Intrapericardial Adhesions Research Articles

Nanostructured Non-Newtonian Drug Delivery Barrier Prevents Postoperative Intrapericardial Adhesions.

With the increasing volume of cardiovascular surgeries and the rising adoption rate of new methodologies that serve as a bridge to cardiac transplantation and that require multiple surgical interventions, the formation of postoperative intrapericardial adhesions has become a challenging problem that limits future surgical procedures, causes serious complications, and increases medical costs. To prevent this pathology, we developed a nanotechnology-based self-healing drug delivery hydrogel barrier composed of silicate nanodisks and polyethylene glycol with the ability to coat the epicardial surface of the heart without friction and locally deliver dexamethasone, an anti-inflammatory drug. After the fabrication of the hydrogel, mechanical characterization and responses to shear, strain, and recovery were analyzed, confirming its shear-thinning and self-healing properties. This behavior allowed its facile injection (5.75 ± 0.15 to 22.01 ± 0.95 N) and subsequent mechanical recovery. The encapsulation of dexamethasone within the hydrogel system was confirmed by 1H NMR, and controlled release for 5 days was observed. In vitro, limited cellular adhesion to the hydrogel surface was achieved, and its anti-inflammatory properties were confirmed, as downregulation of ICAM-1 and VCAM-1 was observed in TNF-α activated endothelial cells. In vivo, 1 week after administration of the hydrogel to a rabbit model of intrapericardial injury, superior efficacy was observed when compared to a commercial adhesion barrier, as histological and immunohistochemical examination revealed reduced adhesion formation and minimal immune infiltration of CD3+ lymphocytes and CD68+ macrophages, as well as NF-κβ downregulation. We presented a novel nanostructured drug delivery hydrogel system with unique mechanical and biological properties that act synergistically to prevent cellular infiltration while providing local immunomodulation to protect the intrapericardial space after a surgical intervention.

Prevention of postoperative intrapericardial adhesion by dextrin hydrogel

ObjectivePostoperative intrapericardial adhesion increases the risk of complications in patients undergoing reoperation. We investigated the effect of a bioabsorbable dextrin hydrogel (DHG) on the formation of intrapericardial adhesions.MethodsIntrapericardial adhesion was surgically induced in Japanese white rabbits with DHG treatment (Adh + DHG) or without DHG treatment (Adh). The sham group was not treated with DHG and intrapericardial adhesion was not induced. The extent of intrapericardial adhesion was assessed by adhesion scoring and crystal violet staining of the pericardial cavity. Bromodeoxyuridine (BrdU) uptake assay was performed to assess the proliferative response to the injury in the tissue beneath the intrapericardial adhesion.ResultsThe Adh + DHG group showed looser intrapericardial adhesions compared to the Adh group. The adhesion area of the Adh + DHG group was 4.6 ± 2.2%, whereas that of the Adh group was 32.6 ± 6.4% at the end of the 28-day observation period (p < 0.01). The induction of intrapericardial adhesion resulted in a proliferative response mainly in the cardiac tissue just beneath the adhesion. There were 48.6 ± 10.7 cells/0.1 mm2 BrdU-positive cells in the Adh + DHG group and 135.7 ± 23.8 cells/0.1 mm2 BrdU-positive cells in the Adh group on day 28 (p < 0.05).ConclusionThese findings indicate that DHG effectively prevented intrapericardial adhesion in this model.

Bullet Proof - Previous Coronary Artery Surgery Preventing Tamponade in a Gun Shot Wound to the Chest

Purpose: We present the case and pertinent radiology of a 74-year-old male with a history of coronary artery bypass grafting who sustained a self-inflicted gun shot wound to his anterior chest from a 0.22 calibre rifle loaded with bird shot. The injury was sustained several hours prior to presentation, with no adverse haemodynamics. CT scan demonstrated multiple pellets related to the antero-inferior aspect of the right ventricle, and a pseudoaneurysm, likely contained by pericardial adhesions from previous surgery. Hepatic segments 2 and 3 were lacerated, and there were pellets surrounding the descending aorta. He underwent laparotomy and wedge resection of segments 2 and 3 of the liver and repair of the diaphragm, however, the injury to the right ventricle was managed conservatively. The patient was referred to a psychiatric service following an uneventful admission. Conclusion: We believe that intrapericardial adhesions from previous cardiac surgery prevented this patient from developing a large volume haemopericardium, tamponade, and perhaps death. Of course, had a larger bullet size or calibre entered his chest, he would have been unlikely to survive.

