Jordan D. Secor, MD and Thoralf M. Sundt III, MD
Massachusetts General Hospital, Boston, MA, USA
Essential Operative Steps
- Arterial and central venous line placement (pulmonary artery catheter placement on a case-by-case basis)
- General endotracheal anesthesia
- Intraoperative transesophageal echocardiogram
- Consider preparation for peripheral cardiopulmonary bypass if redo sternotomy or high-risk patient
- Median sternotomy*
- Open both pleural cavities
- Identify and preserve both phrenic nerves. Avoid chemical paralysis. Contraction of the diaphragm indicates proximity
to the phrenic nerve. - Perform complete pericardiectomy. Excise all pericardium anterior to the phrenic nerves from the great vessels superiorly
to the diaphragm inferiorly. Then excise the pericardium posterior to the left phrenic nerve to the level of the pulmonary
veins and IVC including the diaphragmatic surface. - Assess hemostasis, place pleural and mediastinal tubes
- Sternotomy closure
*Pericardiectomy via left anterolateral thoracotomy has been described but is not our preferred approach
Potential Complications and Pitfalls
- Failure to anticipate the need for cardiopulmonary bypass (peripheral or central) based on patient risk factors (redo
sternotomy, axial imaging, age, comorbidities, difficult dissection, etc.) - Injury to the phrenic nerve(s)
- Incomplete pericardiectomy is the biggest pitfall. Failing to remove the visceral pericardium, the pericardium posterior
to the left phrenic nerve, and the pericardium on the diaphragmatic surface are the most common mistakes - Tricuspid regurgitation, if present, will worsen, not improve, after pericardiectomy. Tricuspid regurgitation, if present,
should be addressed surgically at the time of pericardiectomy
Template Dictation
Preoperative Diagnosis: Constrictive pericarditis
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure Performed: Pericardiectomy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication for Procedure: The patient is a [BLANK]-year-old [SEX] with 3-month history of progressive signs and
symptoms of congestive heart failure. Preoperative transthoracic echocardiography demonstrated a circumferentially thickened
pericardium with normal valvular anatomy and ventricular function consistent with constrictive pericarditis. Chest computed
tomography also demonstrated a thickened pericardium. Coronary angiogram revealed normal coronary arteries without
calcification. Right heart catheterization showed elevated right atrial pressure, increased right ventricular end diastolic pressure,
equalization of right and left ventricular diastolic plateau pressures, a dip and early plateau in ventricular diastolic pressure,
and interventricular dependence with systolic discordance on inspiration. The patient found some symptom improvement with
diuretics but was ultimately referred by their cardiologist to the cardiac surgery clinic for consideration of pericardiectomy.
Informed consent for pericardiectomy was obtained from the patient after a full discussion of potential risks, benefits, and
alternatives.
Description of the Procedure: The patient was taken to the operating room and placed on the operating room table in the
supine position. A Swan Ganz catheter and radial artery line were inserted. General anesthesia was administered, and an
endotracheal tube was placed. Prior to incision, preoperative transesophageal echocardiogram demonstrated a thickened
pericardium with normal biventricular function and a typical septal bounce. The patient was prepped and draped in the usual
sterile fashion. Care was taken to include the groins and clavicles in case peripheral cardiopulmonary bypass might be needed.
The chest was opened through a median sternotomy in the standard fashion. The pericardium was abnormally thickened. The
right pleural space was opened, and the right phrenic nerve was identified. The pericardium was opened in the midline. The
visceral pericardium was mobilized off of the right ventricle and right atrium. A moist laparotomy pad was used to cover the
heart. Working from the right pleural space with the phrenic nerve in view, the pericardium 1cm anterior to the right phrenic
nerve was excised from the superior vena cava to the diaphragm. Resection of the right sided pericardium permitted subsequent
traction on the heart without hemodynamic compromise due to right atrial compression. The left-sided pericardium including
both the visceral and parietal layers was then dissected off of the remainder of the right ventricle and the left ventricle anteriorly,
laterally, and inferiorly. The dissection of the pericardium was carried inferiorly to the diaphragm and superiorly to the
pericardial reflection overlying the great vessels. A moist laparotomy pad was then wrapped around the heart to protect it.
