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© 2003 European Association of Cardio-Thoracic Surgery
Surgical approach for pericardiectomy: a comparative study between median sternotomy and left anterolateral thoracotomyDepartment of Cardiothoracic Surgery, Osmania General Hospital, Hyderabad, Andhra Pradesh, India
* Corresponding author. Department of ECMO, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK Received January 15, 2003; received in revised form April 5, 2003; accepted April 8, 2003
Pericardiectomy is the definitive treatment for constrictive pericarditis but the best surgical approach remains controversial. In this study we compared the results of pericardiectomy performed on 36 patients with constrictive pericarditis between 1995 and 2001. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. All patients were reviewed at 6 weeks post operatively. Both groups of patients were similar in age, sex distribution, NYHA shortness of breath status, aetiology, presenting symptoms and duration of symptoms. Mortality was similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. NYHA status improved in both thoracotomy (3.0±0.8 to 1.6±0.7;  ) and median sternotomy (2.9±0.7 to 1.5±0.6;  ) groups. The degree of improvement was not significant between the two groups ( ). In addition ionotropic support and postoperative hospital stay were similar between the two groups. There was a higher incidence of wound infections (23.8 versus 6.6%;  ) and pulmonary complications (23.8 versus 13.3%;  ) associated with thoracotomy. In conclusion pericardiectomy improves NYHA status in all patients and mortality rates are similar in both the approaches.
Key Words: Pericarditis; Pericardiectomy; Median sternotomy; Thoracotomy
Constrictive pericarditis is a chronic inflammatory process that leads to progressive pericardial fibrosis encasing the heart in a thickened and fibrotic pericardium. This leads to impaired diastolic filling of the cardiac chambers, with elevation of right atrial mean pressure and end diastolic pressure in both ventricles with the end result of reduced cardiac output. It is an uncommon condition with the largest series reported from the Mayo Clinic of 366 patients extending over 60 years [1]. Surgical management remains the only effective treatment available for this potentially curable disorder [2]. Various approaches and techniques have been suggested since Rehn and Sauerbruch in 1913 performed a successful pericardial resection for the chronic constrictive pericarditis by a left anterolateral thoracotomy approach [3]. The approaches described for pericardiectomy include Left anterolateral thoracotomy, Median Sternotomy, a U incision with the base of U lying at the left sternal border (Harrington approach) and bilateral thoracotomy [4]. Pericardiectomy has also been performed with [5] and without [6] the use of cardiopulmonary bypass with each having its proponents. Of all the approaches median sternotomy and left anterolateral approaches are widely used. In this study we reviewed 36 cases of pericardiectomy carried out for chronic constrictive pericarditis and compared the results of pericardiectomy performed by left anterolateral thoracotomy versus median sternotomy without the use of cardiopulmonary bypass with regard to morbidity, mortality and functional outcome.
2.1. Patient selection All patients with the diagnosis of chronic constrictive pericarditis and underwent pericardiectomy between April 1995 and December 2001 at our institution were included in the study. During this period, 36 patients were identified and their data collected retrospectively from the case notes. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. The decision for the approach was dependent on the operating surgeon's preference and all the operations were performed by three surgeons. All the patients were reviewed at 6 weeks postoperatively and their clinical status assessed and complications following discharge documented. The cause of constrictive pericarditis was tubercular in 15 patients and was non-specific in 21 patients. Patients with tuberculosis pericarditis were given anti-tuberculosis therapy for at least 6 weeks before the surgery and the full course was completed following the surgery. Deaths occurring during the 6 weeks follow up period whether prior to or after discharge were included in operative mortality 2.2. Surgical technique Following median sternotomy or thoracotomy the pericardium over both the ventricles was excised in all cases. The resection over the left ventricle extended to the left phrenic nerve in all cases and resection beyond the phrenic nerve to the left pulmonary veins was carried out when ever possible. The resection of pericardium over the atria and the major vessels was done depending on the adequacy of the exposure and the possibility of developing the cleavage plane. All the operations were performed without cardiopulmonary bypass.2.3. Statistical analysis All data are expressed as mean±standard deviation or as percentages. Statistical significance was tested for with paired and unpaired Student's t-test or 2 test and a P value of less than 0.05 was taken to be significant.