Video-Assisted Pericardioscopic Surgery for Epimyocardial Lead Implantation

Video-assisted pericardioscopic surgery (VAPS) for epimyocardial lead implantation has demonstrated positive acute results concerning the safety and degree of freedom inside the pericardium. We evaluated the employment of a newly developed trocar for pericardioscopy with regard to long-term effects and feasibility of reoperation. Eight adult sheep were divided into three groups. In two animals, VAPS was used exclusively. All other animals received four small-caliber epicardial leads through VAPS. After 6 and 12 months (n = 3 each), reoperation was conducted for reevaluation of entry site, intrapericardial adhesions, lead position, and morphology of the implantation site. Reentry close to the previous entry site proves unproblematic. Adhesions were mild to moderate in the immediate area of the implanted leads. Throughout the follow-up, pacing parameters were satisfactory. Lead dislodgement occurred in 1 of 24 leads. The deployment of small-caliber flexible endoscopes through the new trocar provided sufficient navigation, stability, and maneuverability. Reoperation from the same subxiphoid approach proved feasible. Lead removal and reimplantation were feasible at both 6 months and 12 months after initial implantation. The intrapericardial adhesions caused by VAPS alone are mild.

Synergism Between Keratinocyte Growth Factor and Carboxymethyl Chitosan Reduces Pericardial Adhesions

Mesothelial injury is the pivot in the development of adhesions. An increase in the proliferation of mesothelial cells was verified by in vitro studies with the use of keratinocyte growth factor (KGF). This study investigated the influence of KGF associated with thermo-sterilized carboxymethyl chitosan (NOCCts) in the reduction of pericardial adhesions. An induction model of pericardial adhesion was carried out in 24 pigs. Animals were randomly allocated to receive topical application of KGF, KGF + NOCCts, NOCCts, or saline (control). At 8 weeks, intrapericardial adhesions were evaluated and a severity score was established. The time spent to dissect the adhesions and the amount of sharp dissection used, were recorded. Histologic sections were stained with sirius red for a morphometric evaluation using a computer-assisted image analysis system. Cytokeratin AE1/AE3 immunostaining were employed to identify mesothelial cells. The severity score expressed in median (minimum to maximum), in relation to the control group (17 [15 to 18]), was lower in the KGF + NOCCts group (7 [6 to 9], p < 0.01) followed by the KGF group (11.5 [9 to 12], 0.01 < p < 0.05) and the NOCCts group (12 [9 to 14], p > 0.05). The dissection time was significantly lower in the KGF + NOCCts group (7.1 + or - 0.6 vs 33.9 + or - 9.2 minutes, p < 0.001). A significantly less sharp dissection was also required in the KGF + NOCCts group. In the adhesion segment, a decreased collagen proportion was found in the KGF + NOCCts group (p < 0.05). Mesothelial cells were present more extensively in groups in which KGF was delivered (p = 0.01). The use of KGF associated with NOCCts resulted in a synergic action that decreases postoperative pericardial adhesions in a highly significant way.

Three-dimensional imaging of intrapericardial adhesions within a large pericardial effusion

A 59-year-old man presented with fever and cough. An examination revealed jugular venous distention, pulsus paradoxus of 15 mmHg, bibasilar pulmonary rales and diminished heart sounds. A chest x-ray showed cardiomegaly and a right lower lobe infiltrate. Two-dimensional transthoracic echocardiography (Figure 1) demonstrated a large pericardial effusion (EFF) with signs of cardiac tamponade. Multiple intrapericardial strands (arrowheads) were seen within the pericardial fluid. Three-dimensional transthoracic echocardiography (Figure 2) provided additional information regarding the size, thickness and extent of the strands. Three-dimensional imaging revealed the strands to be an extensive network of intrapericardial adhesions (arrowheads) extending from the visceral pericardium to the thickened parietal pericardium (PER). Right heart catheterization was performed and demonstrated a right atrial pressure of 19/14 mmHg, right ventricular pressure of 36/16 mmHg and mean pulmonary capillary wedge pressure of 15 mmHg. Following echocardiographic-guided removal of 1700 mL of exudative fluid, right atrial pressure fell to 8/2 mmHg. Pericardial fluid stains and cultures were negative. The patient improved after the institution of antibiotics for pneumonia. Figure 1 Figure 2

