Indications, timing and techniques of radical pericardiectomy via modified left anterolateral thoracotomy (ukc's modification) and total pericardiectomy via median sternotomy (holman and willett) without cardiopulmonary bypass

Abstract

Background: Patients with constrictive pericarditis can be treated by pericardiectomy by either left anterolateral thoracotomy or median sternotomy. The terms “radical,” “total,” “extensive,” “complete,” “subtotal,” “adequate,” “near-total,” and partial pericardiectomy have been used often without much clarity. We describe our experience with a radical pericardiectomy technique via modified left anterolateral thoracotomy and compare the same to total pericardiectomy via median sternotomy. Methods: In this study, 67 (54.9%) patients underwent radical pericardiectomy via modified left anterolateral thoracotomy (Group I), and 55 (45.1%) patients underwent total pericardiectomy via median sternotomy (Group II). Results: The operative mortalities were 2.9% and 7.2% for the radical and total pericardiectomy groups, respectively. The time taken for normalization to Class I/II in Groups I and II was 30 ± 11 and 36 ± 14 days, respectively (P = 0.009). Surgical techniques did not affect the outcome of atrial fibrillation (P = 0. 77). Reoperation was not required for any patient. The radical pericardiectomy was also associated with less postoperative low cardiac output state as compared to patients undergoing total pericardiectomy (P < 0.001). There was no difference in mean duration of hospitalization; however, the radical pericardiectomy group achieved the New York Heart Association I and II Status quicker than the total pericardiectomy group (P = 0. 009). Conclusions: We conclude that using several technical modifications of pericardial excision, it is possible to achieve radical pericardiectomy via modified left anterolateral thoracotomy, particularly removing the constricting pericardium over the anterolateral, diaphragmatic surfaces of left ventricle and the anterior and diaphragmatic surfaces of the right ventricle until the right atrioventricular groove without using cardiopulmonary bypass in the great majority of patients undergoing pericardiectomy for chronic constrictive pericarditis. Although the surgical approach for pericardiectomy is based on surgeon's preference, left anterolateral thoracotomy is the preferred and noncontroversial approach in the setting of purulent pericarditis and effusive constrictive pericarditis to prevent sternal infection. We recommend median sternotomy approach with or without cardiopulmonary bypass, in the setting of calcific pericardial patches, pericardial masses, reoperations, and calcific pericardial “cocoon” and for those with predominant right-sided and annular involvement.