Pericardiotomy

Surgical dissection, that is, opening the fibrous membrane surrounding the heart - the pericardium or pericardium, is defined as a pericardiotomy, which provides access to the heart during surgery.

Indications for the procedure

In cardiac surgery, access to the heart with opening of the  pericardium  and the sealed pericardial cavity (the slit space between the epicardium and the pericardium) is required:

• in cases of damage to the myocardium and  the cardiac conduction system of  any etiology;
• if it is necessary to correct anatomical anomalies of the heart, for example, a  defect of the interventricular septum  (its hypertrophy or non-closure), aortic defects, anomalies of the atrioventricular valves, etc.;
• during resuscitation thoracotomy (opening the chest) - with compression of the lung behind the heart;
• in the presence of myocardial bulging -  heart aneurysm ;
• for coronary artery bypass grafting;
• if it is necessary to remove benign  heart tumors ;
• with severe prolapse and severe stenosis of the mitral or tricuspid valve, requiring their reconstruction or prosthetics;
• in connection with inflammation of the pericardium - pericarditis, primarily purulent, constrictive and adhesive (with the formation of adhesions between the pericardium and the epicardium).

In acute injuries of the heart, in particular, combined thoracoabdominal injuries, urgent pericardiotomy can be performed for diagnostic purposes: in the form of a pericardial window - transphrenic or subxiphoid - under the xiphoid process (processus xiphoideus) of the sternum. [1]

In addition, an indication for this surgical manipulation may be an excessive amount of  fluid in the pericardium of the heart  (hydropericardium) or an accumulation of blood in it -  hemopericardium of the heart . But for decompression of the pericardial sac and removal of pericardial effusion by aspiration, in most cases, a puncture is performed, that is,  puncture of the pericardium, pericardiocentesis .

Preparation

In fact, preparation does not take place for pericardiotomy, but for a specific operation (depending on the diagnosis), which requires access to the heart, and patients are prepared for it in advance (excluding acute and urgent cases).

Hospitalized patients undergo blood tests (clinical, biochemical, coagulogram) and urine (general), they also undergo a  heart study , which includes:  electrocardiography (ECG) ; Ultrasound of the heart -  echocardiography ; MRI of the mediastinal organs; x-ray or ultrasound of the blood vessels of the heart. [2]

Food intake is stopped 10-12 hours before the operation, only water can be consumed. The procedure requires general anesthesia, therefore, an anesthesiologist must meet with the patient to determine the most suitable anesthetic drug and the method of its use, as well as the means for preliminary sedation. On the morning of the operation, the patient's intestines are cleansed with an enema, after which a shower is taken. [3]

If there is a history of thrombophlebitis or varicose veins disease, the patient's legs are bandaged with an elastic bandage.

Technique pericardiotomy

Several techniques are used to dissect the pericardium. So, with anterior pericardiotomy during heart operations, a vertical dissection of the sternum (median sternotomy) is first performed, and then the anterior surface of the pericardium is dissected in the area where the parietal pleura adjoins the mediastinum.

In sub-sternal pericardiotomy, the  cardiac surgeon  cuts the skin and subcutaneous tissue vertically above the xiphoid process, and the incision passes under the bottom of the chest cavity - above the upper part of the dome of the diaphragmatic septum between the chest and abdominal cavities. Depending on the purpose of the operation, the xiphoid process can be excised. [4]

The right vertical pericardiotomy is performed down the right side, parallel to the site where the pericardium overlaps the diaphragm, towards the inferior vena cava.

The subxiphoid pericardiotomy technique consists of a vertical incision (5-8 cm) from the distal end of the sternum. Then the xiphoid process captured by the clamp is lifted; the attachment of the diaphragm to the sternum and the anterior part of the diaphragm itself are dissected and retracted. Thus, the pericardium is visualized, and the surgeon makes a vertical incision on it. [5]

The opening of the pericardial sac during transphrenic pericardiotomy is preceded by such manipulations as a vertical incision along the midline of the tendon part of the diaphragm and its mixing downward, as well as the separation of the pericardium from the pleura. [6]

Extrapleural pericardiotomy (according to Mints) is performed on the anterior surface of the pericardium - with the imposition of fixing sutures and an incision between the sutures. And access to the pericardium is performed by a longitudinal dissection from the xiphoid process along the upper edge of the oblique abdominal muscle - along the lower edge of the cartilage of the VII rib (with resection of its part), dissection of the perichondrium and separation of the costal part of the diaphragm at the site of its attachment.

Contraindications to the procedure

Surgical interventions are contraindicated for:

• acute infectious diseases or exacerbation of chronic infections (including bronchial and pulmonary);
• febrile condition;
• allergies in the acute stage;
• severe anemia;
• bleeding;
• severe mental disorders.

Consequences after the procedure

Possible consequences after pericardiotomy may manifest as the formation of pleural effusion and effusion into the pericardial cavity; pericardial tamponade; the appearance of intrapericardial adhesions, which negatively affect the work of the heart and coronary circulation. [7]

Surgeons also note the development of postpericardiotomy syndrome caused by an immune-mediated reaction to damage to the pericardial sac or myocardium, which is manifested by fever, chest pain, vomiting, liver enlargement, hypotension, tachycardia. It happens that this condition progresses to  cardiac tamponade .

Complications after the procedure

Complications of pericarditomy depend on the purpose and outcome of the operation in which access to the heart was performed. In most cases, they are associated with chest pain; accession of infection; bleeding; disorders of the lungs due to the development of their atelectasis; an accumulation of blood (hemothorax) or air (pneumothorax) in the pleural cavity. The development of postoperative pericarditis is not excluded.

In addition, in some patients, the dissected sternum does not heal well. [8]

Care after the procedure

Care and rehabilitation after surgery, of which pericardiotomy is a part, consists in antiseptic treatment of the postoperative wound on the chest in order to prevent its infection, which causes hyperemia, swelling, increased pain, and blood discharge. When such symptoms appear, antibiotic treatment is prescribed.

Daily measurement of body temperature is mandatory. For pain, the doctor prescribes pain relievers. [9]

You can take a shower no earlier than ten days after the operation. And physical activity after operations on the heart and coronary vessels should be dosed and correspond to the condition; Patients receive individual recommendations from a physiotherapist.

It is recommended to follow a  diet after surgery .

After a sternotomy, each patient's breast bone grows together in different ways - from two to four months, and during this time, stress on the chest should be avoided, including not lifting heavy (maximum - 2-3 kg), not driving, don't swim.