Keratinocyte growth factor: a new mesothelial targeted therapy to reduce postoperative pericardial adhesions☆

Several methods have been utilized to prevent pericardial and retrosternal adhesions, but none of them evaluated the mesothelial regenerative hypothesis. There are evidences that the mesothelial trauma reduces pericardial fibrinolytic capability and induces an adhesion process. Keratinocyte growth factor (KGF) has proven to improve mesothelial cells proliferation. This study investigated the influence of keratinocyte growth factor in reducing post-surgical adhesions. Twelve pigs were operated and an adhesion protocol was employed. Following a stratified randomization, the animals received a topical application of KGF or saline. At 8 weeks, intrapericardial adhesions were evaluated and a severity score was established. The time spent to dissect the adhesions and the amount of sharp dissection used, were recorded. Histological sections were stained with sirius red and morphometric analyses were assessed with a computer-assisted image analysis system. The severity score was lower in the KGF group than in the control group (11.5 vs 17, p=0.005). The dissection time was lower in the KGF group (9.2+/-1.4 min vs 33.9+/-9.2 min, p=0.004) and presented a significant correlation with the severity score (r=0.83, p=0.001). A significantly less sharp dissection was also required in the KGF group. Also, adhesion area and adhesion collagen were significantly lower in the KGF group than in the control group. The stimulation of pericardial cells with KGF reduced the intensity of postoperative adhesions and facilitated the re-operation. This study suggests that the mesothelial regeneration is the new horizon in anti-adhesion therapies.

Cardiac Tamponade With Fibrin Strands Leading to the Diagnosis of Systemic Lupus Erythematosus

HomeCirculationVol. 116, No. 11Cardiac Tamponade With Fibrin Strands Leading to the Diagnosis of Systemic Lupus Erythematosus Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBCardiac Tamponade With Fibrin Strands Leading to the Diagnosis of Systemic Lupus Erythematosus Rami N. Khouzam, Daniel Minderman, Ahmad Munir and Ivan A. D’Cruz Rami N. KhouzamRami N. Khouzam From the Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, and Memphis VA Medical Center, Memphis, Tenn. Search for more papers by this author , Daniel MindermanDaniel Minderman From the Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, and Memphis VA Medical Center, Memphis, Tenn. Search for more papers by this author , Ahmad MunirAhmad Munir From the Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, and Memphis VA Medical Center, Memphis, Tenn. Search for more papers by this author and Ivan A. D’CruzIvan A. D’Cruz From the Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, and Memphis VA Medical Center, Memphis, Tenn. Search for more papers by this author Originally published11 Sep 2007https://doi.org/10.1161/CIRCULATIONAHA.107.709097Circulation. 2007;116:e342–e344A 59-year-old male with an unremarkable past medical history presented with worsening dyspnea and a history of chest tightness for 2 weeks. He had arthritis of multiple hand and foot joints bilaterally. Muffled heart sounds and pulsus paradoxus of 15 mm Hg were noted on examination. Laboratory findings were remarkable for anemia, with a hemoglobin level of 8.9 g/dL (normal, 13.5 to 17 g/dL), proteinuria level of 0.9 g/d, positive antinuclear antibody level of 906 U/mL (normal, 0 to 99 U/mL), and positive anti-DNA (DS and SS) antibodies. A chest x-ray showed a large cardiac silhouette. A 2-dimensional transthoracic echocardiogram revealed a large circumferential pericardial effusion (Figure 1, asterisks), with remarkable intrapericardial adhesions (fibrin strands) that had a worm-like appearance and were partially attached and floating between the visceral and parietal pericardium (Figure 1 and Data Supplement Movie). Download figureDownload PowerPointFigure 1. Two-dimensional transthoracic echocardiogram in the apical 4-chamber view of the heart and modified apical views revealed a large circumferential pericardial effusion (asterisks), with intrapericardial adhesions (fibrin strands) partially attached and floating between the visceral and parietal pericardium. RA indicates right atrium; RV, right ventricle; LV, left ventricle; and a, apex of the heart.Pericardiocentesis was performed to drain 1700 mL of bloody fluid. Posteroanterior chest x-ray (Figure 2) showed the heart before (left) and after (right) pericardiocentesis. An ECG (Figure 3) before (upper) and after (lower) pericardiocentesis is shown. Download figureDownload PowerPointFigure 2. Posteroanterior chest x-ray showing the heart before (left) and after (right) pericardiocentesis.Download figureDownload PowerPointFigure 3. ECG before (upper) and after (lower) pericardiocentesis.The final diagnosis of systemic lupus erythematosus presenting with cardiac tamponade was made.The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/116/11/e342/DC1.DisclosuresNone.FootnotesCorrespondence to Rami Khouzam, MD, 480 Cerrillos Dr, Farmington, NM. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Maharaj S and Chang S (2015) Cardiac tamponade as the initial presentation of systemic lupus erythematosus: a case report and review of the literature, Pediatric Rheumatology, 10.1186/s12969-015-0005-0, 13:1, Online publication date: 1-Dec-2015. Maharaj S and Chang S (2015) Pericardial effusions in systemic lupus erythematosus — Who is most likely to develop tamponade?, International Journal of Cardiology, 10.1016/j.ijcard.2014.11.191, 180, (149-150), Online publication date: 1-Feb-2015. September 11, 2007Vol 116, Issue 11 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.709097PMID: 17846336 Originally publishedSeptember 11, 2007 PDF download Advertisement SubjectsEchocardiographyPericardial Disease

