IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Constrictive Pericarditis with Constrictive Epicarditis
Dan Lindblom, MD,
Jesper Nyman, MD,
Jenny Vedin, MD
Department of Cardiothoracic Surgery and Anesthesiology Karolinska University Hospital, Stockholm, Sweden
Dan Lindblom, Tel: +46 704840172, Fax: +46 8 331931, Email: dan.lindblom{at}karolinska.se, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-17176 Stockholm, Sweden.
A 63 year old male was referred because of heart failure. He had received combined radiotherapy and chemotherapy for a thymic carcinoma seven years earlier and was considered in remission. He was severely symptomatic, mainly from right heart failure, with leg oedema and with large amounts of ascites, requiring frequent laparocenteses. He had been treated with steroids and high doses of diuretics orally and intravenously for several months with limited clinical response. A preoperative computed tomography of the chest showed a thickened pericardium without calcifications and there were no signs of recurrent tumour (Figure 1a, 1b
). A chest X-ray was not conclusive (Figure 2). Constrictive pericarditis was diagnosed by left and right heart catheterization and by Doppler echocardiography with Tissue Velocity Imaging techniques. He underwent pericardectomy via a median sternotomy. The pericardium was fibrotic and thickened (5 mm) and adherent to the heart except in a small anterior area. The thymus was enlarged and fibrotic and was clinically suspicious for malignancy, but a frozen section was without evidence of recurrent cancer. The pericardium was dissected away from the heart (from phrenic to phrenic) en bloc with the thymus. Following this, there was some hemodynamic improvement (the central venous pressure decreased from 30 mm of mercury to 24 mm). The heart was, however, still engaged in a thick, white, fibrous epicardial tissue which seemed to prevent adequate filling of the heart. Removal of the epicardial peel was attempted but abandoned for fear of severe myocardial injury. Instead we choose to perform a number of transverse and longitudinal incisions in the epicardium allowing the heart to successively dilate and fill, and the central venous pressures decreased further (Figure 3). This method was originally described by Heimbecker in 19831 and was than called "the Waffle procedure". It has later been presented as "the Turtle Cage Operation".2 Our patient made a fast recovery and was asymptomatic with a low dose of diuretics at follow-up. As the final histopathologic examination of the specimen showed remaining viable malignancy, he will, however, need further chemotherapy.
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Figures 1a, 1b. Preoperative computed tomography of the chest illustrating fibrous thickening of the pericardium without calcifications.
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Figure 3. "Waffle" or "Turtle cage"? Multiple incisions in the epicardial peel following pericardectomy allowed further dilatation of the heart with decreasing filling pressures.
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REFERENCES
- Heimbecker RO, Smith D, Shimizu S, Kestle J. Surgical technique for the management of constrictive epicarditis complicating constrictive pericarditis (the waffle procedure). Ann Thorac Surg 1983;36(5):605–6.[Abstract]
- Faggian G, Mazzucco A, Tursi V, Bortolotti U, Gallucci V. Constrictive epicarditis after open heart surgery: the turtle cage operation. J Card Surg. 1991 Jun;6(2):355–6.[Medline]
Asian Cardiovasc Thorac Ann 2009;
17:102-104
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102332
