Pericardial Closure Research Articles

Epicardial placement of human placental membrane allografts in coronary artery bypass graft surgery is associated with reduced postoperative atrial fibrillation: a pilot study for a future multi-center randomized controlled trial

BackgroundPost-operative atrial fibrillation (POAF) occurs in up to 40% of patients following coronary artery bypass grafting (CABG) and is associated with a higher risk of stroke and mortality. This study investigates how POAF may be mitigated by epicardial placement of aseptically processed human placental membrane allografts (HPMAs) before pericardial closure in CABG surgery. This study was conducted as a pilot feasibility study to collect preliminary for a forthcoming multi-center randomized controlled trial.MethodsThis retrospective observational study of patients undergoing CABG surgery excluded patients with pre-operative heart failure, chronic kidney disease, or a history of atrial fibrillation. The “treatment” group (n = 24) had three HPMAs placed epicardially following cardiopulmonary bypass decannulation but before partial pericardial approximation and chest closure. The only difference in clinical protocol for the control group (n = 54) was that they did not receive HPMA.ResultsHPMA-treated patients saw a significant, greater than four-fold reduction in POAF incidence compared to controls (35.2–8.3%, p = 0.0136). Univariate analysis demonstrated that HPMA treatment was associated with an 83% reduction in POAF (OR = 0.17, p = 0.0248). Multivariable analysis yielded similar results (OR = 0.07, p = 0.0156) after controlling for other covariates. Overall length of stay (LOS) between groups was similar, but ICU LOS trended lower with HPMA treatment (p = 0.0677). Post-operative inotrope and vasopressor requirements were similar among groups. There was no new-onset post-operative heart failure, stroke, or death reported up to thirty days in either group.ConclusionsEpicardial HPMA placement can be a simple intervention at the end of CABG surgery that may provide a new approach to reduce post-operative atrial fibrillation by modulating local inflammation, possibly reducing ICU and hospital stay, and ultimately improving patient outcomes.

Pericardial Closure With Expanded Polytetrafluoroethylene Patch in Left Ventricular Assist Device Surgery.

To reduce adhesions after left ventricular assist device (LVAD) implantation, pericardial closure using an expanded polytetrafluoroethylene (ePTFE) patch has been suggested. However, as foreign material, ePTFE patches could increase the risk of infectious complications. In this single-center retrospective study, we investigated outcomes of pericardial closure using an ePTFE patch in LVAD implantation. We included all patients who underwent LVAD implantation at our center between 2011 and 2020 (n = 166). Primary endpoint was development of mediastinitis at any point of time between LVAD implantation and heart transplantation (HTx) or death. Secondary endpoint was overall survival. Preoperative and postoperative clinical data were collected to ensure comparability between the groups. We included 166 patients with LVAD. A total of 116 patients (70%) underwent pericardial closure using an ePTFE patch. There were significant differences between the groups in treatment setting, previous cardiac surgery, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level, development of driveline infection, and HTx. Patients with an ePTFE patch developed mediastinitis more frequently (16%) than patients without ePTFE patch (4%) ( p = 0.039). A significant difference in overall survival between the groups could not be confirmed ( p = 0.29). The use of PTFE patches for pericardial closure in LVAD implantation was associated with a higher incidence of mediastinitis, but not with a difference in overall survival.

Fibrin Hydrogel Layer-Anchored Pericardial Matrix Prevents Epicardial Adhesion in the Severe Heart Adhesion-Induced Miniature Pig Model.

