Pericardiectomy

Pericardiectomy

Anesthesia type	General endotracheal
Airway	ETT
Lines and access	2+ PIVs, central venous access +/- Swan, arterial line
Monitors	Standard, arterial line, PA catheter, TEE
Primary anesthetic considerations
Preoperative	Functional status, starting H/H for CPB management
Intraoperative	CPB
Postoperative	ICU disposition
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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. 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. 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. 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).
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.
4. Occult CP: Rare form of CP. Often diagnosed after fluid bolus challenge during cardiac catheterization.

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.

• 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

• TEE (transesophageal echocardiography) used intraoperatively to guide resection and assess results.
• CPB as a topic is beyond the scope of this article but will be discussed briefly with the general steps below
  1. Median sternotomy
  2. Exposure of the heart
  3. Aortic cannulation
  4. Right atrial cannulation
  5. Insertion of aortic root and the LV vent
  6. Resection of pericardium

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	Rule out esophageal abnormalities, varices, issues swallowing given TEE
Hematologic	Starting H/H for CPB management/sequestration/priming of CPB cannulas. Assess underlying coagulopathy or anticoagulation given need for CPB
Renal	Assess renal function
Endocrine	Assess history of diabetes, preoperative A1C
Other

Labs and studies

• Cardiology Assessment: Detailed history and physical examination.
• Imaging: Echocardiogram to assess septal thickness and LVOT gradient. Cardiac MRI may also be used.
• Functional Testing: Stress testing to evaluate symptomatology and obstruction severity.
• Labs
  • CBC
  • CMP
  • Coagulation studies
  • Blood cultures
  • +/- TEG if patient has history of comorbid condition that affects coagulopathy

Intraoperative management

Monitoring and access

• Standard ASA monitors
• Arterial line
• Central access CVP +/- PA pressures(indicated for RV or LV failure)
• Transesophageal echo(TEE)

Induction and airway management

• General anesthesia with endotracheal intubation.
• Propofol or thiopental may be used, with careful consideration of dose given the myocardial depressant effects and decreased afterload they cause. Etomidate is also an option given its relative lack of effect on the cardiovascular system.

Positioning

• Supine with shoulder roll, arms tucked

Maintenance and surgical considerations

• Isoflurane pre CPB. Isoflurane is continued by perfusionists while patient is on CPB. Patient is often transported to ICU postoperatively with IV sedation infusion(Propofol/precedex)

Emergence

• Transport to ICU while sedated, and often while intubated

Postoperative management

Disposition

• Intensive care unit (ICU) monitoring initially.
  • Often intubated
  • Frequently requiring vasopressors or inotropic agents post-CPB.
• Continuous ECG monitoring for arrhythmias.

Pain management

• Regional anesthetic techniques for sternotomy
• Long acting opiates(dilaudid or methadone)
• Tylenol
• Avoid NSAIDs given patients undergoing cardiac surgery are at higher risk for kidney injury and patients are often coagulopathic from CPB

Potential complications

• Arrhythmias (atrial fibrillation, ventricular arrhythmias)
• Ventricular wall perforation
• Infection
• Bleeding
• CPB specific complications