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ORIGINAL ARTICLE |
Department of Cardiothoracic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqwa and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Georgios P Georghiou, MD, Tel: +357 22819666, Fax: +357 22819667, Email: georgios_georghiou{at}cytanet.com.cy, Department of Cardiothoracic Surgery, American Heart Institute, PO Box 25610, 1311 Nicosia, Cyprus.
ABSTRACT
Delayed-onset pericardial effusion following cardiac surgery can give rise to significant morbidity due to its presentation as well as management by traditional surgical techniques. An institutional experience of a video-assisted thoracoscopic technique to create a pericardial window, with the advantages of a minimally invasive approach combined with excellent visualization in such patients, was reviewed. A retrospective analysis was conducted on all patients undergoing video-assisted thoracoscopic for delayed pericardial effusion after cardiac surgery from January 2001 to January 2006 at our center. Seven patients with echocardiographically diagnosed delayed tamponade underwent video-assisted thoracoscopy; 5 were receiving anticoagulants after valve replacement, and 2 had undergone heart transplantation. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operative time was 45 min. There were no complications of the thoracoscopic technique. Video-assisted thoracoscopic creation of a pericardial window is safe and effective treatment for loculated pericardial effusions secondary to cardiac surgery.
Key Words: Cardiac Tamponade • Pericardial Effusion • Pericardiectomy • Pericardial Window Techniques • Thoracic Surgery • Video-Assisted
INTRODUCTION
Percutaneous catheter drainage and balloon pericardiotomy are being increasingly performed for diagnostic and therapeutic purposes. However, recurrent or loculated effusions are best managed surgically with a pericardial window.1 Since 2001, video-assisted thoracoscopic pericardial fenestration has been offered at our institute to patients with recurrent or symptomatic pericardial effusions following cardiac surgery. The aim of this study was to retrospectively assess the validity of video-assisted thoracoscopic pericardial fenestration for treatment of loculated effusions secondary to cardiac surgery following failure of percutaneous catheter maneuvers. The use of a video-assisted thoracoscopic technique after cardiac surgery has been less well reported.
PATIENTS AND METHODS
A retrospective analysis was conducted on all patients undergoing video-assisted thoracoscopic for delayed pericardial effusion after cardiac surgery from January 2001 to January 2006 at our center. Inclusion criteria were echocardiographically documented pericardial effusions after cardiac surgery causing tamponade physiology as indicated by right atrial compression, or right ventricular diastolic collapse, or both. Seven patients underwent video-assisted thoracoscopic pericardial fenestration for complications of cardiac surgery. All presented with delayed tamponade at 3 to 5 weeks postoperatively. Mitral valve replacement had been performed in 5, and cardiac transplantation in 2.
A computed tomography scan was carried out to determine the side of intervention. The specific site of intervention was based on the predominant localization of the loculated pericardial effusion (Figure 1
). The procedure was performed in the lateral decubitus position under general anesthesia and double-lumen intubation.2 Trocars for the passage of an endoscopic camera and the various surgical instruments were introduced through 2 or 3 thoracic incisions of less than 10 mm at the level of the 4th and 6th intercostal spaces. Pericardiocentesis was performed under direct vision. After the phrenic nerve was identified, a stab incision was usually created on the surface of the distended pericardium, using electrocautery. The pericardium was grasped with endoscopic forceps and incised with curved endoscopic scissors (Figure 2). Loculations and septa were broken down, and the heart was circumferentially freed with a thoracoscopic suction device. A large pericardial window was created, taking special care to protect the phrenic nerve. A chest drain was inserted into the cavity through one of the port sites, with no attempt to drain the pericardium. The patient was extubated and transferred to the recovery room for a few hours of observation, and returned to the ward on the same day. The chest tube was removed when the amount of daily drainage was less than 100 mL. Patient-controlled analgesia was provided postoperatively in all cases. Postoperative morbidity and duration of chest drainage and hospitalization were noted. Patients were examined clinically and echocardiographically 6 months after surgery for the development of recurrent effusions.