Both groups of patients were similar in age, sex distribution and New York Heart Association (NYHA) shortness of breath status, aetiology, presenting symptoms and duration of symptoms as seen in Table 1. It is of interest to note that 40% of cases were caused by tuberculosis and no obvious cause of pericarditis was identified in the rest of patients in both groups. None of the patients were operated on during the acute infection phase and no other causative agents apart from tuberculosis were identified.
The mortality rates were similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. All the deaths were cardiac related and occurred in the perioperative period as a result of low cardiac output syndrome. Both groups of patients had a similar and significant improvement in their NYHA status which improved from 3.0±0.8 to 1.6±0.7 ( ) in the thoracotomy group and from 2.9±0.7 to 1.5±0.6 () in the median sternotomy group. The degree of improvement was not significant between the two groups (). In addition hospital stay postoperatively was similar between the two groups as well as the inotropic support requirement in the perioperative period (Table 2).
However, there was a higher incidence, although not significant, of wound infections in the thoracotomy group in five patients (23.8%) versus one patient (6.6%) in the median sternotomy group. These were infections that required antibiotic treatment or local incision and drainage of wound collection. There was also a higher rate of pulmonary complications in the thoracotomy patients with two having lobar pneumonias requiring antibiotic therapy and two patients required bronchoscopy for retained secretions and a fifth patient had a pleural effusion, which required drainage. In the median sternotomy patients one had a pneumothorax and the other had pleural effusion necessitating drainage.
The idea of resecting pericardium for constrictive pericarditis dates back to 1898, when De Lorme first suggested it. However, it remained for the German Surgeon, Rehn in 1913 to resect a constricting pericardium through a left anterolateral thoracotomy with great improvement in his patient condition [7]. Subsequent successes were reported by Churchill in 1928, using a curved left parasternal incision and resecting anterior portions of the left third to seventh ribs and their adjacent costal cartilages [4]. A number of different operative techniques and approaches have been described since then [8] and despite the experience spanning over 60 years controversy continues as to what constitutes the best approach. The operative approaches described by Churchill and Harrington is now of historical interest and the most commonly used approaches in the present era are the Median sternotomy especially when pericardiectomy is carried out routinely using Cardiopulmonary bypass as reported by Copeland et al. [5] and Omoto et al. [9] and the left anterolateral thoracotomy. The choice of the approach appears to be of the surgeon's personal preference. Median sternotomy allows a more radical clearance of pericardium over the right atrium and vanae cavae and it allows extensive pericardial removal using cardiopulmonary bypass. Without cardiopulmonary bypass it is difficult to gain access to the left ventricle, particularly the diaphramatic surface. Cardiopulmonary bypass aids in the surgical dissection by emptying the ventricular cavities to define clearly the appropriate plane of dissection, and facilitates the management of inadvertent cardiac injury. The disadvantage of using cardiopulmonary bypass is the potential for increased bleeding and other related complications [4]. However, there are not many studies suggesting the need for removal of pericardium over the atria and the vanae cavae and normalisation of cardiac hemodynamics has been reported after decortication of the anterior surface of the ventricles from the atrioventricular grove on the right to the left phrenic nerve and the diaphragmatic surface [10]. Viola [11] suggested that resection of the pericardium overlying the right atrium and the great veins is not essential. Culliford and colleagues [8] suggested that delayed improvement and persistent symptoms are most commonly the result of incomplete decortications. However, outcome is related not only to the extent of the surgery but also to myocardial involvement. Autopsy findings indicate that myocardial fibrosis and atrophy may result [12]. Long periods of myocardial compression contribute to remodelling of the ventricles with greater involvement of the myocardium in patients with longer duration of symptoms [13]. Left anterolateral thoracotomy offers excellent exposure of the anterolateral and inferior aspects of the left ventricle with minimal manipulation and retraction of heart. If necessary the incision can be extended across the sternum and onto the right side of the chest. Fatal bleeding caused by a tear in the right atrium or the venae cavae during surgery performed by left anterolateral thoracotomy has been reported but is not encountered commonly [14]. In our study cardiopulmonary bypass was not instituted in any of the study patients and we were able to achieve a good functional result with adequate pericardial resection through either of the two approaches. However as seen from the results and as expected left anterolateral thoracotomy was associated with higher pulmonary complications and wound infections. It may be therefore argued that in cases of acute infection it may preferred to the transsternal approach because contamination of the sternum can be avoided. On the other hand, although not evident from our experience the use of median sternotomy allows a more radical pericardiectomy and the use of bypass if required. The mortality of the median sternotomy (13.3%) patients was similar to that of the thoracotomy patients (14.2%) and this is comparable with reported mortality in the literature ranging from 4 to 18% [4,8,15]. Although most of the latest reports on this condition [1] suggest that the mean age of the patients at presentation is increasing with a median age of 61 in the period 1985–1995 versus 45 years in the preceding 50 years, we note that the mean age of our cohort is in the mid twenties. This is probably related to the different aetiology with 40% of our cases caused by tuberculosis while the main identifiable causes in the report by Ling et al. [1] were cardiac surgery, pericarditis and mediastinal irradiation accounting for 47% of cases. However with the rising incidence of tuberculosis in the western world this aetiology might change in time. One limitation of this study might be the small number of patients included. This is however a result of the uncommon nature of this disease. We conclude that the results of pericardiectomy in terms of improvement in the NYHA status and mortality are similar in both the approaches.
