Difference between revisions of "Pericardiectomy"

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{{Infobox surgical procedure
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Provide a brief summary here.
== Overview ==
Surgical procedure involving the removal of part or all of the pericardium, the fibrous sac surrounding the heart. It is primarily performed to treat constrictive pericarditis(CP)—a condition where the pericardium becomes scarred and loses elasticity, impeding normal cardiac filling and function<ref name=":0">{{Cite journal|last=Al-Kazaz|first=Mohamed|last2=Klein|first2=Allan L.|last3=Oh|first3=Jae K.|last4=Crestanello|first4=Juan A.|last5=Cremer|first5=Paul C.|last6=Tong|first6=Michael Z.|last7=Koprivanac|first7=Marijan|last8=Fuster|first8=Valentin|last9=El-Hamamsy|first9=Ismail|last10=Adams|first10=David H.|last11=Johnston|first11=Douglas R.|date=2024-08-06|title=Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review|url=https://www.sciencedirect.com/science/article/pii/S073510972407548X|journal=Journal of the American College of Cardiology|volume=84|issue=6|pages=561–580|doi=10.1016/j.jacc.2024.05.048|issn=0735-1097}}</ref>. The procedure aims to relieve constriction and improve cardiac output.
Constrictive pericarditis(CP): Granulation tissue formation in and around the pericardium(protective fibroelastic sac that covers the heart). This granulation tissue results in loss of pericardial elasticity, leading to restriction in ventricular filling.  The leading cause of CP worldwide is tuberculosis. <ref>{{Cite journal|last=Albarrán|first=Ali Ayaon|last2=González|first2=José Antonio Blázquez|last3=García|first3=José María Mesa|date=2018-06|title="Malignant" Chronic Constrictive Pericarditis|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC6039145/|journal=The Eurasian Journal of Medicine|volume=50|issue=2|pages=140|doi=10.5152/eurasianjmed.2018.17358|issn=1308-8734|pmc=6039145|pmid=30002587}}</ref>  In developed nations, the leading cause is idiopathic vs. post-viral infection.  With the fibrotic pericardial sac, ventricular filling is limited, leading to decreased end-diastolic volume and subsequently, a decreased stroke volume and cardiac output.
The right heart does not experience the decrease in intrathoracic pressure during inspiration that is typical in healthy patients, referred to as dissociation between intrathoracic and intracardiac pressures.  This dissociation distinguishes it from cardiac tamponade. 
Types of constrictive pericarditis:
# Subacute CP: Early, inflammatory stage of CP.  Patients may have chest pain, pericardial effusion, elevated inflammatory markers.
## Transient CP: Variant of subacute CP.  Resolves spontaneously or with medical therapy in 3-6 months.  Pathophysiology is acute pericardial inflammation as opposed to permanent fibrosis and calcification(seen with chronic CP)<ref name=":0" />
### Treatment involves treating the underlying cause of inflammation.  Examples: autoimmune disorder, infection. 
### Treatment includes anti-inflammatory, NSAIDs, colchicine.
# Effusive-Constrictive pericarditis: 1-2% of patients with pericarditis.  Cardinal finding is elevated CVP/Right atrial pressures(RAP).<ref name=":0" />
# Chronic CP: Usually irreversible, requires radial pericardiectomy commonly.  Signs and symptoms include pericardial calcifications, a-fib, liver cirrhosis, cachexia. Low likelihood or response to medical management with anti-inflammatory medications.<ref name=":0" />
# Occult CP: Rare form of CP.  Often diagnosed after fluid bolus challenge during cardiac catheterization. <ref name=":0" />
=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===
There are no current American Heart Association/American College of Cardiology guidelines for management of pericardial disease.  However, European counterparts(Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology - ESC) published guidelines for treatment of pericardial diseases in 2015, which are as follows.<ref name=":0" />
* Pericardiectomy is recommended in patients with chronic CP and NYHA functional class III or IV symptoms. 
* Pericardiectomy may be considered in patients with refractory or persistent recurrent pericarditis(RP).
** Patients who failed medical therapy or are intolerant to it.
* Pericardiectomy is recommended in patients with partial agenesis of the pericardium leading to cardiac herniation and hemodynamic compromise.
** Pericardial agenesis is often asymptomatic but should be monitored
=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
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!System
!Considerations
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|Airway
|Ability to lie flat
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|Neurologic
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|Cardiovascular
|CHF like symptoms, orthopnea, decreased cardiac output, decreased venous return,
|-
|Pulmonary
|Orthopnea, dyspnea on exertion.
|-
|Gastrointestinal
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|-
|Hematologic
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|-
|Renal
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|-
|Endocrine
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|-
|Other
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|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
== Intraoperative management ==
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
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|
|-
|Indications
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|-
|Position
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|-
|Surgical time
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|EBL
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|Postoperative disposition
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|Pain management
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|Potential complications
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== References ==
[[Category:Surgical procedures]]

Revision as of 12:59, 1 July 2025

Pericardiectomy
Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Provide a brief summary here.

