Surgery of the Pericardium

Question 1

Anatomy of the pericard

Answer 1

Fibrous and serous pericard

Parietal and visceral laminas

Sternopericardial lig is close to the xiphoid cart

Int thoracic A

Pericardiophenic a

Phrenic nerve

Hypovasc, the small sac filled with fluid btw the 2 layers allows for movement

** at dors/mid third: the phrenic nerve runs through must preserve this to avoid paralysis of the diaphragm

Question 2

Pericardectomy indications:

Answer 2

1. Pericard effusion
2. Constrictive pericarditis
3. Pericard cyst
4. Pericard rupture
5. Chylothorax

Question 3

Causes of pericard effusion

Answer 3

Idiopathic

Neoplasia

• HSA of RA is pathognomic
• Chemodectoma: wide based and slow-growing
• Mesothelioma: origin can be pleura or pericardium

Bact: septic! may be caused by migrating FB

Pathogenesis: the fluid in the sac is compressing the heart– R failure (thinner wall)– L failure– complete failure

Question 4

Reaching a diagnosis

Answer 4

History

Phys exam: chest and cardiac area: ausc and percussion (dullness)

Signs of R sided HF: ascites, hepato/splenomegaly, ventr SC edema

X-ray: dilation/ enlrgement

ECG

Echo at low voltage will show an enlarged space btw epi and peri

Angigraphy: angulation of the caud v.cava can cause congestion!

Question 5

Surgery possibilities

Answer 5

1. Pericard window
2. Subtotal (partial) subphrenic
3. Total
4. Percutaneous Balloon pericardiotomy

Question 6

Making a pericard window

Answer 6

Lat thoracotomy on the R at 5th ICS

Thorascopia: transdiaphragmatic or intercostal

3x3cm piece removed to allow drainage of fluid- if make it too big then cardia herniation– strangulation

If too small- will close

Question 7

Subtotal subphrenic pericardectomy

Answer 7

Lat thoracotomy on R side at 5th ICS

Median sternotomy

Thoracoscopy- transdiaphragmatic

** resect the pericard right underneath the phrenic nerve

Question 8

Total pericardectomy

Answer 8

Median sternotomy

V rare!!

Maybe when multiple mesotheliomas

Need to elevate the phrenic nerve from pericard

Question 9

Percutaneous Ballonn Pericardiotomy

Answer 9

Puncture pericard through the thorax with a needle that needs to be large enough to introduce a balloon catheter– inflate and drain (very small hole)

Question 10

Postop

Answer 10

Hospital

Analgesia

Chest drain for as long as it’s draining.. wehn the amount drops below 1-2ml/day you can remove

The longer the time taken to drain, the poorer the prognosis

ECG rechecks for idiopathic vs neoplastic effusion

Question 11

Prognosis

Answer 11

Idiopathic is good but often turns neoplastic!!

HSA: grave

Chemodectoma: guarded

MST: 730 days with pericardiectomy, 42 days without

recurrence in 1.5-5 mnths, but if no metastasis to pleura or pericard then the prognosis isnt bad!

Constrictive pericarditis: guarded!! beause bleeding, pulm embolisms, arrhythmia. if mobilizable i.e no adhesions btw epi and peri then prognosis is better!