Asian Cardiovasc Thorac Ann 2007;15:e69-e71
© 2007 Asia Publishing EXchange Ltd
Off-pump Pericardiectomy Using an Ultrasonic Scalpel and a Heart Positioner
Atsushi Fukumoto, MD,
Masaaki Yamagishi, PhD,
Kiyoshi Doi, PhD,
Mitsugu Ogawa, MD,
Tomoya Inoue, MD,
Hitoshi Yaku, PhD
Department of Cardiovascular and Thoracic Surgery, Graduate School of Medical Science, Kyoto, Prefectural University of Medicine, Kyoto, Japan
For reprint information contact: Atsushi Fukumoto, MD, Tel: 81 75 251 5752, Fax: 81 75 257 5910, Email: fukumoto{at}koto.kpu-m.ac.jp, Department of Cardiovascular and Thoracic Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
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ABSTRACT
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The surgical treatment of constrictive pericarditis often requires extensive pericardial dissection under cardiopulmonary bypass. We performed a pericardiectomy in a patient with constrictive pericarditis without cardiopulmonary bypass, with assistance of a sternal retractor and a suction heart positioner. The severely calcified pericardium, which adhered tightly to the epicardium, was dissected with an ultrasonic scalpel. The operation was completed without blood transfusion. There was no malignant arrhythmia.
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INTRODUCTION
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The surgical treatment of constrictive pericarditis often requires extensive pericardial dissection, performed under cardiopulmonary bypass (CPB). The myocardium and coronary arteries are at risk of injury during decortication, which increases the risk of operative morbidity and mortality. The use of a heart-lung machine for the surgical treatment of constrictive pericarditis increases the risk of perioperative hemorrhage, as well as of other postoperative complications. We performed an off-pump pericardiectomy in a patient with constrictive pericarditis, using an ultrasonic scalpel, a sternal retractor, and a suction heart positioner.
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CASE REPORT
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A 61-year-old woman presented with chest discomfort and general fatigue of several months duration. She had no history of cardiac trauma or surgery, mediastinal irradiation, tuberculosis or other infectious diseases, or neoplasms. Two-dimensional transthoracic echocardiography showed restricted motion of the right and left ventricles, with paradoxical motion of the intraventricular septum. Computed tomography revealed constrictive pericarditis with severe calcification (Figure 1
). At cardiac catheterization, the right ventricular pressure showed a dip and plateau pattern. The mean right atrial pressure was 18 mm Hg, and the pulmonary capillary wedge pressure 16 mm Hg. There was 75% stenosis of the right coronary artery (Figure 2).
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Figure 1. Computed tomography revealed a severely calcified pericardium adhering to the epicardium, with no pericardial space.
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Figure 2. Coronary angiography revealed 75% stenosis of the right coronary artery (a) and severely calcified pericardium over the right ventricle (b).
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Under general anesthesia, with the patient in a supine position, the chest was opened via a median sternotomy. A saphenous vein graft (SVG) was harvested from the distal lower left extremity. The calcified pericardium adhered tightly to the epicardium, without effusion. We began the pericardial dissection from the right ventricular outflow tract to the anterior wall of the left ventricle, using an ultrasonic scalpel (Harmonic Scalpel®; Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) with a hooked blade. The pericardium that adhered tightly to the left ventricle was dissected by the "quick-touch" method.1 The sharp-hook edge of the ultrasonic scalpel was used to dissect and cut the firm fibrotic tissue. Next, in order to expose a deep surgical field of vision and gain sufficient operative space, we lifted the left side of the split sternum using a sternal retractor and a standard sternal spreader. While gradually lifting the apex of the heart anteriorly with a StarfishTM cardiac positioner (Medtronic Inc., Minneapolis, MN, USA), we dissected the pericardium on the inferior cardiac surface, which was fully exposed by elevating and rotating the left ventricle (Figure 3A). The postero-lateral pericardium was decorticated, with the exception of a band near the left phrenic nerve (Figure 3B).
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Figure 3. Surgeon’s view of the pericardium dissected by OPCAB techniques, with a StarfishTM cardiac positioner (a), a Harmonic® ultrasonic scalpel (b), and a sternal retractor (c); dissected pericardium (d).
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After completing the left ventricular pericardiectomy, we lifted the right side of the sternum and dissected the pericardium overlying the right ventricle and right atrium. Finally, we performed a proximal anastomosis of the SVG to the aorta with the use of an aortic connector system (St. Jude Medical, St. Paul, MN, USA), followed by a distal anastomosis of the SVG to the posterior descending artery. The operation was performed without CPB or blood transfusion. There was no malignant arrhythmia and no postoperative left ventricular systolic dysfunction. Swan-Ganz catheterization showed a cardiac index of 3.1 L·min–1·m–2, mean right atrial pressure of 5 mm Hg, and a pulmonary capillary wedge pressure of 9 mm Hg, without administration of cardiac inotropes. The patient was discharged 7 days after the operation with no postoperative complications.
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DISCUSSION
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Hoit2 reported that surgery for constrictive pericarditis is associated with a mortality rate of 6% to 19%, with a higher risk in patients with severe calcification and involvement of the visceral pericardium. Left ventricular systolic dysfunction may also occur after decortication of a severely constricted heart. To reduce this higher operative risk, we attempted the performance of a pericardiectomy without CPB for a patient with severely calcified pericarditis, using specialized instruments.
The Harmonic® ultrasonic scalpel has been used to harvest fully skeletonized internal arteries and for adhesiotomies in patients undergoing re-operation and surgery for constrictive pericarditis during CPB.2–5 Vibrating 55,500 times per second, the Harmonic Scalpel® uses ultrasonic energy for both cutting and coagulation, which are controlled by the surgeon by adjusting the power level, blade edge, tissue traction, and blade pressure. With the ultrasonic scalpel, the tissue temperature rises to 50–100° C, as compared to 150–400° C during electrocautery. Collateral thermal damage to tissue is minimal because the ultrasonic energy is transferred coaxially along the blade, and not to the lateral aspect of the hook (Figure 4).2,3 As we used the blade tangentially and dissected the heart surface, we avoided thermal muscular injury and coronary vascular perforations. In addition, no malignant arrhythmia occurred during dissection as the electrical pulses were not transferred to the heart surface. Finally, our procedure is likely to prevent the development of fibrosis on the myocardial surface, which might impede diastolic motion of the ventricle.
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Figure 4. Harmonic® ultrasonic scalpel with a hooked blade (a); the ultrasonic energy is transferred coaxially along the blade from the edge of the hook, and not to the lateral side of the hook (b).
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Recently, suction heart positioners have been used for off-pump coronary artery bypass (OPCAB), and for other cardiac operations.6 The posterior and lateral aspects of the heart can be exposed, without negatively affecting cardiac function.7 With the StarfishTM cardiac positioner and a sternal retractor, we safely and easily exposed the heart as is performed with OPCAB, without risk of the perioperative complications incurred with CPB. In addition, the use of the Harmonic® ultrasonic scalpel prevented injury to the heart surface and minimized bleeding, compared to that associated with CPB. This shortened the operation and obviated the need for transfusion. Our procedure was less invasive than conventional techniques and resulted in a favorable outcome and prompt recovery.
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REFERENCES
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ABSTRACT
INTRODUCTION
