Pericardectomy

Diseases of the cardiovascular system occupy one of the first places in the overall structure of pathologies. Therefore, cardiology is considered the leading direction in medicine in any country of the world. Many cardiologic diseases are known, to which people of almost all ages are subject, and one such pathology is pericarditis, which affects the pericardial bag, or the outer shell of the heart. In case of chronic pericarditis or purulent form of the disease, one of the treatment options may be pericardectomy, a surgical correction, a rather complex operation performed by a cardiovascular surgeon. [1]

The pericardium is the pouch that houses the heart. The purpose of this bag is to protect and ensure normal cardiac function. Violations in this area negatively affect the blood supply of the organ, can cause the development of purulent complications, the formation of fibrosis adhesions. To prevent the development of life-threatening conditions, pericardectomy is prescribed - surgical intervention, during which the pericardium is removed - partially or completely. [2]

Indications for the procedure

The affected parts of the pericardium are removed only in extreme cases, when there is a danger and threat to the patient's life. If indicated, the entire bag can be removed - this operation is called subtotal pericardectomy. When excision of only the affected parts of the operation is performed Rena-Delorme. By the way, the first type of surgery, involving complete removal of the pericardium, is practiced more often, as it allows you to prevent further obstructive changes. Both variants of intervention are quite complex, the patient is carefully prepared for them, and after the operation, a long-term follow-up is established.

The basic indications for pericardectomy are exudative and constrictive forms of pericarditis. These are pathological conditions accompanied by the accumulation of exudate, blood or fluid in the pericardial space. This leads to a violation of the cardiac blood supply, the formation of adhesions, increasing the risk of death of the patient as a result of myocardial infarction or heart failure. Signs of pericarditis are as follows: change in blood pressure indices in one direction or another, severe dyspnea, arrhythmia, pain and heaviness behind the sternum.

In turn, the causes of pericarditis can be viral or other infections, chest trauma, metabolic disorders, renal failure, connective tissue diseases, Crohn's disease, etc. [3]

Preparation

Since the pericardectomy operation is very complex and involves a large number of risks, the patient is prescribed a number of diagnostic measures beforehand. It should be noted that pericardectomy should always be clearly conditioned, and the doctor should make sure that the patient has no contraindications.

If there is an accumulation of exudative fluid in the pericardial area, the surgeon may first perform a puncture. This is necessary to clarify the origin of the fluid and to drain it. Some time before pericardectomy, the patient is prescribed diuretics and medications to improve cardiovascular function.

On admission to the department for surgical treatment, the patient is asked to undergo a number of investigations. These are usually chest radiography, electrocardiography, echocardiography (if necessary, an esophageal transducer is used), and certain clinical and biochemical laboratory tests.

All women from 45 years of age and men from 40 years of age undergo cardiac catheterization, coronary angiography, and in some cases aortography and ventriculography. If the diagnosis reveals a lesion of the coronary arteries (narrowing or blockage), the surgeon will make adjustments to the surgical treatment regimen and perform additional aortocoronary bypass with the creation of bypass circulatory pathways.

The patient is forbidden to drink alcoholic beverages one week before the pericardectomy. It is strongly recommended to eliminate smoking, or at least minimize the number of cigarettes smoked.

An important stage of preparation for pericardectomy is nutrition. Doctors advise before the operation not to load the digestive tract, avoid overeating and heavy (fatty, meat) food.

The day before the intervention, the patient should not eat or drink anything. In the morning, the patient takes a shower and shaves off the chest hair (if required). [4]

Technique of the pericardectomies

Pericardiolysis, or Rena-Delorme, is a variant of partial pericardiectomy, which consists of partial excision of the pericardium, with separation of the cardiac-pericardial junctions. In this situation, the pericardium is removed only in certain areas.

In subtotal pericardectomy, almost the entire pericardium is excised. This intervention is most often practiced: after the operation, only a small part of the pericardium remains, localized at the posterior cardiac surface.