Postoperative adhesion is a very common and serious complication that occurs frequently in cardiac surgery. The purpose of this study was to evaluate the efficacy of a fibrin hydrogel layer-anchored decellularized pericardial matrix in preventing pericardial adhesions in a miniature pig model with a myocardial injury. Fibrin hydrogel layer-anchored decellularized pericardial matrix was prepared by spraying a mixture of fibrinogen and thrombin on a fibrinogen-doped decellularized pericardium. Cardiac injury was generated by abrading and desiccating the epicardial surface of a miniature pig to induce severe postoperative adhesions. The adhesion between the epicardial surface and fibrin hydrogel layer-anchored decellularized pericardial matrix in three different regions (left outer, front, and right outer) was evaluated macroscopically one month after surgery. The fibrin hydrogel layer-anchored decellularized pericardial matrix showed significantly less adhesion than an autologous pericardium (0.2 ± 0.7 in DPM-FHG0.5 and 0.4 ± 0.8 in DPM-FHG1, p < 0.01) and expanded polytetrafluoroethylene (ePTFE) (1.6 ± 0.5, p < 0.05). The fibrin hydrogel concentration had no effect on preventing postoperative adhesion. A thinner fibrin hydrogel layer was observed on the decellularized pericardial matrix one month after surgery; however, the inside of the matrix was filled with fibrin hydrogel. Fibrin hydrogel layer-anchored decellularized pericardial matrix prevented postoperative epicardial adhesions in a miniature pig model. Our findings suggest that pericardial closure using a fibrin hydrogel layer-anchored decellularized pericardial matrix is a promising method for preventing adverse outcomes in reoperative surgeries.

Technical considerations in the management of penetrating cardiac injury.

Penetrating cardiac injuries require rapid diagnosis, efficient exposure and nuanced technical approaches, within a framework of highly coordinated and integrated multidisciplinary care. Acute care surgeons, with both strategic and technical expertise, are ideally positioned to address the potentially devastating consequences of these injuries. The aim of this narrative review is to offer a technical approach to the rapid evaluation, exposure, operative repair and postoperative care of penetrating cardiac injuries. A comprehensive review of the cardiac trauma literature, dating back to 1970, has provided a detailed toolbox of approaches to subxiphoid pericardial windows, resuscitative thoracotomy, median sternotomy, pericardiotomy, aortic clamping, cardiac hemorrhage control, cardiac repair, coronary artery injuries, pericardial closure, drain placement, chest wall closures, damage control thoracic procedures and immediate postoperative cardiac care, all based on fundamental physiological principles and anatomical considerations.

Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019. Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.

Haemodynamic Effects of Pericardial Closure after Cardiac Surgery

Introduction: Whether pericardial closure should be done or not is still a debated topic. While many studies favour pericardial closure after cardiac surgery, many are still not in favour of the same. Objective : Objective of this study was to analyse the changes induced by pericardial closure on the haemodynamic of the patient using easily measurable variables. Methods : Data of 30 patients were analysed of which 14 underwent mitral valve replacement, 10 underwent coronary artery bypass grafting and 6 underwent double valve replacement. Results: There was statistically significant change in cardiac output (p&lt;0.01), central venous pressure (p&lt;0.05) and left ventricular end diastolic diameter (p&lt;0.01) after pericardial closure. Clinically the pericardial closure was well tolerated. Conclusion: Despite exhaustive experience, the topic of closing pericardium is still debated. Our study shows that clinically pericardial closure is well tolerated and in return it also safeguards the risks associated with re-do operations

Can Redo Sternotomy Become as Easy as First-Time Sternal Opening?

