Pericardiectomy

Pericardiectomy

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Airway
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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

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

Procedure variants

	Variant 1	Variant 2
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