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 of any country in the world. There are many known cardiac diseases that affect people of almost all ages, and one such pathology is pericarditis, which affects the pericardial sac, or the outer lining of the heart. In chronic pericarditis or a purulent form of the disease, one of the methods of treatment can be pericardectomy - surgical correction, a rather complicated operation performed by a cardiovascular surgeon.[1]

The pericardium is a marsupial that contains the heart. The purpose of such a bag is to protect and ensure normal cardiac function. Violations in this area negatively affect the blood supply to 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 - a surgical procedure in 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 danger and a threat to the life of the patient. According to indications, the entire bag can be removed - such an operation is called subtotal pericardectomy. When excising only the affected parts, the Rena-Delorme operation is performed. By the way, the first type of surgery, which involves the complete removal of the pericardium, is practiced more often, as it helps to prevent further obstructive changes. Both intervention options are quite complex, the patient is carefully prepared for them, and after the operation a long-term observation is established.

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

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

Preparation

Since the operation of pericardectomy is very complicated and involves a large number of risks, a number of diagnostic measures are preliminarily prescribed to the patient. It should be noted that pericardiectomy should always be clearly defined, and the doctor should make sure that the patient has no contraindications.

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

Upon admission to the department for surgical treatment, the patient is offered to undergo a series of studies. Typically, these studies are chest X-rays, electrocardiography, echocardiography (if necessary, an esophageal probe is used), as well as certain clinical and biochemical laboratory studies.

All women over 45 and men over 40 undergo cardiac catheterization, coronary angiography, and in some cases aortography and ventriculography. If during the diagnosis a lesion of the coronary arteries (narrowing or blockage) is detected, the surgeon will make adjustments to the surgical treatment scheme and perform additional coronary artery bypass grafting with the creation of bypass circulation paths.

The patient is forbidden to drink alcohol a week before pericardectomy. It is strongly recommended to exclude smoking, or at least minimize the number of cigarettes smoked.

An important step in preparing for pericardectomy is nutrition. Doctors advise not to burden the digestive tract before the operation, to avoid overeating and eating heavy (fatty, meat) foods.

On the eve of the intervention, the patient should not eat or drink anything. In the morning he takes a shower and shaves his chest (if required).[4]

Technique of the pericardectomy

The operation of pericardiolysis, or Renat-Delorme, is a variant of partial pericardectomy, which consists of a partial excision of the pericardium, with separation of the cardio-pericardial adhesions. In such a situation, the removal of the pericardium is carried out only in certain areas.

With subtotal pericardectomy, almost the entire pericardium is excised. Such an intervention is practiced most often: 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 this in advance. On the day of the operation, the patient takes a shower, changes into sterile underwear and goes to the preoperative ward, where he undergoes all the necessary procedures.

The patient is immersed in endotracheal anesthesia, connected to a ventilator, attached to the device to monitor the heart rate and blood pressure. Next, the surgeon proceeds directly to the operation of pericardectomy by access through the sternum or transversally with a transverse sternal intersection:

• make a small incision (up to 2 cm) above the left ventricle, which allows you to open the epicardium;
• the surgeon finds a layer that separates the pericardium from the epicardium, then grabs the pericardial edges with an instrument and pushes them apart, separating both layers;
• when deep calcified areas are found in the myocardium, the doctor bypasses them around the perimeter and leaves them;
• detachment of the pericardium is performed from the left ventricle to the left atrium, the orifices of the pulmonary trunk and aorta, the right ventricle and atrium, the openings of the vena cava;
• after excision 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 in layers, and drains are installed to remove fluid for 2 days.

Some large clinical centers practice the method of videothoracoscopy instead of traditional pericardectomy - abdominal 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 largely risky operation that requires special qualifications of the operating doctor and careful preliminary diagnosis. The doctor needs to be 100% sure that the patient has no contraindications to surgery.