Injury to vital vascular and cardiac structures is a redoubtable complication associated with redo sternotomy. This may be one reason why the pericardium should be closed whenever possible at least over the great vessels and the cranial part of the heart in every patient. This is of particular importance in those patients in whom a redo surgery may be expected (congenital surgery, valvular reconstruction and/or implantation of tissue valves, implantation of left ventricular device as bridging therapy). In many patients, however, a complete closure of the pericardium is not possible because of the intraoperative swelling of the heart or just because the necessary filling of the heart at the end of the procedure precludes a tension-free pericardial closure. In these cases, implantation of a pericardial or artificial membrane as pericardial replacement may be a wise decision. Independently of the presence of a membrane or not, computed tomography or magnetic resonance imaging is of great value before reopening the sternum to estimate the proximity of the posterior surface of the sternum to the most important cardiovascular structures (right ventricle, ascending aorta, innominate vein) or previous implants (pulmonary conduit or homograft, and saphenous vein grafts or internal thoracic artery in case of previous coronary artery bypass grafting). Previous subcutaneous implantation of different pericardial replacement patches in a porcine model has shown the following results: CorMatrix (CorMatrix Cardiovascular, Inc, Sunnyvale, CA) showed gradual and consistent patch resorption and subsiding inflammatory and fibrosis process. Full scaffold degradation and replacement by mild fibrosis and subcutaneous tissue were seen by 1 year. Xenopericardial patches remained intact, and the initially severe inflammatory and fibrotic reactions reduced gradually to moderate fibrosis and chronic inflammation. Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) showed foreign body reaction.1Mosala Nezhad Z. Poncelet A. Fervaille C. Gianello P. Comparing the host reaction to CorMatrix and different patch materials implanted subcutaneously in growing pigs.Thorac Cardiovasc Surg. 2019; 67: 44-49Crossref PubMed Scopus (6) Google Scholar The GoreTex polytetrafluoroethylene membrane has most probably been the most frequently implanted pericardial substitute so far. Its protective effects in case of redo sternotomy are recognized, but the adhesions with the epicardial surfaces may be strong. Among more recent alternatives, CorMatrix has been described as an interesting recellularized scaffold but the results among different studies were somewhat conflicting,2Bustamante-Munguira J. Serrano R. Figuerola-Tekerina A. et al.Is CorMatrix really a recellularization scaffold as a pericardial substitute in cardiac surgery?.J Cardiovasc Surg (Torino). 2018; 59: 142-143PubMed Google Scholar whereas bovine pericardium subjected to a novel anticalcification tissue-engineering process (CardioCel, LeMaitre Vascular, Inc, Burlington, MA) seems promising: A neointimal layer of varying thickness developed on the visceral surface of 5 CardioCel explants with endothelialization of the longest duration explant.3Prabhu S. Armes J.E. Bell D. et al.Histologic evaluation of explanted tisue-engineered bovine pericardium (CardioCel).Semin Thorac Cardiovasc Surg. 2017; 29: 356-363Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In this issue of The Annals of Thoracic Surgery, Hu and coauthors4Hu C. Tang F. Wu Q. et al.Novel trilaminar polymeric anti-adhesion membrane prevents postoperative pericardial adhesion.Ann Thorac Surg. 2021; 111: 184-190Abstract Full Text Full Text PDF Scopus (8) Google Scholar from Beijing have to be congratulated for another important step—that is, a novel trilaminar membrane that was compared (mainly adhesive effects) to the well-known expanded polytetrafluoroethylene membrane in an animal study. The goal of this new membrane is to minimize post-sternotomy adhesions (through the resorbable components) while maintaining a permanent physical barrier (through the middle layer). All layers contain a novel polymer made of polyvinyl alcohol and carboxymethylcellulose. Because the generation of adhesions and granulation tissue are most active 5 to 7 days after implantation and adhesions become stable approximately from day 14 post implantation, the new material resorbs rapidly after implantation during initial surgery. This might be of particular interest if, for any reason, a reexploration becomes necessary during the early follow-up period. Looking at the microscopic specimen in animals, every cardiac surgeon may be eager to have this new pericardial replacement membrane in their fingers as soon as available on the market. Novel Trilaminar Polymeric Antiadhesion Membrane Prevents Postoperative Pericardial AdhesionThe Annals of Thoracic SurgeryVol. 111Issue 1PreviewPostoperative pericardial adhesion formation is a prominent cause of morbidity and death in cardiovascular surgery, but there is still no ideal prevention method, especially in redo cases. This study investigated a novel antiadhesion trilaminar polymeric film compared with the Gore PRECLUDE Pericardial Membrane (W. L. Gore & Associates, Flagstaff, AZ) and a negative control. Full-Text PDF

Incidental finding of PFO during cardiac surgery and implications - A dilemma in decision making

