Maintenance of hemodynamic stability during pericardiectomy with the Starfish 2 Heart Positioner

Abstract

Pericardiectomy for chronic pericarditis can be a technically difficult procedure associated with high mortality. 1 The use of cardiopulmonary bypass (CPB), although necessary on occasion, can be associated with significant bleeding, leading many surgeons to prefer its avoidance. Technologic advances in heart positioning devices have enabled the widespread application of beating-heart coronary revascularization. In this report we describe our use of the Starfish 2 Heart Positioner (Medtronic, Inc, Minneapolis, Minn) in the treatment of chronic pericarditis. Clinical Summaries PATIENT 1. A 41-year-old Iranian war veteran had a severalweek history of progressive shortness of breath, increasing abdominal girth, and peripheral edema. Echocardiography and computed tomography confirmed the diagnosis of severe constrictive pericarditis. Subsequent cardiac catheterization demonstrated the typical dip and plateau pattern. At the operation, the heart was approached through a median sternotomy with a Cell Saver system (Haemonetics Corporation, Braintree Mass) available and CPB on standby. The thickened (7 mm), calcified parietal pericardium was resected laterally toward each phrenic nerve. Once the visceral pericardium at the apex of the left ventricle was exposed, the Starfish 2 Heart Positioner was applied in the standard position used for off-pump coronary artery bypass grafting (OPCAB; Figure 1). With the Starfish retractor, the remaining parietal pericardium was resected from phrenic to phrenic nerve, including its diaphragmatic surface. In addition, the visceral pericardium (5 mm in thickness) was resected in its entirety, except for a small portion along both the left anterior descending coronary artery and posterior left atrium. The patient remained in hemodynamically stable condition throughout the case without inotropic or vasopressor support, and no blood transfusions were needed. He was extubated 5 hours after the operation and discharged from the hospital on postoperative day 6. Pathologic examination revealed nonspecific fibrous pericarditis with calcification. PATIENT 2. A 29-year-old man had chronic chest pain after an episode of pneumonia that was diagnosed as pericarditis. His pain was refractory to nonsteroidal anti-inflammatory agents, colchicine, and oral steroids. On referral to our service, he had class III New York Heart Association dyspnea. The diagnosis of pericarditis was confirmed on echocardiography and chest CT. This patient’ s heart was also approached through a median sternotomy with a Cell Saver system available and CPB on standby. The conduct of the operation and use of the Starfish 2 Heart Positioner were both similar to those in our first patient. The thick parietal pericardium (8 mm) was resected to both phrenic nerves and along the diaphragm. The 6-mm visceral pericardium was subsequently resected from all heart surfaces, except a small patch on the posterior left atrium. There was no need for inotropes or vasopressors, because the patient remained in hemodynamically stable condition throughout; in addition, no blood transfusions were needed. The patient was extubated 7 hours after the procedure and discharged from the hospital on postoperative day 4. Pathologic examination revealed chronic pericarditis with granulation tissue.