structures, provides mechanical protection, and also has a hemodynamic effect on
the atria and ventricles. The description of “pericardial anatomy” as far as we can
establish entered the lexicon of anatomy and physiology in 1835 by RB Todd [121].
It is intriguing to note that the description is still relevant more than 180years after
it was described. Macroscopically, this thin ask-shaped membrane is composed of
two interconnected structures: the brous, and the serous pericardia, arranged in 3
layers with uid lining between them [1, 64, 75, 115, 116]. Its development occurs
through a process of cavitation of the embryonic body wall by expansion of the
secondary pleural cavity, its lateral walls are thus covered by the mediastinal parietal pleura [61, 71].
1.2 Fibrous Pericardium
The brous pericardium is a roughly conical, closed sac composed of dense interlacing connective tissue, completely surrounding but not attached to the heart. The
covering is made of 3 layers of collagen, cross-woven at 120° to each other, thus
limiting stretch and ensuring a physical barrier to disease [101, 115, 116].
The brous pericardium is anchored to the mediastinum and helps maintain the
normal cardiac position. The brous pericardium is continuous superiorly with the
adventitial covering of great vessels and pretracheal fascia. The neck of the pericardium superiorly is closed by extensions around the great vessels. Inferiorly, it is
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_1
1© The Author(s), under exclusive license to Springer Nature Singapore Pte
2
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attached through the pericardiophrenic ligaments to central tendon of the diaphragm. Although, diaphragmatic attachment of pericardium mostly consists of
brous tissue that can be easily isolated or separated, a portion of the pericardium
overlying the central tendon is completely fused. Anteriorly, it attaches to the posterior surface of sternum through sternopericardial ligaments that run cephalocaudally from manubrium sterni to sterno-xiphoid junction. Posteriorly, the pericardium
lies in contact with major bronchi caudal to carina and close to brous fasciae of
esophagus and the descending thoracic aorta [1, 8, 9, 64, 71, 74, 75, 107–109,
114–116].
With the descent of the diaphragm during inspiration, the pericardial sac is pulled
downward and becomes elongated; thus forcing the heart assume a more vertical
position. During expiration, the ascent of the diaphragm relaxes the heart to become
more horizontal. The pericardium with its contents comprises the middle mediastinum. The anterior mediastinum is in front of the pericardial sac and posterior mediastinum lies behind it.
The mediastinal portion of the parietal pleura invests the lateral surfaces.
Pericardium is overlapped and largely obscured anteriorly by bilateral pleural sacs
and anterior edges of both lungs, which occupy the sternocostal recesses. Before
adolescence, the thymus intervenes between the pericardium and the sternum, but in
adults, there is little demonstrable thymic tissue in the anterior mediastinum and the
pericardium is in contact with the posterior sternal surface at the level of 4th and 5th
left costal cartilages.
The pericardiophrenic vessels and phrenic nerves run in a cephalocaudal direction in the form of two bundles along the lateral surface of the heart. These bundles
lie anterior to the pulmonary hilum between mediastinal pleura and the brous
pericardium.
Occasionally, a small infracardiac bursa is present behind the pericardium just
above the diaphragm. The bursa is a remnant of the embryonic pneumoenteric
recess. The ascending aorta, superior caval vein and the pulmonary arteries and
veins, receive extensions of the brous pericardium; the inferior caval vein traverses
the central tendon of the diaphragm, thus has no covering. According to the modalities of assessment, the pericardial thickness varies (~ 0.8–1.0 mm on anatomic
specimens, 0.7–1.2mm on cardiac computed tomography, and 1.5–2.0mm on cardiac magnetic resonance imaging) [10–14, 65, 128].
1 Anatomy, Histology, Applied Anatomy, and Physiology of the Human…
1.3 Serous Pericardium
The serous pericardium is a continuous sac with a large infold containing the heart.
An appropriate analogy for this would be a st (representing the heart) which is
pushed into the side of a deated balloon (representing the serous pericardium),
thus being encased by two individual layers of material. The exterior lining of the
serous pericardium is known as the parietal pericardium which is fused with the
thick layer of the brous pericardium (Fig.1.1) [17, 18].
1.3 Serous Pericardium
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Fig. 1.1 Parietal and
visceral pericardium. This
diagram shows the two
components of
pericardium: parietal and
visceral pericardium. The
parietal pericardium
comprises of two layers: a
serosal layer (thin red line)
and a brous layer (thicker
yellow line). The
epicardium or visceral
pericardium is a single
layer of serosal lining
which covers the entire
heart (thin red line
overlying the myocardium
in blue colour). The serosal
lining of the visceral and
parietal pericardium is a
continuous layer of
mesothelial cells. The
potential space between
parietal and visceral
pericardium is the
pericardial cavity
3
The visceral pericardium or the epicardium is a thin, transparent, smooth and
glossy lamina. It is attached closely to the epicardial surface of the heart and covers
coronary tissue containing fat and coronary vessels present in the subepicardial
layer. The pericardium completely covers the epicardial surface of both atria and
ventricles, except for the left atrial roof, where a sine epicardio area lies corresponding to the atrial venous mesocardium. It also covers the atrial appendages, the intrapericardial part of both caval veins except the superior and inferior postcaval
mesocardium. External to serous pericardium lies the parietal pericardium which is
fused to the thick layer of brous pericardium (Fig.1.1).
The pericardial reection at some areas, generates recesses and sinuses that are
characteristically related with the aortopulmonary great vessels and venous pole of
the heart (Figs.1.2 and 1.3). The pericardial cavity contains pericardial uid [89,
117, 118].
Ligament of the left superior caval vein or vestigial fold of Marshall is a triangular fold of the visceral pericardium, which descends obliquely from the left pulmonary artery between the left atrial appendage and left superior pulmonary vein. It is
a serous layer formed over remnant of the lower part of the left superior caval vein
(duct of Cuvier) that remains as a brous band between the highest left superior
caval vein and left atrium, where it aligns with a small vein known as the vein to the
left atrium (or oblique vein of Marshall) which eventually opens into the coronary
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