ICVTS on-line discussion Author: Praveen Varma, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Cardio-vascular and thoracic surgery, SCTIMST, Trivandrum 695011, India Date: 26-May-2003 21:35 Message: The study proves that the adequacy of release is more important than the choice of incision. The release of cavae and the atria are less optimal via a left thoracotomy, while the release of LV is compromised in mid sternotomy. But mid sternotomy is more advantageous for 2 reasons:
The study would have been more complete if the authors could provide us with
Response Author: Ravindranath Tiruvoipati, Glenfield Hospital, ECMO, Groby Road, Leicester LE3 9QP, UK Date: 17-Jun-2003 14:06 Message: We do agree with your views although we have not used CPB in any of our cases. The decrease in the CVP was noted in both the groups and the decrease was not found to be different between both the approaches. We do not have the latest results for the time being. Hopefully we should be able to have them in near future. Author: Antonio Corno, CHUV, Cardiovascular Surgery, 46 rue du Bugnon, Lausanne CH 1011, Switzerland Date: 04-Jun-2003 07:49 Message: One curiosity is about the incidence of phrenic nerve lesions: did the Authors find any difference among the two groups (median sternotomy versus left antero-lateral thoracotomy)? Another information the Authors could provide the readers is what are the implications of their study. Are they still considering either one of the two possible surgical approaches for pericardiectomy, or because of the observation of reduced incidence of wound infections and pulmonary complications in the group with median sternotomy, they would suggest this approach as the most suitable one? Response Author: Ravindranath Tiruvoipati, Glenfield Hospital, ECMO, Groby Road, Leicester LE3 9QP, UK Date: 17-Jun-2003 14:21 Message: We did not have any phrenic nerve lesions in our series and we think it is probably because we stopped our dissection at the level of phrenic nerve in most of the cases. The other possibility could be because we have not used cardio pulmonary bypass in any of our cases, so the chance of ice slush induced phrenic nerve lesions were eliminated. We do not consider either of the approaches ideal for all patients and the choice of the approach depends upon the surgeon's preference, depending on the pathology, like in patients with acute infections a thoracotomy may be preferred to sternotomy to avoid contamination of the sternum and if the surgeon feels that there might be a need for cardiopulmonary bypass for any reason then obviously the approach would be by median sternotomy. Author: Enrico Aidala, Osp. Infantile "Regina Margherita", Pediatric Cardiac Surgery, P.zza Polonia 94, Torino 10126, Italy Date: 11-Jun-2003 01:57 Message: The series by Tiruvoipati; 36 cases in six years is impressive. Although the mortality risk is the same, the morbidity is greatly different between the two approaches. We prefer always to use sternotomic approach, because of two points, both correlated to pulmonary complications. Through the sternum, as described, it is possible a complete resection of the pericardium over the right atrium and the venae cavae. This fact allows the drop in the systemic venous pressure, reducing the risk of pleural and peritoneal drainage and the perilobular oedema and bronchial secretions, source of pulmonary infection. The authors disscuss this problem but no data about central venous pressure, for example, is described. The second point is that the thoracotomy improved thoracic pain and reduced left ventilation, again favouring effusions and infections. doi:10.1016/S1569-9293(03)00074-4
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Abstract
1. Introduction