Pericardial Closure Research Articles

Massive tricuspid regurgitation due to pacemaker-lead puncture of the tricuspid valve: successful diagnosis by 3-dimensional echocardiography.

An 83-year-old woman presented to our echocardiographic center with symptoms of right heart failure. A dual-chamber DDDR pacemaker had been implanted 9years earlier. Two-dimensional echocardiography revealed right atrial and ventricular enlargement and massive tricuspid regurgitation with immobilization of the anterior leaflet of the tricuspid valve. Three-dimensional transesophageal echocardiography showed that the pacemaker lead had punctured the leaflet. These echocardiographic findings were confirmed during surgery. The pacemaker lead was transected and removed, and pericardial patch closure of the leaflet hole and tricuspid annuloplasty were performed. The mechanism of regurgitation was elucidated by real-time three-dimensional echocardiography, and surgical repair was straightforward.

Repair of Traumatic Aortoinnominate Disruption Using CorMatrix

Blunt traumatic injuries to the innominate artery are rare but potentially devastating injuries. Patients with an innominate injury who survive typically have an isolated intimal tear with an intact adventitia. There are multiple case reports and series describing off-pump repair of innominate injuries using synthetic grafts, and even reports of successful endovascular stenting. We report the first successful case of innominate artery disruption and repair using CorMatrix (CorMatrix Alpharetta, GA) extracellular matrix.

Management of pulmonary venous obstruction

Although improved surgical techniques have led to significantly better outcomes of surgery for total anomalous pulmonary venous connection, the risk of progressive pulmonary venous obstruction continues to be a clinical problem. Both obstructed total anomalous pulmonary venous connection and post-repair pulmonary venous obstruction are associated with a significant risk of recurrent obstruction or death, requiring reoperation for stenosis. In general, side to side anastomosis of the pulmonary venous confluence to the functional left atrium has been performed for supracardiac and infracardiac total anomalous pulmonary venous connection. Repair of total anomalous pulmonary venous connection to the coronary sinus invariably involved unroofing the coronary sinus, followed by pericardial patch closure of the atrial septal defect. Recently, sutureless technique has been adopted as the primary operation for the subgroups of patients that are thought to be at high risk for post-repair pulmonary venous obstruction, such as those with total anomalous pulmonary venous connection associated with right isomerism, infracardiac total anomalous pulmonary venous connection with small individual pulmonary veins, or mixed-type total anomalous pulmonary venous connection. Because the sutureless technique does not require direct anastomosis to the confluence, aggressive resection of the obstructed pulmonary venous tissue can be achieved, and surgically induced distortion of the suture line can be avoided, which may help to prevent subsequent pulmonary venous obstruction. Conventional management strategies for recurrent pulmonary venous obstruction have typically been associated with poor outcomes. Recent reports have supported the use of the sutureless technique to treat post-repair pulmonary venous obstruction.

A review of the current status of pericardial closure following cardiac surgery

Some cardiac surgeons prefer to close the pericardium whenever possible following surgery, others specifically avoid this practice, and still others believe that neither alternative has any meaningful influence on clinical outcomes. Unfortunately, scientific evidence supporting either approach is scarce, making a consensus regarding best practice impossible. In this article, the known functions of the native intact pericardium are summarized, and the arguments for and against pericardial closure after surgery are examined. In addition, the techniques and materials that have been utilized for pericardial closure previously, as well as those that are currently being developed, are assessed.

Epicardial left atrial appendage clip occlusion also provides the electrical isolation of the left atrial appendage

The exclusion of the left atrial appendage (LAA) has been used to reduce the risk of stroke associated with atrial fibrillation (AF). While LAA exclusion has been associated with a reduced risk of stroke, the effect on the electrical activity of the LAA (a potential source of AF) remains unknown. As such, we sought to demonstrate whether surgical epicardial clip occlusion leads to the electrical isolation of the LAA. From December 2010 until August 2011, 10 patients with paroxysmal AF underwent off-pump coronary artery bypass surgery with bilateral pulmonary vein isolation and an LAA clip occlusion with a new epicardial clip. Before and after the clip was placed, pacing manoeuvres were performed to assess the electrical exit and entry blocks from the LAA. All clips were applied successfully. The mean procedure time for the clip application was 4 ± 1 min. No complications occurred related to clip application. Prior to the pericardial closure, 18 ± 3 min after the clip placement, the LAA stimulation and pacing manoeuvres demonstrated complete electrical isolation of the LAA in all cases. Epicardial LAA clip occlusion leads to the acute electrical isolation of the LAA and may not only provide stroke prevention but also reduce the recurrence of AF.