The operation of pericardectomy is not prescribed in such situations:

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

Relative contraindications to pericardectomy are:

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

It should be noted that relative contraindications are usually temporary or reversible. Therefore, pericardectomy is postponed until the main problems that can lead to the development of complications are eliminated.

Before surgery, the doctor assesses the patient's condition and decides on the possibility of the operation. If there are still contraindications and pericardectomy cannot be performed, then doctors will look for other options to improve the patient's condition.[5]

Consequences after the procedure

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

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

Subtotal pericardectomy has a mortality rate of 6-7%.

The main factor of lethality during surgery is the presence of previously undiagnosed myocardial fibrosis.

The main negative consequences can be:

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

The appearance of certain consequences of pericardectomy may be observed 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 a relatively low complication rate, pericardiectomy is an invasive procedure and carries certain risks.[8]

The main complications that occur during pericardectomy are directly related to the activity of the cardiovascular system. Factors that increase the risk of complications are age, comorbidities (diabetes mellitus, chronic renal insufficiency, chronic heart failure), as well as multifactorial damage to the coronary circulation.

Many patients complain about poor sleep, restless and even nightmares, memory impairment, irritability and tearfulness, and weakened concentration for several days or weeks after pericardectomy. Doctors say that we are talking about the usual postoperative reactions that disappear on their own within the first few weeks.

Even after pericardectomy, the patient may not immediately feel relief, but the pain necessarily disappears at the end of the rehabilitation period. Pain behind the sternum may be a consequence of the process of adaptation of the heart to new conditions for it. The adaptation period is different for each patient.

The chances of improving health and quality of life after surgery must be secured with the help of a complex of physiotherapy exercises, 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 is left in hospital for about 7 days. The patient requires special observation by the doctor for 4-5 days after the operation. For the first 1-2 days, strict bed rest is observed, then the activity expands, depending on the patient's well-being.[10]

The period of rehabilitation or recovery provides for compliance with the following recommendations of doctors:

• for several days the patient must observe bed rest, in order to avoid deterioration of the condition;
• for 1.5-2 weeks after pericardectomy, any physical activity is contraindicated;
• until the moment of complete wound healing, you can not take a bath (only a shower is allowed);
• it is impossible to drive vehicles in the first 8 weeks after the intervention;
• after discharge, the patient should regularly visit the attending doctor, conduct a control diagnosis of the cardiovascular system and the general condition of the body;
• be sure to practice physiotherapy exercises - about 30 minutes daily, to stabilize cardiac activity;
• it is important to systematically take medications prescribed by the doctor, to avoid stress and nervous tension.

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

Reviews and key questions from patients

• What is the main danger of pericardectomy?

The average operative mortality rate for patients with pericardectomy varies between 6-18%. The higher the qualification of the clinic, the more reassuring is the statistics, which can be explained objectively. The main cause of death during pericardectomy is the failure to detect myocardial fibrosis before surgery, a pathology in which surgical treatment is contraindicated. That is why it is very important to undergo qualified diagnostics, which allows you to minimize the risks, both during the operation and after it.

• When is the best time to avoid pericardectomy?

There are many surgical risks associated with pericardiectomy, but doctors manage to minimize these risks in most cases. However, surgery is not desirable in patients with mild constriction, myocardial fibrosis, and severe pericardial calcification. Factors such as the patient's age and renal insufficiency increase operational risks.

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

The recovery period for each patient may be different. Most often, the first few hours after the intervention, the patient is in the intensive care unit, then he is transferred to the intensive care unit. If everything is in order, the patient is placed in a regular clinical ward, where he stays for several days, until discharge.

Feedback on the performance of pericardectomy in most cases is favorable. Patients notice clear improvements already for a month after the operation. Fully cardiac activity is normalized within 3-4 months. It is important to note that the favorable prognosis largely depends on the experience and qualifications of doctors and all medical staff of the chosen clinic.

After pericardial resection, the patient should regularly visit a doctor for routine examinations by a cardiologist at the place of residence, as well as strictly follow the recommended preventive measures.

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