Pericardectomy is performed using general anesthesia, and the patient is prepared for it in advance. On the day of the operation, the patient takes a shower, changes into sterile underwear and goes to the pre-operative room, where all the necessary procedures are performed.

The patient is immersed in endotracheal anesthesia, connected to an artificial lung ventilation apparatus, a device for monitoring heart rate and blood pressure indicators is attached. Then the surgeon proceeds directly to the pericardectomy operation by access through the sternum or percutaneous pleural with transverse sternal crossing:

• make a small incision (up to 2 cm) above the left ventricle to open the epicardium;
• The surgeon finds the layer separating the pericardium from the epicardium, then grasps the pericardial edges with an instrument and pulls apart, separating the two layers;
• if deep calcified areas are found in the myocardium, the physician goes around the perimeter and leaves them;
• pericardial detachment is performed from the left ventricle to the left atrium, pulmonary trunk and aortic orifices, right ventricle and atrium, and vena cava openings;
• After dissection of the pericardium, the residual edges are sutured to the intercostal muscles on the left and to the sternal edge on the right;
• The wound area is sutured layer by layer, and drains are placed for 2 days to drain the fluid.

Some large clinical centers practice videothoracoscopy instead of traditional pericardectomy - cavity access with opening of the sternum. In such a situation, adhesions are separated using a laser.

Contraindications to the procedure

Pericardectomy is a complex and in many ways risky operation that requires special qualifications of the operating doctor and careful preliminary diagnostics. The doctor needs to be 100% sure that the patient has no contraindications to surgery.

Pericardectomy surgery is not indicated in these situations:

• in myocardial fibrosis, which significantly increases the likelihood of complications and even death;
• in calcareous accumulations in the pericardial space, which are formed most often against the background of mucous or effusion form of pericarditis;
• for mild constrictive pericarditis.

Relative contraindications to pericardectomy include:

• acute renal failure, as well as the chronic form of the disease;
• existing gastrointestinal bleeding;
• fever of unclear origin (possibly infectious);
• active phase of the infectious-inflammatory process;
• acute stroke;
• severe anemia;
• Malignant uncontrolled arterial hypertension;
• severe electrolyte metabolism disorders;
• severe comorbidities that may cause further complications;
• severe intoxication;
• congestive heart failure in decompensation, pulmonary edema;
• complex coagulopathy.

It should be taken into account that relative contraindications are usually temporary or reversible. Therefore, pericardectomy is postponed until the underlying problems that may lead to complications are resolved.

Before surgical intervention, the doctor assesses the patient's condition and decides whether the operation can be performed. If contraindications still exist and pericardectomy cannot be performed, doctors will look for other options to improve the patient's condition. [5]

Consequences after the procedure

Early postoperative consequences of pericardectomy may include bleeding into the pleural cavity, increased insufficiency of cardiovascular function. Later, purulent processes in the surgical wound and the development of purulent mediastinitis are possible. [6]

In general, pericardectomy has a favorable prognosis. In most cases, a month after the intervention, the patient's well-being significantly improves, and within 3-4 months, cardiac activity stabilizes.

Subtotal pericardectomy is characterized by a mortality rate of 6-7%.

The presence of previously undiagnosed myocardial fibrosis is considered a major factor in mortality during surgical intervention.

The main adverse effects can be:

• bleeding into the pleural space;
• arrhythmias;
• festering in the area of the surgical wound;
• heart attack;
• purulent mediastinitis;
• stroke;
• low cardiac output syndrome;
• pneumonia.

The appearance of certain consequences of pericardectomy can be noted depending on the age of the patient, the general health of the body and the cause of the formation of pericarditis. In addition, the development of complications is influenced by the anatomical feature of the heart, the amount and structure of fluid in the heart cavity. [7]

Complications after the procedure

Despite the relatively low complication rate, pericardectomy is an invasive procedure and its performance is associated with certain risks. [8]

The main complications that occur during pericardectomy are directly related to the cardiovascular system. Factors that increase the risk of complications are age, concomitant pathologies (diabetes mellitus, chronic insufficient renal function, chronic heart failure), and multifactorial lesions of the coronary circulation.

