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18 Incidence and Management of Postoperative Low Cardiac Output Syndrome…
The currently available monitoring technologies for hemodynamic monitoring
vary in the cost and diversity of information provided. Critically ill patients may
benet from the more invasive techniques as a result of the greater breadth of information gained. Physicians must thoroughly understand the haemodynamic data
obtained and utilize it in a goal-directed fashion if the monitoring technology is to
improve patient outcome. Use of presepTM and FlotracTM increases the cost. But,
a decrease in the duration of ventilation and ICU stay, resulting from its use may
render it cost effective.
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131. Westerhof PW, Van der Putte SCJ. Radiation pericarditis and myocardial brosis. Eur J
132. Yetkin U, Kestelli M, Yilik L, Ergunes K, Kanlioglu N, Emrecan B, etal. Recent surgical
133. Zhu P, Mai M, Wu R, Lu C, Fan R, Zheng S.Pericardiectomy for constrictive pericarditis:
18 Incidence and Management of Postoperative Low Cardiac Output Syndrome…
ow during pericardial tamponade. Correlation with microscopic anatomy and intrinsic myocardial contractility. J Thorac Cardiovasc Surg. 1974;68:847–56.
surgery. Eur J Anaesthesiol. 1992;5 Suppl:21–6.
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experience in chronic constrictive pericarditis. Tex Heart Inst J. 2003;30:27–30.
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Chapter 19
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Cardiopulmonary Bypass andMechanical
Circulatory Assistance intheManagement
ofPericardiectomy
19.1 Role ofCardiopulmonary Bypass intheManagement
ofPericardiectomy
Literature is divided on the recommendation of routine usage of cardiopulmonary
bypass during pericardiectomy. Circulatory support with cardiopulmonary bypass
is not usually required for pericardiectomy in effusive or inammatory pericarditis.
The need arises when the patient does not tolerate cardiac manipulation when trying
to achieve a complete pericardiectomy. Complete pericardiectomy has proven benets in terms of long-term functional outcomes compared to a partial pericardiectomy. Usually a more advanced stage of constrictive pericarditis requires
cardiopulmonary bypass for pericardiectomy. This is reected by the studies in
which cardiopulmonary bypass was associated with lower survival and higher risk,
including the Stanford series, the Mayo clinic, and the German series [2–4].
Thus, one should not be reluctent to utilize cardiopulmonary bypass, if needed to
facilitate a complete resection, since this is associated with a more favourable outcome compared to partial pericardiectomy. Additionally, in these pateints the use of
cardiopulmonary bypass allows one to control uid shifts. This concept of avoiding
cardiac over distension using extracorporeal circulation and ultra ltration is not
well appreciated by investigators across the globe [2–13, 16].
Cardiopulmonary bypass aids in the surgical disection by emptying the ventricular cavities to clearly dene the appropriate plain of disection, and also facilitates
management of inadvertent cardiac injury.
Although using cardiopulmonary bypass routinely for achieving total pericardiectomy is a debatable issue, it may be employed in special circumstances, namely,
(i) inadvertent injury to a cardiac chamber or great vessels, (ii) reccurent pericarditis
following previous partial pericardiectomy, (iii) pericardiectomy following mediastinal irradiation, (iv) coexisting cardiac lesions requiring surgical intervention, and
(v) presence of calcic pericardial “cocoon” encompressing all cardiac chambers,
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_19
321© The Author(s), under exclusive license to Springer Nature Singapore Pte
322
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19 Cardiopulmonary Bypass and Mechanical Circulatory Assistance in…
(vi) calcic pericardial patch compressing predominently the right atrium and right
ventricular outow tract, and vii) signicant gradient (> 2mmHg) at the superior or
inferior cavoatrial junction [1, 5–18, 23–25, 29, 31].
Tokuda and associates from Japan Adult Cardiovascular Database and Timothy
George from Johns Hobkins Medical Institutions demonstrated cardiopulmonary
bypass as an independent risk factor for worse outcome. The results by multivariate
analysis indicated that cardiopulmonary bypass was not merely a surrogate of severity of the disease, but that use of cardiopulmonary bypass itself was a risk factor for
a poorer outcome [2–4, 17, 18, 29, 31].
The disadvantage of using cardiopulmonary bypass was the potential for
increased perioperative bleeding and other bypass related complications. The
Japanese study further observed that reoperation for bleeding and prolonged ICU
stay were more frequently reported in patients undergoing cardiopulmonary bypass
than in those without bypass [31].
Although modied left anterolateral thoracotomy (UKC’s modication) is useful
to achieve radical pericardial resection, it is necessary to identify the distribution of
the calcied plaque over the right atrium or great vessels and calcic spurs penetrating the myocarium, if any. The distribution of calcic plaque and myocardial penetration can easily be demonstrated by using contrast computed tomography
(Figs.19.1, 19.2, 19.3, and 19.4).
This subset of patients with anticipated requirement of cardiopulmonary bypass
may be better managed through a sternotomy. Additionally, the left thoracotomy
abc
d
Fig. 19.1 Frontal chest radiograph (a) shows plaque-like calcication along the atrioventricular
groove. Four-chamber (b) and short-axis (c) reconstructions of CT angiography and volume rendered images (d, e and f) show extensive pericardial calcication predominantly along the atrioventricular groove. Note is made of biatrial dilation. (LA- Left atrium, LV-Left ventricle, RA-Right
atrium, RV-Right ventricle)
ef
ab
cd
19.1 Role ofCardiopulmonary Bypass intheManagement ofPericardiectomy
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323
a
e
Fig. 19.2 Frontal (a) and left lateral (b) chest radiographs show calcication along the diaphragmatic surface and left border of the heart. Four-chamber (c) and short-axis (d) reconstructions of
CT angiography and volume rendered images (e–g) show extensive pericardial calcication predominantly along the free wall of the ventricles and the atrioventricular groove. Note is made of
biatrial dilation. (LA- Left atrium, LV-Left ventricle, RA-Right atrium, RV-Right ventricle)
b
f
c
d
g
Fig. 19.3 Volume rendered images (a–c) show extensive pericardial calcication predominantly
along the free wall and diaphragmatic surface of bilateral ventricles and the atrioventricular
groove. Volume rendered image (d) shows thick calcic spurs inltrating into the right ventricular
myocardium. (LA- Left atrium, LV-Left ventricle, RA-Right atrium, RV-Right ventricle)
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