Flexible Videopericardioscopy in cT4 Nonsmall-Cell Lung Cancer With Radiologic Evidence of Proximal Vascular Invasion

The purpose of this study was to evaluate feasibility and effectiveness of flexible videopericardioscopy (FVP) in assessing resectability of cT4 nonsmall-cell lung cancer (NSCLC) with radiologic evidence of proximal vascular invasion. Between March 2003 and December 2005, 22 patients with NSCLC deemed unresectable owing to signs of proximal vascular invasion at multislice computed tomography were included in a nonrandomized prospective study entailing FVP performed before curative-intent thoracotomy. Primary outcome measures were technical feasibility (graded from 1 = poor to 3 = excellent) and quality of anatomic visualization (graded as diagnostic or nondiagnostic). Patients with FVP evidence of proximal vascular invasion did not receive thoracotomy and were included in an induction chemoradiotherapy protocol. Mean operative time was 31 +/- 6 minutes. Technical feasibility ranged from good to excellent in 21 patients. In 1 patient, FVP was not completed owing to intrapericardial adhesions. In 7 patients, FVP disclosed no tumor spread to intrapericardial pulmonary vessels, and radical resection was carried out. The FVP findings were considered not diagnostic because of poor visualization of the right pulmonary artery in 2 patients with bulky hilar tumors. There was no operative mortality and morbidity. Mean hospital stay was 2.9 +/- 1 days for patients who did not undergo thoracotomy and 6.3 +/- 1 days for patients receiving FVP plus resection. Definitive pathologic staging in patients undergoing resection was pT3N1 (n = 2), pT3N0 (n = 2), pT2N0 (n = 3), and pT2N1 (n = 1). Flexible videopericardioscopy proved safely feasible and allowed a better assessment of centrally located NSCLC, with radiologic evidence of proximal vascular involvement eventually resulting in increased resectability rate.

