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16 Calcic Constrictive Pericarditis
as required and is removed piecemeal avoiding injury to the underlying cardiac chambers, great vessels, coronaries and phrenic nerves. Special precautions need to be exercised while removing calcied pericardial patches over the right atrium, right ventricle and pulmonary artery.
Some investigators have used a cavitational ultrasonic surgical aspiration system (CUSA) for removal of calcium or nerve stimulators for identication of the phrenic nerve.
Calcic pericarditis is more easily recognized preoperatively from chest radio­graph, computed tomogram or during catheterization, and is an indicator for chro­nicity of the disease [140–142]. The role of calcic constrictive pericarditis on postoperative outcome remains controversial [8, 10, 27–33, 39, 53, 54, 94, 95, 115,
116, 132–135, 148]. Whereas some single centre studies have shown that calcic
pericarditis does not affect perioperative mortality, other studies have shown a nega­tive impact on perioperative mortality and long-term survival [8, 10, 23–37, 53, 54,
115, 116].
Contrary to the observations of these single centre studies, Gopaldas and associ­ates in nationwide US sample studies on 13,593 patients undergoing pericardiec­tomy noted the presence of calcied pericardium in 15% of patients, independently associated with a lower requirement for cardiopulmonary bypass and quicker dis­charge from hospital without ancillary home support. Their analysis has shown a 52% lower in-hospital mortality in patients with calcic pericarditis [57].
We concur with the observations of other investigators that although a majority of patients undergoing pericardiectomy survive the operation, subsets of patients do not experience any clinical improvement or normalization of haemodynamic param­eters. A continual dispute is in progress about the reason for the lack of response in these patients. The following hypotheses have been put forward to elucidate this enigma:
(i) Myocardial atrophy (reversible) caused by prolonged restriction of unimpeded
cardiac movements by the rigid, calcied pericardium,
(ii) Irreversible myocardial brosis as a consequence of the inammatory process
from the pericardial layers to the myocardium.
The rst hypothesis is supported by Stalpaert and Westerhof, who have shown a certain period of latency, possibly up to 2 years, before the pathological pressure curves return to normal [133]. The second hypothesis is based on histological prepa­rations from patients who died from chronic constrictive pericarditis, documenting a brotic, thickened epicardium and myocardial brosis [56, 81, 82, 98–100, 109,
121–123, 126, 133, 147].
Review of the literature indicates that the ‘myocardial factor’ (myocardial atro­phy or brosis) may be the major factor leading to death after pericardiectomy [3,
42, 43, 56, 69–71, 76, 77, 83–85, 94, 95, 98, 99, 102, 106, 109, 110, 116, 121– 123, 134].
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Chapter 17
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The Operation: Total Pericardiectomy forCalcic Constrictive Pericarditis via Median Sternotomy Without Cardiopulmonary Bypass
17.1 Surgical Management
17.1.1 Total Pericardiectomy forCalcic Chronic Constrictive
Pericarditis Via Median Sternotomy [1–4]
17.1.1.1 The Operation
The preferred approach of pericardiectomy for calcic constrictive pericarditis would be median sternotomy. Both groins are prepared for immediate institution of cardiopulmonary bypass, if required, in cases of inadvertent injury to the cardiac chambers and/or great vessels. Furthermore, in case of a circumferential pericardial “cocoon” calcication encompassing all cardiac chambers, and calcic spurs pen­etrating the ventricular chambers, we would electively perform total pericardiec­tomy under cardiopulmonary bypass. Additionally, we would insert a peritoneal dialysis catheter and intercostal drain in cases of massive ascites, and signicant pleural effusions electively at the time of surgery to prevent autotransfusion on com­pletion of operation.
Step I: Subtotal thymectomy, mobilization of the pleural reection
• The thymus is subtotally excised to expose the pericardium overlying the aorta and pulmonary artery. Subsequently, the thymus and pleural reection are mobilised laterally to obtain a wide width of pericardium (Fig.17.1).
Step II: Identication of both phrenic pedicles
• Both pleural spaces are entered to visualize both phrenic nerves and to decom­press the pleural effusion if present. It is important to remove the large amount of fat which usually overlies the left ventricular apex in close proximity to the left phrenic nerve.
Ltd. 2023 U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_17
281© The Author(s), under exclusive license to Springer Nature Singapore Pte
282
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Fig. 17.1 Intraoperative views of total pericardiectomy for calcic constrictive pericarditis via median sternotomy. The chest is opened through the midsternotomy incision
17 The Operation: Total Pericardiectomy for Calcic Constrictive Pericarditis…
Step III: Removal of calcic pericardium piecemeal and development of a dis­section plane between the pericardium and the heart
• The calcic pericardium overlying the myocardium is crushed with the help of a hemostat into multiple fragments and removed piecemeal (Fig.17.2a-e).
• Utmost precautions are taken to develop the plane of dissection between the epicardial peel of Harrington and epicardial fat avoiding injury to the underly­ing coronary vessels, myocardium, phrenic nerves, and pericardial phrenic vessels. The calcic fragments are removed from the myocardium with the help of DeBakey’s forceps, thick hemostat, and No.15 scalpel blade in vary­ing combinations as needed (Fig.17.3a–17.3d).
• In cases of calcied pericardial patches overlying the cardiac chambers, the pericardium is inspected and palpated for a soft and uncalcied area. The soft and uncalcied pericardium is incised using a cautery setting between 8 and 10 mV during the process of dissection, to avoid cautery-induced ventricular brillation. An attempt is made to incise the pericardium up to the level of the pulmonary artery superiorly and diaphragm inferiorly.
Step IV: Development of a pericardial ap on the left side
• Pericardial mobilization is started at the caudal end of the ‘I’ incision on left side and progresses superiorly towards the aorta and pulmonary artery till the inferior border of the brachiocephalic vein, creating a ap of about 1cm width (Fig.17.4a–e).
Step V: Creation of the pericardial ap on the left side, and division in two halves.
• Generally, I prefer to start the mobilization of the pericardium at the lower end of the calcied patch on the left side. The patch is grasped with a heavy artery­forceps and broken into small pieces using twisted movements, taking care not to injure the coronary arteries, cardiac chambers and great vessels. We always attempt to divide the ap in two halves to facilitate mobilization with
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