Pericardiectomy

Not the same as tamponade - a rigid pericardium lets the ventricle fill fast and early, then stops it dead in mid-diastole, where tamponade impedes filling throughout. Both give a fixed stroke volume, but only this one improves once the peel is off.

Fixed stroke volume - the rigid shell caps total cardiac volume, so stroke volume cannot rise and cardiac output is heart rate multiplied by a number you cannot change. Diastolic pressures equalise across all four chambers and each ventricle fills only at the other's expense.

Chronic organ failure - constriction has usually been present for months to years, so hepatic congestion, ascites, coagulopathy, renal impairment and a wasted nutritional state arrive alongside the stiff heart. You are not anesthetizing an isolated cardiac lesion.

Hemodynamic goals - keep preload high, the rate up, sinus rhythm, contractility and afterload preserved, from induction to release. Bradycardia is a proportional fall in output here, so treat it early, and do not diurese a high central venous pressure on the morning of surgery.

Poorly tolerated atrial fibrillation - losing rate control and the atrial kick at once, in a venously congested heart that cannot raise stroke volume, drops output quickly. Restore rate and rhythm early rather than watching it, because output is rate dependent.

Compensation lost at induction - output rests on a high filling pressure, a fast rate and sympathetic tone, and propofol and volatile take all three. Ketamine and etomidate are the workhorses here; titrate in divided doses with a vasopressor infusion already running.

The cost of positive pressure - raising mean airway pressure cuts the gradient driving venous return, in a heart whose only compensation is rate. Modest tidal volumes, minimal PEEP, a long expiratory time, and accept a higher carbon dioxide rather than buying it with airway pressure.

Sternotomy over an adherent heart - the heart is often stuck to the back of the sternum, so the saw can lacerate the right ventricle or right atrium or open a patent graft. Pads on, blood in the room, groins prepped, rapid infuser primed and the perfusionist ready before the saw runs.

Low output after release - a chronically under-filled, disused ventricle is suddenly handed a volume load it has never had to eject, and some hearts cannot do it. Have an inotrope running before the peel is finished, and give volume in small increments guided by the echo picture.

Arrhythmia during the peel - sharp dissection on the myocardial surface provokes ectopy, ventricular tachycardia and atrial fibrillation, much of which stops when the surgeon changes plane. Say what the rhythm is doing rather than treating it silently, and keep magnesium and potassium in range.

A transfusion case - years of hepatic congestion deplete procoagulant factors, and the stripped epicardium is a broad raw surface with no plane left to compress. Send coagulation and platelets preoperatively, have product physically in the room, and direct replacement with viscoelastic testing.

Echo over filling pressures - before release it shows filling stop abruptly in early diastole and the septal shift of ventricular interdependence. During dissection it catches a new regional wall motion abnormality, and after release it tells you whether the ventricle is handling the volume.

Monitoring before induction - an arterial line sited awake under generous local gives you the beat to beat trace through the highest risk minutes, and central access is standard. Two large bore cannulae and a rapid infuser are for the sternotomy, not for the peel.

Constrictive pericarditis is the end state of a pericardium that has scarred, thickened, and often calcified into a rigid shell, usually after cardiac surgery, mediastinal radiation, or tuberculous infection, and often with no cause found. The shell fixes total cardiac volume. Early diastolic filling is actually rapid, because atrial pressures are high and the ventricles start under-filled, but filling stops abruptly once the chambers meet the rigid limit, so restriction falls in mid to late diastole. The result is a fixed stroke volume, a cardiac output that depends almost entirely on heart rate, equalised diastolic pressures across all four chambers, and ventricular interdependence: with total volume capped, one ventricle fills only at the other's expense. The shell also uncouples the heart from the thorax, so intrathoracic pressure swings no longer transmit to the chambers. Years of systemic venous congestion behind that shell produce hepatic congestion, ascites, coagulopathy, and renal impairment.

Setup before the knife - external defibrillator pads on the chest and back, groins prepped and exposed, a perfusionist and a primed or crash-primed bypass circuit in the room, and cross-matched blood physically present. None of this is ceremonial. A redo sternotomy over an adherent heart can open a chamber in the first minute, and the rescue has to already be in the room.