Overview

Surgical procedure involving the removal of part or all of the pericardium, the fibrous sac surrounding the heart. It is primarily performed to treat constrictive pericarditis(CP)—a condition where the pericardium becomes scarred and loses elasticity, impeding normal cardiac filling and function[1]. The procedure aims to relieve constriction and improve cardiac output.

Constrictive pericarditis(CP): Granulation tissue formation in and around the pericardium(protective fibroelastic sac that covers the heart). This granulation tissue results in loss of pericardial elasticity, leading to restriction in ventricular filling. The leading cause of CP worldwide is tuberculosis. [2] In developed nations, the leading cause is idiopathic vs. post-viral infection. With the fibrotic pericardial sac, ventricular filling is limited, leading to decreased end-diastolic volume and subsequently, a decreased stroke volume and cardiac output.

The right heart does not experience the decrease in intrathoracic pressure during inspiration that is typical in healthy patients, referred to as dissociation between intrathoracic and intracardiac pressures. This dissociation distinguishes it from cardiac tamponade.

Types of constrictive pericarditis:

  1. Subacute CP: Early, inflammatory stage of CP. Patients may have chest pain, pericardial effusion, elevated inflammatory markers.
    1. Transient CP: Variant of subacute CP. Resolves spontaneously or with medical therapy in 3-6 months. Pathophysiology is acute pericardial inflammation as opposed to permanent fibrosis and calcification(seen with chronic CP)[1]
      1. Treatment involves treating the underlying cause of inflammation. Examples: autoimmune disorder, infection.
      2. Treatment includes anti-inflammatory, NSAIDs, colchicine.
  2. Effusive-Constrictive pericarditis: 1-2% of patients with pericarditis. Cardinal finding is elevated CVP/Right atrial pressures(RAP).[1]
  3. Chronic CP: Usually irreversible, requires radial pericardiectomy commonly. Signs and symptoms include pericardial calcifications, a-fib, liver cirrhosis, cachexia. Low likelihood or response to medical management with anti-inflammatory medications.[1]
  4. Occult CP: Rare form of CP. Often diagnosed after fluid bolus challenge during cardiac catheterization. [1]

Indications

There are no current American Heart Association/American College of Cardiology guidelines for management of pericardial disease. However, European counterparts(Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology - ESC) published guidelines for treatment of pericardial diseases in 2015, which are as follows.[1]

  • Pericardiectomy is recommended in patients with chronic CP and NYHA functional class III or IV symptoms.
  • Pericardiectomy may be considered in patients with refractory or persistent recurrent pericarditis(RP).
    • Patients who failed medical therapy or are intolerant to it.
  • Pericardiectomy is recommended in patients with partial agenesis of the pericardium leading to cardiac herniation and hemodynamic compromise.
    • Pericardial agenesis is often asymptomatic but should be monitored

Surgical procedure

Preoperative management

Patient evaluation

System Considerations
Airway Ability to lie flat
Neurologic
Cardiovascular CHF like symptoms, orthopnea, decreased cardiac output, decreased venous return,
Pulmonary Orthopnea, dyspnea on exertion.
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Intraoperative management

Monitoring and access

Induction and airway management

Positioning

Maintenance and surgical considerations

Emergence

Postoperative management

Disposition

Pain management

Potential complications

Procedure variants

Variant 1 Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 1.5 Al-Kazaz, Mohamed; Klein, Allan L.; Oh, Jae K.; Crestanello, Juan A.; Cremer, Paul C.; Tong, Michael Z.; Koprivanac, Marijan; Fuster, Valentin; El-Hamamsy, Ismail; Adams, David H.; Johnston, Douglas R. (2024-08-06). "Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review". Journal of the American College of Cardiology. 84 (6): 561–580. doi:10.1016/j.jacc.2024.05.048. ISSN 0735-1097.
  2. ↑ Albarrán, Ali Ayaon; González, José Antonio Blázquez; García, José María Mesa (2018-06). ""Malignant" Chronic Constrictive Pericarditis". The Eurasian Journal of Medicine. 50 (2): 140. doi:10.5152/eurasianjmed.2018.17358. ISSN 1308-8734. PMC 6039145. PMID 30002587. Check date values in: |date= (help)

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