Many patients for several days or weeks after pericardectomy complain of poor sleep, restless and even nightmarish dreams, memory impairment, irritability and tearfulness, and impaired concentration. Doctors claim that these are normal postoperative reactions that disappear on their own within the first few weeks.

Even after a pericardectomy, the patient may not feel relief immediately, but the pain will definitely go away after the rehabilitation period is over. Chest pain may be a consequence of the process of heart adaptation to new conditions. The adaptation period is different for each patient.

The chances of improving health and quality of life after surgery should be fixed with the help of a complex of physical therapy, drug therapy, as well as compliance with the prescribed diet and normalization of work and rest. [9]

Care after the procedure

After pericardectomy, the patient will be hospitalized for about 7 days. The patient requires special doctor's supervision for 4-5 days after surgery. For the first 1-2 days, strict bed rest is observed, then the activity is expanded, depending on the patient's well-being. [10]

The rehabilitation or recovery period involves adhering to such recommendations of doctors:

• For several days, the patient should observe bed rest to avoid worsening of the condition;
• for 1.5-2 weeks after pericardectomy, any physical activity is contraindicated;
• Until the moment of complete wound healing, it is not allowed to take a bath (only showers are allowed);
• Do not drive vehicles for the first 8 weeks after the intervention;
• After discharge, the patient should regularly visit the attending doctor, conduct control diagnostics of the cardiovascular system and the general condition of the body;
• It is mandatory to practice physical therapy for about 30 minutes daily to stabilize the heart;
• it is important to systematically take medications prescribed by the doctor, avoid stress and nervous tension.

In addition, an important moment for recovery after pericardectomy is the observance of special principles of dietary nutrition. Such a diet involves limitation of animal fats, salt and sugar, exclusion of alcoholic beverages, coffee, chocolate. The basis of the diet should be easy to digest foods: fruits and vegetables, lean meat, fish and cereals. Of drinks are most useful green tea, infusion of rose hips, and of the first courses - vegetable broths. It is necessary to eat about six times a day, in small portions. [11]

Patient feedback and key questions

• What is the main danger of pericardectomy?

The average operative mortality rate of patients undergoing pericardectomy varies between 6-18%. The higher the qualification of the clinic, the more comforting the statistics are, which can be explained objectively. The main cause of lethal outcome during pericardectomy is considered to be the non-detection of myocardial fibrosis before the operation - a pathology in which surgical treatment is contraindicated. That is why it is very important to undergo qualified diagnostics, which allows to minimize the risks both during and after the operation.

• When is it best to forgo pericardectomy?

Pericardectomy is accompanied by many surgical risks, but physicians are able to minimize these risks in most cases. Nevertheless, the operation is undesirable for patients with mild variants of constriction, myocardial fibrosis and pronounced pericardial calcification. Such factors as patient's age and renal insufficiency increase surgical risks.

• How long will the patient have to stay in the hospital after pericardectomy?

The rehabilitation period varies from patient to patient. Most often, for the first few hours after the intervention, the patient is in the intensive care unit, and then he or she is transferred to the intensive care unit. If all is well, the patient is placed in a regular clinical ward, where he stays for several days, until discharge.

Reviews of pericardectomy in most cases are favorable. Patients notice clear improvements as early as one month after surgery. In full cardiac activity normalizes within 3-4 months. It is important to note that the favorability of the prognosis depends largely on the experience and qualifications of doctors and the entire medical staff of the selected clinic.

After pericardial resection, the patient should visit the doctor regularly for routine checkups with the cardiologist in the place of residence, as well as clearly follow the recommended preventive measures.

In general, pericardectomy is an effective surgical operation that ensures normal heart function in conditions of impaired blood supply. The main thing is to identify the disorder in time and carry out treatment, which will eliminate the life-threatening condition of the patient.