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Asian Cardiovasc Thorac Ann 2002;10:288-289
© 2002 Asia Publishing EXchange Pte Ltd

LETTER TO THE EDITOR

Pericardiectomy for Chronic Constrictive Pericarditis

Theodor Tirilomis, MD

Department of Thoracic, Cardiac, and Vascular Surgery University of Göttingen Robert-Koch-Str. 40 Göttingen D-37075, Germany
I read with interest the contribution of Omoto and colleagues1 on pericardiectomy for chronic constrictive pericarditis. Pericardiectomy is the only treatment for improving cardiac hemodynamics in this disease. However, disagreements exist, especially over the surgical approach, the extent of pericardiectomy, and the indication for the routine use of cardiopulmonary bypass (CPB).

Left anterolateral thoracotomy and median sternotomy are the most frequently used approaches. Fatal bleeding caused by a tear in the right atrium or the venae cavae during surgery performed through a left anterolateral thoracotomy has been reported.2,3 In contrast, median sternotomy facilitates excision of the pericardium overlying the right atrium and the venae cavae. Resection of the posterior surface of the pericardium through a median sternotomy is more difficult.

The debate over the extent of pericardiectomy is more controversial. Normalization of cardiac hemodynamics has been reported after radical pericardiectomy4 as well as after decortication of the anterior surface from the atrioventricular groove on the right to the left phrenic nerve and the diaphragmatic surface.5 While Viola6 suggested that resection of the pericardium overlying the right atrium and the great veins is not essential, Culliford and colleagues7 suggested that delayed improvement and persistent symptoms of pericardial constriction are most commonly the results of incomplete decortication. However, outcome is related not only to the extent of surgery but also to myocardial involvement. Autopsy findings indicate that myocardial fibrosis and atrophy may result.8,9 Long periods of myocardial compression contribute to "remodeling" of the ventricles with greater involvement of the myocardium in patients with longer duration of symptoms of pericardial constriction.10

Copeland and coworkers11 routinely used CPB in pericardiectomy. Omoto’s team1 also used CPB in almost all the patients, but concomitant operations undertaken to repair congenital or acquired heart disease made its use necessary in 25 out of 79 patients (32%). In our previous study12 of 71 patients who underwent only pericardiectomy for chronic constrictive pericarditis (patients with concomitant cardiac disease were excluded), CPB was used only in one case where it was indicated because of extensive bleeding. Its routine use is, in our opinion, not indicated. A possible drawback of routine use is the potentially increased risk of postoperative bleeding and other complications related to extracorporeal circulation. We suggest putting CPB on standby during pericardiec-tomy. Through the median sternotomy, the patient can be easily connected to the CPB in case of extensive bleeding, which cannot be controlled otherwise.

Finally, we suggest that pericardiectomy should be performed early and as radically as possible. Care must be taken to resect every constrictive epicardial layer to avoid persistent pericardial constriction.

REFERENCES

    Omoto T, Minami K, Varvaras D, Böthig D, Körfer R. Radical pericardiectomy for chronic constrictive pericarditis. Asian Cardiovasc Thorac Ann 2001;9: 286–90.[Abstract/Free Full Text]

  1. Astudillo R, Ivert T. Late results after pericardiectomy for constrictive pericarditis via left thoracotomy. Scand J Thorac Cardiovasc Surg 1989;23:115–9.[Medline]

  2. McPhail JL, Sukumar IP, Vytilingam KI, Cherian G, John S. Surgical management of constrictive pericarditis. J Thorac Cardiovasc Surg 1967;53:360–5.[Medline]

  3. Lazarides DP, Avgoustakis DG, Lekos D, Michaelides GB. Evaluation of radical pericardiectomy for constrictive pericarditis. A clinical, hemodynamic, and electro-cardiographic study of twenty cases. J Thorac Cardiovasc Surg 1966;51:821–33.[Medline]

  4. Kloster FE, Crislip RL, Bristow JD, Herr RH, Ritzmann LW, Griswold HE. Hemodynamic studies following pericardiectomy for constrictive pericarditis. Circulation 1965;32:415–24.[Abstract/Free Full Text]

  5. Viola AR. The influence of pericardiectomy on the hemodynamics of chronic constrictive pericarditis. Circulation 1973;48:1038–42.[Abstract/Free Full Text]

  6. Culliford AT, Lipton M, Spencer FC. Operation for chronic constrictive pericarditis: Do the surgical approach and degree of pericardial resection influence the outcome significantly? Ann Thorac Surg 1980;29:146–52.[Abstract]

  7. Levine HD. Myocardial fibrosis in constrictive pericarditis. Electrocardiographic and pathologic observations. Circulation 1973;48:1268–81.[Abstract/Free Full Text]

  8. Dines DE, Edwards JE, Burchell HB. Myocardial atrophy in constrictive pericarditis. Staff Meet Mayo Clin 1958; 33:93–9.

  9. Senni M, Redfield MM, Ling LH, Danielson GK, Tajik AJ, Oh JK. Left ventricular systolic and diastolic function after pericardiectomy in patients with constrictive pericarditis: Doppler echocardiographic findings and correlation with clinical status. J Am Coll Cardiol 1999;33:1182–8.[Abstract/Free Full Text]

  10. Copeland JG, Stinson EB, Griepp RB, Shumway NE. Surgical treatment of chronic constrictive pericarditis using cardiopulmonary bypass. J Thorac Cardiovasc Surg 1975;69:236–8.[Abstract]

  11. Tirilomis T, Unverdorben S, von der Emde J. Peri-cardiectomy for chronic constrictive pericarditis: risks and outcome. Eur J Cardio-thorac Surg 1994;8:487–92.[Abstract]




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