Diagnosis of Regional Tamponade in Patients with Pericardial Effusion and Intrapericardial Adhesions: Recognition of a Distinctive Echocardiographic Configuration

Diagnosis of Regional Tamponade in Patients with Pericardial Effusion and Intrapericardial Adhesions: Recognition of a Distinctive Echocardiographic Configuration

Reduction of retrosternal and pericardial adhesions with rapidly resorbable polymer films

Background. The formation of postoperative cardiac adhesions makes a repeat sternotomy time consuming and dangerous. Many attempts have been made to solve this problem by using either drugs to inhibit fibrinolytic activity or different types of pericardial substitutes. The results have not been satisfactory. Methods. The efficacy of bioresorbable film prototypes made of polyethylene glycol (EO) and polylactic acid (LA) (EO/LA = 1.5, 2.5, and 3.0) in the prevention of adhesions after cardiac operations in canine models was tested. After desiccation and abrasion of the epicardium, a transparent bioresorbable film was placed over the heart. The pericardium was closed to allow intrapericardial adhesions (n = 32) or left open and attached to the chest wall to induce retrosternal adhesions (n = 17). Postoperative recovery was similar among the groups. Retrosternal and pericardial adhesions were evaluated at necropsy 3 weeks later by assessing area, tenacity, and density of the adhesions. Results. In the control dogs, tenacious, dense adhesions were observed. In contrast, adhesion formation was reduced at all sites covered by the films. The bioresorbable films were efficacious in the reduction of adhesion formation between epicardium and pericardium or between epicardium and sternum after cardiac operation. The EO/LA 1.5 film most effectively prevented the early adhesions. Conclusions. The bioresorbable films (EO/LA = 1.5, 2.5, and 3.0) significantly reduced adhesion formation, with EO/LA = 1.5 (Repel CV) being optimal. As the barrier was rapidly resorbed, the capsule formation induced by permanent barriers was avoided.

A New Biologic Membrane in Cardiovascular Surgery

Reconstruction techniques for major vessels and intracardiac defect repair use synthetic grafts or autogenic pericardium. Here, autologous abdominal parietal peritoneum with the overlying posterior rectus sheath as a biologic membrane are evaluated. Twelve adult canines were used. Via a midline subumbilical incision, the parietal peritoneum and overlying posterior rectus sheath were harvested. In the first group of six, the membrane was used to repair the right ventricular infundibulum and perform pulmonary artery annuloplasty. In the second group of six, under cardiopulmonary bypass and moderate hypothermia, the right atrium was opened and a secundum type defect was created. Autopsies performed 90 days after surgery revealed mild intrapericardial adhesions and moderate pericardial reaction over the cardiotomy incisions. The right ventricular outflow tract patch was nonaneurysmal. The interatrial patch was intact without thrombi. Histologic examination revealed intact membrane morphology, fibroblasts, smooth muscle cells, and endothelialization. Proline C14 uptake and autoradiography detected cellular viability of implanted membranes. These findings suggest that the peritoneum with overlying sheath repaired vascular and intracardiac defects and substituted for pericardium. Future studies are needed before clinical use.

Effectiveness of fibrin glue in the reduction of postoperative intrapericardial adhesions.

The hemostatic properties of fibrin sealant have been well described. Previously published reports have attempted to clarify the possible role of fibrin glue in the inhibition of the formation of intrapericardial adhesions following cardiac surgery. Earlier work hypothesized that fibrin glue may reduce the severity of postoperative adhesions and that the use of autologous fibrin glue may have similar effects, without the risks that accompany homologous blood products. Six juvenile farm pigs were utilized to test this hypothesis. Conventional fibrin glue and single-donor fibrin glue were tested in open-heart surgery. This experimental model was also reexamined and found to be of significant utility in simulating adult reoperative cardiac surgery. The fibrin glue subjects were universally easier to reoperate due to fewer adhesions, as demonstrated grossly and histologically. The single-donor fibrin glue had no significant advantage on adhesion formation, when compared to the conventional fibrin glue group, but the ramifications of formulating fibrin glue in this fashion offer a significant benefit toward the complete use of autologous blood products in open-heart surgery.