Introduction Patent foramen ovale (PFO) is common finding during coronary artery bypass graft (CABG) surgery. There is lack of data to help guide treatment decisions regarding incidental findings of PFO during CABG surgery. Certainly, the benefit versus risk equation seems to be a reasonable approach on individualized basis. Methods 67 years old female with history of unstable angina, no other comorbidities and normal preoperative Echocardiogram underwent elective CABG. Intraoperative TOE showed good biventricular function, no significant valvular abnormality and moderate size PFO with left-right shunt. The PFO was not treated as the patient was asymptomatic preoperatively. Immediately in postoperative period the patient was hypoxic. CTPA showed basal atelectasis, TOE demonstrated pericardial collection and reversal of the flow across the PFO. Percutaneous closure of PFO was considered but deemed inappropriate due to lack of evidence. Following discharge patient was readmitted with shortness of breath. She underwent a complicated redo-sternotomy for surgical removal of pericardial collection and PFO closure. Injury to the RV due to adhesion required femoral cannulation and led to compartment syndrome. Peri-operative TOE demonstrated moderate PFO with significant right-left shunt. Failure of mechanical ventilation wean mandated another review by cardiology and decision to percutaneously close the PFO was agreed. PFO closure was followed by immediate drop in oxygen requirement and facilitated immediate extubation and wean from ventilation. Discussion There is no evidence to suggest incidental PFO in patients undergoing cardiac surgery is linked to morbidity or mortality, and no evidence to support closure. One study showed that change from a planned procedure to include PFO closure increased risk of postoperative stroke with no long-term survival benefit. PFOs in patients with history of cryptogenic stroke are known to be larger (>4 mm) with longer tunnels (>1 cm) and that size and history of paradoxical embolism are major factor behind the surgeon's decision to close PFO. Conclusion Lack of strong evidence has led to our patient's unanticipated complication and longer hospital stay. Closure of PFO in asymptomatic patient should be decided on individual basis. Stronger evidence and recommendations are necessary to prevent complications.

Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions

BackgroundA prospective, multi-center study (RECON) was conducted to evaluate the clinical outcomes of pericardial closure using a decellularized extracellular matrix (ECM) graft derived from porcine small intestinal submucosa.MethodsPatients indicated for open cardiac surgery with pericardial closure using ECM were eligible for the RECON study cohort. Postoperative complications and readmission of the RECON patients were compared to the patient cohort in the Nationwide Readmissions Database (NRD). Inverse probability of treatment weighting was used to control the differences in patient demographics, comorbidities, and risk factors.ResultsA total of 1420 patients at 42 centers were enrolled, including 923 coronary artery bypass grafting (CABG) surgeries and 436 valve surgeries. Significantly fewer valve surgery patients in the RECON cohort experienced pleural effusion (3.1% vs. 13.0%; p < 0.05) and pericardial effusion (1.5% vs. 2.6%; p < 0.05) than in the NRD cohort. CABG patients in the RECON cohort were less likely to suffer bleeding (1.2% vs. 2.9%; p < 0.05) and pericardial effusion (0.2% vs. 2.2%, p < 0.05) than those in the NRD cohort. The 30-day all-cause hospital readmission rate was significantly lower among RECON patients than NRD patients following both valve surgery (HR: 0.34; p < 0.05) and CABG surgery (HR: 0.42; p < 0.05). In the RECON study, 14.4% of CABG patients and 27.0% of valve patients had postoperative atrial fibrillation as compared to previously reported risks, which generally ranges from 20 to 30% after CABG and from 35 to 50% after valve surgery.ConclusionsPericardial closure with ECM following cardiac surgery is associated with a reduction in the proportion of patients with pleural effusion, pericardial effusion, and 30-day readmission compared to a nationwide database.Trial registrationNCT02073331, Registered on February 27, 2014.

Pericardial Patch Exclusion Technique for Left Atrial Appendage Closure.

We describe a technique of left atrial appendage occlusion that consists of autologous pericardial patch closure of the left atrial appendage orifice from within the left atrium. This pericardial patch exclusion technique has little added risk of bleeding, can be performed through sternotomy or right minithoracotomy, and can be used in re-operative situations.