Working from within the left pleural space with the left phrenic nerve under direct vision, the pericardium anterior to the
phrenic nerve was excised with electrocautery down to the level of the diaphragm inferiorly and superiorly towards the great
vessels. A plane of dissection was then established inferiorly between the thickened pericardium and the central tendon of the
diaphragm. Then, with the heart retracted rightward, the surgeon’s left hand was placed in the left pleural space encircling and
protecting the phrenic nerve as the pericardium posterior to the left phrenic nerve was incised. This incision was taken down
onto the diaphragm. The diaphragmatic and posterior lateral pericardium was excised en bloc. One mediastinal Blake drain
and bilateral pleural chest tubes were placed.
The sternum was reapproximated with #5 stainless steel wires in figure-of-eight fashion. The pectoral fascia and dermis were
closed with 2-0 and 3-0 vicryl, respectively. The skin was closed with a 4-0 monocryl subcuticular stitch. Sterile dressings
were applied. The patient tolerated the procedure well. Postoperative transesophageal echocardiographic demonstrated
resolution of the ventricular septal bounce. The central venous pressure dropped dramatically to normal levels. The patient
was then transferred to the ICU in stable condition.
All sponge, instrument, and needle counts were correct at the completion of the case.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Multiple Choice Question(s)
- Constrictive pericarditis can be differentiated from restrictive cardiomyopathy by the following:
A. Pericardial calcification is the most sensitive imaging finding to diagnose constrictive pericarditis
B. Reversal of blood flow in the hepatic veins is seen during expiration in patients with constrictive pericarditis
C. Elevated left atrial filling pressure is unique to restrictive cardiomyopathy
D. Endomyocardial biopsy is necessary to differentiate constrictive pericarditis from restrictive cardiomyopathy
Answer: B. Pericardial calcification may be indicative of constrictive pericarditis. However, many patients with constrictive
pericarditis do not have pericardial calcification. Pericardial thickening is the most common axial imaging finding in
constrictive pericarditis. Expiratory hepatic flow reversal is indicative of constrictive pericarditis and inspiratory hepatic flow
reversal is indicative of restrictive cardiomyopathy. Elevated filling pressures (including left atrial pressure) are common in
both constrictive pericarditis and restrictive cardiomyopathy. Endomyocardial biopsy can be used to diagnose restrictive
cardiomyopathy but is not necessary in most cases. Differentiating constrictive pericarditis from restrictive cardiomyopathy is
critically important, particularly in patients with a history of mediastinal radiation. Both diseases share similar presentations
and many of the same diagnostic abnormalities. However, patients with restrictive cardiomyopathy must be identified
preoperatively as they derive no benefit from pericardiectomy. - A complete pericardiectomy includes:
A. Resection of the entire pericardium including both phrenic nerves
B. Initiation of peripheral cardiopulmonary bypass prior to opening the pericardium
C. Post-operative mortality is not significantly different after complete pericardiectomy compared to subtotal
pericardiectomy
D. Resection of both visceral and parietal pericardium
Answer: D. Complete pericardiectomy includes excision of all visceral and parietal pericardium anterior and medial to the
phrenic nerves from the great vessels superiorly to the diaphragm inferiorly. Furthermore, the pericardium posterior to the left
phrenic nerve should be excised to ensure the left ventricle is entirely liberated. The phrenic nerves should be identified and
preserved. Incomplete or subtotal pericardiectomy is associated with reduced survival. Cardiopulmonary bypass is usually not
required for pericardiectomy but can be used selectively for high-risk patients or when significant adhesions between the heart,
great vessels, and pericardium are encountered.
Sources
Sorajja P and Hoit BD. Differentiating constrictive pericarditis and restrictive cardiomyopathy. In: UpToDate, LeWinter MM
(Ed), UpToDate, Waltham, MA. (Accessed on March 25, 2022.)
Villavicencio MA, Dearani JA, and Sundt TM 3rd. (2008). Pericardiectomy for Constrictive or Recurrent Inflammatory
Pericarditis. Operative Techniques in Thoracic and Cardiovascular Surgery, 13(1), 2–13.
Góngora E, Dearani JA, Orszulak TA, Schaff HV, Li Z, Sundt TM 3rd. Tricuspid regurgitation in patients undergoing
pericardiectomy for constrictive pericarditis. Ann Thorac Surg. 2008 Jan;85(1):163-70.