Use of an intraluminal shunt to repair a coronary bypass graft injury during resternotomy

In recent years, there has been an increase in the number of patients who are subjected to second cardiac procedures for correction of congenital heart defects, valve problems, and repeat coronary artery revascularization. Catastrophic hemorrhage is a rare complication that may occur while the sternum is being reopened. The most frequent causes include tears of the right ventricle and lesions of previous coronary bypass grafts; less common are bleeding from ascending aortic aneurysms or tears in the right atrium. In 1985, a 66-year old patient had undergone an aortic valve replacement with a Capentier-Edwards bioprosthesis (Baxter Healthcare Corp, Edwards Div., Santa Ana, Calif.) and a saphenous vein graft to the circumflex artery with jump anastomoses to an intermediate branch, the first diagonal branch, and the left anterior descending artery. Postoperative recovery was uneventful, and the patient felt well until 1992. At this time, the patient reported having exertional dyspnea and increasing weariness. A cardiologic examination was performed and transthoracic echocardiography demonstrated degeneration of the bioprosthesis, resulting in moderate aortic stenosis (mean systolic gradient 45 mm Hg, peak-to-peak gradient 70 mm Hg, and a valve opening area of 0.8 cm2 ). Left ventricular function was severely depressed with an ejection fraction of 0.26. At coronary angiography, each coronary–saphenous vein anastomosis was patent but some atherosclerotic changes were described in the proximal part of the graft. A median sternotomy was performed with the oscillating saw; during preparation and mobilization of the sternal borders, the aneurysmal proximal part of the saphenous vein bypass graft, which was completely adherent to the sternum, was damaged. Because of the important myocardial area supplied by the graft, it could not have been occluded either with clamps or with Fogarty catheters. Therefore we elected to insert a small intraluminal silicone shunt, which is usually used during carotid endarterectomy to preserve homolateral cerebral perfusion, as a bridge between the proximal and distal vein graft segments and secured it with tourniquets (Fig. 1). With this technical assistance, the bleeding could be easily controlled and no electrocardiographic changes or hemodynamic alterations appeared. Femoral artery cannulation was then performed, the right atrium was dissected, and a single-stage cannula was introduced into the right atrium. Extracorporeal circulation was instituted and conducted at moderate hypothermia. Myocardial protection was performed by retrograde continuous cardioplegia. After the aorta was crossclamped, the bioprosthesis was resected and a mechanical prosthesis was inserted. A short venous graft was interposed to repair the lesion and exclude the aneurysmal segment (Fig. 2). Postoperative recovery was uneventful and no clinical or electrocardiographic signs of perioperative myocardial infarction appeared. The patient was discharged on postoperative day 10. Several factors account for the increased risk of reoperation: age, progressive extent of coronary atherosclerosis, impairment of left ventricular function, additional cardiac procedures, technical difficulties during reentry and caused by intrapericardial adhesions, and prolonged bypass time and more difficult myocardial protection.1Lytle BW Loop FD Coronary reoperations.Surg Clin North Am. 1988; 68: 559-580PubMed Google Scholar Various methods have been proposed in the past for sternal reentry. Femoral artery cannulation can be used when the right ventricle seems to be adherent to the sternum, when there is strong suspicion that the internal mammary artery or a venous bypass graft is crossing the midline, when the chest has been reconstructed by muscle flaps, and when an ascending aortic aneurysm is present.2Mahfood S Higgins TL Loop FD. Management of complications related to coronary artery bypass surgery.in: Complications in cardiothoracic surgery. Mosby, St Louis1991: 265-280Google Scholar, 3Loop FD Catastrophic hemorrhage during sternal reentry.Ann Thorac Surg. 1984; 37: 271-273Abstract Full Text PDF PubMed Scopus (71) Google Scholar When progressive coronary artery disease necessitates a second operation with a new graft to the anterior and posterolateral walls of the left ventricle, thoractomy may allow excellent exposure of the left anterior descending branch and obtuse marginal branches. Proximal anastomoses are then performed to the descending aorta.4Burlingame MW Bonchek LI Vazales BE Left thoracotomy for reoperative coronary bypass.J Thorac Cardiovasc Surg. 1988; 95: 508-511PubMed Google Scholar In the case presented here, the use of an intraluminal shunt allowed us to control the bleeding and maintain a sufficient perfusion to prevent myocardial ischemia; furthermore, it allowed controlled, unhurried institution of cardiopulmonary bypass. This elegant method, preventing bleeding and myocardial ischemia, prompted us to review the literature, and we found only one similar description.5Robison RJ Brown JW Deschner WP King RD Intraluminal shunting of operatively severely injured aortocoronary saphenous vein grafts.Ann Thorac Surg. 1986; 42: 475-476Abstract Full Text PDF PubMed Scopus (3) Google Scholar