Subxiphoid robotic thymectomy with pericardial patch closure

Subxiphoid robotic thymectomy with pericardial patch closure

Robotic pericardial patch closure by the subxiphoid approach

Robotic pericardial patch closure by the subxiphoid approach

ECG de febrero de 2016

The patient was a 7-day-old boy who was in the immediate postoperative period after undergoing aortic arch repair involving coarctation repair with end-to-end anastomosis and pericardial patch closure of a perimembranous ventricular septal defect. There had been no adverse intraoperative events. The infant was transferred to the pediatric intensive care unit with inotropic support consisting of dopamine and milrinone. Twenty-four hours after the intervention, a change took place in his rhythm, with progressive hypotension and oliguria (Figure). Adenosine triphosphate was administered and electrical cardioversion was performed with no response. What is your diagnosis? How would you treat this patient?

Pericardial Closure Defect with Right Atrial Herniation in a Dog

A 16 years old German Shepherd dog was referred to the teaching hospital of Veterinary Medicine Faculty of IaE™i, with cardio-respiratory symptoms. Clinical examination, electrocardiography, thoracic X-ray, echocardiography and necropsy have been performed and congestive heart failure due to right cardiac dilatation was diagnosed. Necropsy revealed a right pericardial closure defect with the hernia and incarceration of the right atrium in the mediastinum. The aim of the study is to describe an uncommon cardiac pathology in a geriatric dog represented by a pericardial tear with the right auricular hernia and incarceration and to raise hypothesis of the etiology of the pathological findings.

Use of PTFE patch for pericardial closure after minimal invasive LVAD implantation

The left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. The thoracotomy approach for LVAD implantation, in which the left ventricle is approached through a pericardial rent, is becoming popular. We demonstrate closure of the pericardial rent with a polytetrafluoroethylene (PTFE) patch and its advantages.

Impact of the total pericardial closure using bilateral trap door incision and pericardial cavity intervention on outcomes following coronary artery bypass grafting: a randomized, controlled, parallel-group prospective study.

In this randomized, controlled and parallel-group prospective study, the feasibility of total pericardial closure with an intrapericardial drain and a pericardio-pleural window (pericardial cavity intervention) was investigated by examining postoperative outcomes, including atrial fibrillation and pericardial effusion, following coronary artery surgery. Cases were classified into two groups using a random procedure: the closure group and the open group. Insertion of an intrapericardial drain along the right atrium, pericardio-pleural window and total closure of the pericardium were performed in patients in the closure group. Partial closure of the pericardium was performed in patients in the open group. A straight semi-rigid drain was inserted into the extrapericardial anterior mediastinum and a right angle drain was inserted into the left chest in all patients. The primary endpoint was to evaluate the impact of surgical technique on the rate of postoperative in-hospital atrial fibrillation in the closure group. The secondary endpoint was to evaluate the relationship between the surgical technique and postoperative amount of pericardial effusion. A total of 142 isolated, on-pump cases were examined: 72 in the open group and 70 in the closure group. Postoperative atrial fibrillation occurred in 27.78% of the cases in the open group and 8.57% of the patients in the closure group (P = 0.003). Another statistically significant outcome was the lower incidence of small pericardial effusion in the patient group with a closed pericardium during the second day of postoperative care (P = 0.039). The length of both critical care unit (P = 0.008) and hospital stay (P = 0.047) were also significantly shorter in the patient group with a closed pericardium. Total pericardiorrhaphy with pericardial cavity intervention can be acceptable and favourable in terms of its outcomes, including reducing incidence of postoperative atrial fibrillation, pericardial effusion and length of hospitalization.

Surgical results of third or more cardiac valve operation.