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All 5 patients who had undergone mitral valve surgery were receiving anticoagulation therapy. The 2 post-transplant patients had a large pericardial space relative to the donor heart. The effusion was localized in 6 patients (lateral surface of the left ventricle in 4, right atrium in 2), and diffuse in one. Mean operating time was 45 min (range, 30 to 60 min). All pericardial drainage procedures were uneventful, and there were no postoperative complications. Previous echocardiographic drainage was successful in 3 of our patients (one with diffuse effusion and the 2 with right atrium-localized effusions), but it was followed by repeat accumulation of the fluid within 1 week on all 3 occasions, despite the addition of hydrocortisone and indomethacin. Mean duration of postoperative chest tube drainage was 2 days (range, 1–4 days), and mean hospitalization was 4 days (range, 3–6 days).
DISCUSSION
Although pericardial effusion commonly develops following open heart surgery, it is clinically significant in 0.8%–6% of patients.3 Factors predisposing to the development of postoperative effusion include valve surgery, use of anticoagulants, coagulation disorders, excessive mediastinal drainage, postpericardiotomy syndrome, and autoimmune reactions.4 Although rare compared to pericardial effusions associated with postpericardiotomy syndrome, the delayed appearance of pericardial effusion after cardiac surgery can lead to significant morbidity.5–7 The optimal treatment for postoperative pericardial effusion remains controversial. Its management usually adheres to the traditional surgical approach of subxiphoid incision or thoracotomy, in addition to drainage under echocardiographic guidance. The options first considered in our patients were steroids to cover the possibility of delayed postpericardiotomy syndrome, and drainage under echocardiographic control. While echocardiographic drainage was successful on all 3 occasions, it was followed by rapid re-accumulation of fluid. It was decided to create a pericardial window by video-assisted thoracoscopy rather than place another percutaneous drain or follow one of the more traditional surgical approaches to the subxiphoid incision or thoracotomy. Although a single pericardiocentesis may fail to resolve the problem, this method is often utilized to relieve tamponade and establish hemodynamic stability in an acute setting. However, a posterior located or loculated pericardial effusion, as in 6 of our patients, is less likely to respond to pericardiocentesis.8
The subxiphoid route is simple and efficacious for emergency relief of tamponade. The subxiphoid incision is rapid, and the effusion can be evacuated promptly. In addition, it allows digital exploration to break up adhesions and permit more effective drainage of blood and fibrinous debris.1 However, access is restricted and the relapse rate ranges from 3% to 18%.8 It should be noted that the subxiphoid approach not useful in patients with a posteriorly located pericardial effusion without communication to the rest of the pericardial cavity. These patients are often treated by repeat sternotomy or an anterior thoracotomy. Recently, a less invasive approach using video-assisted thoracoscopy has been proposed to treat loculated pericardial effusions under direct vision.1
In this study, we decided to create a pericardial window using video-assisted thoracoscopy rather than place another percutaneous drain or adopt one of the more traditional surgical approaches. Thoracoscopy is helpful to the surgeon because it affords excellent visualization of the pericardium, and also beneficial to the patient because it is associated with reduced postoperative pain, a lower incidence of wound-related problems, shorter hospitalization, and faster recovery.1,2 Furthermore, it avoids the formation of substernal pericardial adhesions, a frequent occurrence after sternotomy, and also allows the removal of fibrin deposits. This procedure has been noted to have technical and therapeutic advantages: the surgical approach was less traumatic than that of an anterior thoracotomy, and more extensive pericardial resection is possible compared to the subxiphoid route.8 Thoracotomy is more often followed by pulmonary complications and involves a longer postoperative hospitalization.2 Furthermore, better visualization is afforded than with subxiphoid approach. Loculated effusions, even those located posteriorly that cannot normally be reached without an open thoracotomy, were easily drained.
None of our patients who underwent video-assisted thoracoscopy was hemodynamically compromised, and all were diagnosed on the basis of echocardiographic findings. Echocardiographic evidence of mild tamponade did not render the thoracoscopic approach unsafe. Posterior loculations were a frequent finding, and in most cases, resection of a portion of the pericardium posterior to the phrenic nerve was required. Five patients were receiving anticoagulation therapy which may have contributed to the formation of effusions. We encountered no operative difficulties, and the postoperative periods were uneventful. No recurrent pericardial effusions were noted during follow-up.
The limitations of this study include its retrospective design and the small sample size. However, our results support the use of direct-vision video-assisted thoracoscopy in the treatment of loculated pericardial effusions. It is safe and effective, especially in patients with recurrent effusions following cardiac surgery.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:480-482
© 2009 by SAGE Publications
DOI: 10.1177/0218492309348505
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