Prevention of postoperative pericardial adhesions with a hyaluronic acid coating solution

Postoperative pericardial adhesions complicate reoperative cardiac procedures. Topical application of solutions containing hyaluronic acid have been shown to reduce adhesions after abdominal and orthopedic surgery. The mechanism by which hyaluronic acid solutions prevent adhesion formation is unknown but may be due to a cytoprotective effect on mesothelial surfaces, which would limit intraoperative injury. In this study, we tested the efficacy and safety of hyaluronic acid coating solutions for the prevention of postoperative intrapericardial adhesion formation. Eighteen mongrel dogs underwent median sternotomy and pericardiotomy followed by a standardized 2-hour protocol of forced warm air desiccation and abrasion of the pericardial and epicardial surfaces. Group 1 (n = 6) served as untreated control animals. Group 2 (n = 6) received topical administration of 0.4% hyaluronic acid in phosphate-buffered saline solution at the time of pericardiotomy, at 20-minute intervals during the desiccation/abrasion protocol, and at pericardial closure. The total test dose was less than 1% of the circulating blood volume. Group 3 (n = 6) served as a vehicle control, receiving phosphate-buffered saline solution as a topical agent in a fashion identical to that used in group 2. At resternotomy 8 weeks after the initial operation, the intrapericardial adhesions were graded on a 0 to 4 severity scale at seven different areas covering the ventricular, atrial, and great vessel surfaces. In both the untreated control (group 1, mean score 3.2 +/- 0.4) and vehicle control (group 3, mean score 3.3 +/- 0.2) animals, dense adhesions were encountered. In contrast, animals treated with the hyaluronic acid solution (group 2, mean score 0.8 +/- 0.3) characteristically had no adhesions or filmy, transparent adhesions graded significantly less severe than either the untreated control (group 2 versus group 1, p < 0.001) or vehicle control (group 2 versus group 3, p < 0.001) animals. In separate experiments, six baboons were infused with 0.4% hyaluronic acid in phosphate-buffered saline solution in volumes equivalent to 2.5%, 5%, and 10% of the measured circulating blood volume. The 2.5% and 5% infusions had no effect on the parameters measured; infusion of the 10% volume produced transient hemodynamic, coagulation, and gas exchange abnormalities. Hyaluronic acid solutions are efficacious in the prevention of pericardial adhesions in this model, and they appear safe in doses five times the amount needed to prevent adhesions. Further studies investigating the mechanism by which these solutions prevent adhesions, their optimal dose and method of application, and documentation of their safe use in humans are warranted.

Reduction in experimental pericardial adhesions using a hyaluronic acid bioabsorbable membrane

Various materials have been suggested for pericardial closure following cardiac surgery to limit postoperative adhesion formation. Unfortunately, these devices have caused difficulties with infection, calcification, and epicardial scar formation. A bioabsorbable membrane with a short in-vivo persistence time, acting as a barrier to adhesion formation until mesothelial healing occurs, might obviate many of these problems. We examined the efficacy of a bioabsorbable membrane containing hyaluronic acid in the prevention of experimental pericardial adhesions; hyaluronic acid solutions have been shown experimentally to reduce adhesions following abdominal, orthopedic and cardiac surgery. Eleven dogs underwent sternotomy and pericardiotomy followed by 2-h protocol of desiccation and abrasion of pericardial and epicardial surfaces. In five dogs, the epicardial surfaces were covered with the test material, followed by pericardial and sternotomy closure. Six dogs served as controls. All animals underwent resternotomy 8 weeks after surgery; intrapericardial adhesions were graded on a severity scale (0-4). The test animals (mean adhesion score 1.4 +/- 0.5) had either no adhesions or filmy, avascular adhesions easily taken down with blunt dissection. In contrast, dense adhesions were found in the control animals (mean score 3.2 +/- 0.4), frequently obscuring tissue planes and epicardial anatomy. Use of the bioabsorbable membrane significantly reduced adhesion formation (test vs control, P < 0.001, Mann-Whitney test). We conclude that a hyaluronic acid membrane reduces postoperative pericardial adhesions in this canine model, and that the use of a bioabsorbable barrier in the prevention of pericardial adhesions warrants further investigation.