BackgroundWe evaluated operative outcomes after third or more cardiac operations for valvular heart disease, and analyzed whether pericardial coverage with artificial membrane is helpful for subsequent reoperation.MethodsFrom 2000 to 2012, 149 patients (male: female=70: 79; mean age at operation, 57.0±11.3 years) underwent their third to fifth operations for valvular heart disease. Early results were compared between patients who underwent their third operation (n=114) and those who underwent fourth or fifth operation (n=35). Outcomes were also compared between 71 patients who had their pericardium open during the previous operation and 27 patients who had artificial membrane coverage.ResultsIntraoperative adverse events occurred in 22 patients (14.8%). Right atrium (n=6) and innominate vein (n=5) were most frequently injured. In-hospital mortality rate was 9.4%. Total cardiopulmonary bypass time (225±77 minutes vs. 287±134 minutes, p=0.012) and the time required to prepare aortic cross clamp (209±57 minutes vs. 259±68 minutes, p<0.001) increased as reoperations were repeated. However, intraoperative event rate (13.2% vs. 20.0%), in-hospital mortality (9.6% vs. 8.6%) and postoperative complications were not statistically different according to the number of previous operations. Pericardial closure using artificial membrane at previous operation was not beneficial in reducing intraoperative events (25.9% vs. 18.3%) and shortening operation time preparing aortic cross clamp (248±64 minutes vs. 225±59 minutes) as compared to no-closure.ConclusionClinical outcomes of the third or more operations for valvular heart disease were acceptable in terms of intraoperative adverse events and in-hospital mortality rates. There were no differences in the incidence of intraoperative adverse events, early mortality and postoperative complications between third cardiac operation and fourth or more.

Left ventricular pseudo-aneurysm following cardiac surgery—two cases managed with two different techniques

We report the clinical presentation, diagnosis, and management of two cases of left ventricular pseudo-aneurysm (LVPA) following left ventricular repair surgeries. The first patient, 46-year-old male, presented with New York Heart Association (NYHA) Class III symptoms at 2 months post-repair of acute posterior post-infarction ventricular septal rupture. Large posterolateral LVPA was detected. Surgical repair was done through a left thoracotomy by bovine pericardial patch closure of the defect under femoro-femoral cardiopulmonary bypass, moderate hypothermia, and without aortic cross clamping. The second patient, 57-year-old male, presented with NYHA Class III symptoms 36 months after he underwent repair of sub-mitral aneurysm along with mitral valve replacement and two vessel coronary artery bypass. Large posterolateral LVPA was detected with a 21-mm defect having good edges. He was managed by a hybrid procedure where a small thoracotomy exposed the aneurysmal sac and the defect was closed with a ventricular septal defect (VSD) device (Lifetech) inserted through a purse string on the aneurysmal sac under transesophageal echocardiography (TEE) guidance. Patients undergoing surgical repairs through left ventriculotomy should be carefully followed up for the occurrence of LVPA. The management depends on the site and size of the defect on the ventricular wall.

Abstract 15155: Supracardiac Type (1a) Total Anomalous Pulmonary Venous Return with Right to Left Shunt Atrial Septal Defect Diagnosed by 320 Slice CT

The first choice of imaging modality to evaluate complex congenital heart disease, especially in infants, is transthoracic echocardiogram (TTE) and magnetic resonance imaging. But to evaluate anatomic details of the heart, including coronary arteries with surrounding structures, CT is most useful. We experienced a patient who was diagnosed as having supracardiac type total anomalous pulmonary venous return (TAPVR) with a right to left shunt atrial septal defect (ASD) by 320 slice CT. A 63-year-old female who had palpitations and dizziness was referred to our hospital because of cardiac enlargement shown on chest X ray in a health examination. On chest X ray, enlargement of protrusion of the right first and left first aortic arches was observed. ECG revealed ectopic low part atrial rhythm, right axis deviation of the QRS wave, and incomplete right bundle branch block. On TTE, ASD with right to left shunt was observed, presence of Eisenmenger syndrome was suspected and there seemed to be no surgical indication. But on TTE, right heart configuration seemed not due to pressure load but volume load, which is not indicative of Eisenmenger syndrome. To evaluate the presence of other complications of anatomical cardiovascular heart disease, ECG-gated 320 slice CT (Aquilion ONE, Toshiba Medical) was performed. On CT, supracardiac type TAPVR with right to left shunt ASD could be accurately diagnosed. She then underwent TAPVR surgical repair from the superior approach in which total PV connected to the LA and ligated innominate vein and ASD pericardial patch closure. By this procedure, there was no blood flow from PV to the right heart, with blood from the PV flowing into the LA directly. Hemodynamics was normalized. In summary, this patient had remarkable cardiac enlargement on chest X-ray, and on TTE ASD with right-to-left shunt was detected. 320 slice CT can evaluate complex congenital heart disease as well as coronary arteries accurately and provide information on blood flow.