Median sternotomy - the standard exposure, and the dangerous step. In constriction the heart is usually stuck to the posterior table of the sternum by the same scar that is being resected, so the oscillating saw can lacerate the right ventricle, the right atrium, or a patent bypass graft from a previous operation. The surgeon saws the outer table, lifts, and divides the inner table under direct vision, and in a redo chest may cannulate the femoral vessels first so bypass can be started the instant a chamber is entered.

Anterolateral thoracotomy alternative - a left fifth interspace approach with the left hemithorax elevated is used in some centers and for some localized disease. It gives worse access to the right heart and to the venae cavae, so most surgeons take the sternotomy when a complete resection is the goal.

Finding the plane - a window is developed between the thickened parietal pericardium and the epicardium. Where there is a plane the peel comes off in sheets; where inflammation has fused the layers the surgeon works through calcium with sharp dissection directly on the myocardium. Surgical time is driven by exactly this: the tenacity of the visceral peel is the variable.

Left ventricle first, then right - the classical sequence is to free the left ventricle before the right. If the right ventricle is released first it delivers a suddenly larger output into a left ventricle still trapped in its shell, and that loads the pulmonary circulation into acute pulmonary edema.

Extent of resection - a radical or total pericardiectomy clears the pericardium from phrenic nerve to phrenic nerve over both ventricles, and continues onto the atria, the venae cavae, and the great vessels. A subtotal resection leaves posterior or lateral pericardium behind. Incomplete release, especially a retained constricting band at the atrioventricular groove or over the cavae, is a recognized cause of persistent symptoms.

Phrenic nerve preservation - the phrenic nerves run on the pericardium being resected, and the plane is disrupted by scar and calcium. Injury gives diaphragmatic paralysis, which in a patient with pleural effusions and restrictive lung physiology is a real respiratory problem, not an incidental finding.

Cardiopulmonary bypass, selectively - some surgeons work off pump to avoid heparinization of a raw dissected surface, others use bypass routinely for a dense calcified peel or when concomitant valve or coronary work is needed. Bypass is always standing by whether or not it is planned, because it is also the rescue for an entered chamber.

Hemostasis - after resection the epicardial surface is a broad raw bleeding field with no plane left to compress, and every point of it is bleeding. This is the phase where the blood ordered at the start of the case gets used.

Drains and closure - mediastinal and, where a pleura has been entered, pleural drains are placed, and the chest is closed with the expectation of ongoing drainage. The patient goes to intensive care intubated.

The population is the case. Post cardiac surgery constriction means a redo sternotomy with patent grafts under the bone and the operative history to review before you scrub. Post radiation constriction, typically after mediastinal treatment for lymphoma or breast cancer, brings radiation injury to the myocardium, the conduction system, the coronaries, the valves and the lungs, so the pericardium is only one of several fibrosed structures and these patients have the worst outcomes as a group. Tuberculous constriction may come with active or treated pulmonary disease, and matters for the operating room team as well as the patient. Idiopathic disease behaves best. Ask which one you have, because the answer changes what else you expect to find broken.

Disposition is intensive care, intubated, and the family should have been told that improvement is not immediate. Expect postoperative ventilation for hours, and a low cardiac output state that persists. The physiology explains it: a chronically under-filled, disused, sometimes atrophied ventricle needs time to remodel before it uses the filling it has just been given, so venous congestion, edema, ascites and exercise limitation can take weeks to months to resolve, and a proportion of patients never fully recover. Hand over the resection extent, whether bypass was used, the inotrope and vasopressor trajectory across the release, the transfusion and coagulation picture, and the drain output, and say explicitly that a low output state after release is anticipated rather than a new complication.

Renal function is a chronic and an acute problem in the same patient. Constriction causes renal impairment through a raised venous pressure and a reduced perfusion pressure, so a patient with an abnormal creatinine before surgery is showing you a hemodynamic problem rather than primary kidney disease. That has drug consequences: agents cleared renally, muscle relaxants in particular, behave less predictably, so titrate to a nerve stimulator rather than to a weight based figure. Relief of the constriction is also what starts to fix the kidney, but only after the low output phase has passed, so expect renal function to look worse before it looks better and protect perfusion pressure through that window.