Efficacy of autologous peritoneum as a biological membrane in cardiac surgery

The risks for reoperative cardiac surgery are related to the presence of intrapericardial adhesions and the possibility of catastrophic injury at repeat sternotomy. In an attempt to develop an improved pericardial substitute and vascular patch, the feasibility of using autologous peritoneum was evaluated. Twelve mongrel dogs were studied. A peritoneal-rectus fascia patch, including the overlying posterior rectus sheath was harvested, via a lateral abdominal incision, and stored in normal saline. In the first group of six animals, a pulmonary artery (PA) window was created and then closed with the peritoneal-rectus fascia patch. In the second group a secundum atrial septal defect was created and then closed with the peritoneal patch on cardiopulmonary bypass (CPB). In each animal, the peritoneal-rectus fascia patch was used to permit pericardial closure. Autopsies performed at 90 days postoperatively revealed only slight intrapericardial adhesion formation and a mild epicardial reaction. Histological examination of the peritoneal-rectus fascia patches revealed intact morphology with active fibroblasts and smooth muscle cells. Proline 14C absorption and autoradiography detected viable cells in the implanted patches. These findings suggest that a peritoneal-rectus fascia allograft could be useful as a biological membrane, and as a satisfactory pericardial substitute in the development of strategies to reduce the risk for reoperative cardiac surgery.

CT and MR Evaluation of Pericardial and Retrosternal Adhesions after Cardiac Surgery

The visibility of the pericardium as well as of the space between the dorsal aspect of the sternal surface and the pericardial surface after cardiac surgery was determined by CT and/or MR with electrocardiographic (ECG)-gated spin-echo (SE) and gradient-echo sequences. Seventeen patients who had undergone cardiac operations and who were admitted for cardiac reoperation were investigated with CT and/or MR prior to sternal reentry. Five patients were investigated with CT alone, ten with both CT and MR, and two with MR only. At reoperation, retrosternal adhesions were classified as present or absent, and intrapericardial adhesions were classified as absent, minimal, moderate, or severe. A similar classification was applied to the CT and MR findings. In 14 of 15 patients, the CT findings were in agreement with those found at operation regarding postoperative retrosternal extrapericardial adhesions in the cranial retrosternal space and in 12 of 15 in the caudal retrosternal space. Computed tomography could not detect intrapericardial adhesions. Magnetic resonance was sensitive to metal artifacts from sternal sutures in both sequences and could therefore not be used to detect postoperative retrosternal extrapericardial adhesions. On the other hand, MR with ECG-gated SE sequences confirmed intrapericardial adhesions in 44 of 57 locations.

AN EXPERIMENTAL METHOD FOR THE PRODUCTION OF MITRAL INCOMPETENCE*

Summary1. A new method is described for producing mitral incompetence in sheep. It provides a high percentage of survivors for long‐term experiments.2. The pericardial envelope is not opened during the procedure, and no intrapericardial adhesions are produced. This allows easy access to cardiac structures when surgical correction is attempted subsequently.

Decortication of the heart

Delorme, 1 in 1895, suggested that decortication of the heart should be undertaken much as is decortication of the lung for chronic empyema. Between the years 1895 and 1898, Delorme repeatedly addressed the Clinical Societies of Paris advocating a lysis of the intrapericardial adhesions followed by closure of the pericardium and later recommending actual excision of a portion of the pericardium. The latter operation is the one used today, which is in actuality a pericardiectomy used as the treatment for a constrictive pericarditis. Although the syndrome had been described, it remained for Volhard in 1923 to describe the exact physiology of this constrictive pericarditis and to employ the term inflow stasis. As it stands today, the treatment of constrictive pericarditis usually follows an infective pericarditis, which heals by scar and, often times, calcification; however, as skill in treating traumatic wounds of the chest is gained, the technique should be modified