Guided bone regeneration with Pericardium membranes

There a plethora of evidence suggesting the role of barrier membranes in bone augmentation at sites of inadequate bone volume and height. Amongst the resorbable membranes, native collagen membranes are the standard treatment for guided regeneration procedures. However, native collagen resorbs rapidly whereas cross linking delays it. Pericardium membranes are multilayered, resulting in prolonged barrier function with the properties of native collagen intact. These membranes have proved their utility in the field of vascular, cardiac, thoracic surgery because of their mechanical and clinical handling properties. However, there very little evidence of bone augmentation with pericardium membranes in the field of dentistry, particularly Implantology. The purpose of this review to discuss the potential applications of these membranes in guided bone regeneration. I. INTRODUCTION Periodontal therapy has almost always focused on the arrest of the disease progress and maintenance of the remaining periodontal support. Treatment to restore periodontal health and achieve restitution of attachment apparatus has varied based on the etiology and encompasses procedures such as root planing, soft tissue curettage and various types of flap procedures, often in combination with the placement of bone grafts or bone substitutes into the defects. Most procedures have merely brought about tissue repair, which signifies replacement of the lost apparatus with scar tissue which does not completely restore the architecture or function of the part replaced. Regenerative procedures currently in use in periodontal therapy have not been able to achieve regeneration in the true sense. There have been reports of gaining new attachment by the formation of new cementum.(1) However; bone formation largely insubstantial or delayed. Melchers hypothesis of selective cell repopulation contributed to the understanding of the mechanics of wound healing. This concept was used further by series of experiments and formed the basis of the biologic principle of Guided tissue regeneration. Guided tissue regeneration (GTR) is used to define procedures wherein regeneration of lost periodontal structures (cementum, periodontal ligament, and alveolar bone) sought via selective cell and tissue repopulation of the periodontal wound. Periodontal literature replete with the research work related to tissue and bone regeneration achieved with GTR. This concept further evolved to a more evolved compartmentalized principle of guided bone regeneration (GBR). The biological basis for guided bone regeneration involves fulfillment of bone growth requirement: establishing stable immobile base, allow for release of growth factors, and finally, preserving the blood supply to the area of defects. The guided bone regeneration promotes bone formation by protection against invasion of competing, non osteogenic tissues with the use of barrier membranes. There are three generation of membranes which includes resorbable membranes like collagen and polylactide-co- glycolide, non resorbable membranes like ePTFE and Gore tex and few other membranes under investigation which includes membranes like alloderm, gelfoam, cargile and pericardium membranes. The purpose of this review to throw light on the potential application of pericardium membranes in GBR. The pericardium a fibroserous sac surrounding the mammalian heart. It has long been used in cardiac repair for reconstruction, valve repair and pericardial closure.(2, 3) Pericardial tissue has exceptional handling characteristics and uniform suture retention. In addition, it nonthrombogenic and naturally resists infection. Xenogenic pericardium commonly derived from bovine, porcine and, less frequently, equine sources. Tissues from these sources are available in large patches, allowing custom configuration to a variety of cardiovascular applications. It largely comprised of collagen fibers and has elastic properties allowing conformity to complex anatomy. (4) Bovine pericardium found its application initially as patches for arterial closure during vascular and cardiac surgery. The native structure of bovine pericardium has three layers: 1) the serosa, the inner thin layer consisting of mesothelial cells; 2) the fibrosa, the thicker layer formed by diversely oriented, wavy bundles of collagen and elastin; and 3) the epipericardial connective tissue layer, the outer layer that partly continuous with the pericardiosternal ligaments.(5) BP widely used in cardiac and thoracic surgery, as bioprosthetic valve leaflets, for repair of intracardiac defects, for repair of diaphragmatic defects, vascular surgery, including general surgery, urologic surgery and ophthalmology. The various beneficial properties promoting the use of