Acute superior vena cava obstruction due to tight pericardial closure following congenital defect repair

The obstruction of the superior vena cava (SVC) of acute onset nature following surgery is a rare and serious condition. The tight closure of the pericardium over the heart during surgical procedures may cause external compression on the SVC. Echocardiography and Computed tomography (CT) scan aids in the diagnosis. Cutting open the pericardial stitches relieves the condition.

A frequently found rare tumor at high altitude: Atrial Myxoma; Kashmir experience

Background: Myxomas are the most common type of cardiac tumors in all age groups, and symptoms are produced by mechanical interference with cardiac function or embolization. This study comprises the clinical profile, surgical approach, morbidity, mortality and recurrence rate of atrial myxomas in the Kashmir valley. Patients and Methods: The study was retrospective from January 1991 to July 2005 and prospective from August 2005 to December 2007. All patients admitted with the diagnosis of atrial myxomas were included in the study. Results: The study included 30 patients with a mean age of 52 ± 4.8 years. Females outnumbered males, with a ratio of 2.9:1. Dyspnea was the most common symptom on presentation, with majority of the patients belonging to New York Heart Association Class III (56.6%). Pre-operative diagnosis was established in all patients by echocardiography. Majority of myxomas, i.e. 22 (88%), arose from interatrial septum. Wide excision of tumor with polytetrafluorethylene (PTFE)/pericardial patch closure was the most common surgical procedure performed. Both early and late mortalities were 6.6%. In addition to clinical examination, periodic echocardiography was done on follow-up to detect recurrence, which was seen in one (3.3%) patient. Conclusions: Surgical management is curative with minimal early and late morbidity and mortality. Extensive resection of the myxoma attached to the atrial septum or atrial wall can reduce the likelihood of recurrence to a great extent, and long-term clinical and echocardiographic follow-up is mandatory.

左冠状動脈主幹部狭窄と心外膜炎を合併した非破裂心外型左バルサルバ洞動脈瘤にパッチ閉鎖術と冠状動脈バイパス術を施行した1例

左冠状動脈主幹部狭窄と心外膜炎を合併した非破裂心外型左バルサルバ洞動脈瘤にパッチ閉鎖術と冠状動脈バイパス術を施行した1例

Preliminary experience in the use of an extracellular matrix to repair congenital heart diseases

Congenital heart diseases are corrected early in life, so the surgical procedure has to maintain the maximum potential for growth. The quest for the ideal material for cardiac tissue repair is still ongoing. Here, we describe our preliminary experience with an extracellular matrix for cardiac and vascular tissue repair. Between August 2009 and April 2011, 26 patients underwent cardiac surgery using the CorMatrix patch for vascular repair (10 pulmonary artery, four ascending aorta, three aortic arch and one right ventricular outflow tract) or for valve reconstruction (five aortic, two tricuspid, one mitral and one pulmonary valve); in four cases, the repair was associated with pericardial closure using the same patch. There were no deaths, and at a mean follow-up of 13.2 months, there was no evidence of patch-related complications either in the vascular position or when used for valve repair. The ideal material for cardiac tissue repair should be haemostatic and resistant to tearing and calcification, and possibly one that will not induce an inflammatory cascade. In the last 25 months, we used an extracellular matrix for cardiac and vascular tissue repair. The patch is advocated to induce the patient's own tissue regeneration. The early results are encouraging, but a longer follow-up is needed to understand the real potential of this material.

Secure Closure of the Tracheal Incision After Natural Orifice Transluminal Endoscopic Surgery With a Surgical Sealant (CoSeal)

To evaluate the effectiveness of surgical sealant (CoSeal) in sealing the tracheal assess sites after transtracheal thoracoscopy. Two dogs underwent transtracheal thoracic exploration and pericardial window creation. The thoracic cavity was approached with flexible bronchoscope through a 9-mm tracheal incision. The pericardial window was performed with a needle knife via the working channel of the bronchoscope, and the tracheal assess site was closed with CoSeal using a rubber catheter. The integrity of tracheal healing was evaluated under positive pressure ventilation. Transtracheal creation of pericardial window and closure of tracheal incision with CoSeal was successfully performed in both dogs. There was no evidence of air leaks from the chest tube during positive pressure ventilation. Autopsy revealed no injury to the mediastinum and intrathoracic structure. Endoscopic closure of tracheal access site of NOTES with CoSeal appears to be a feasible technique.

Surgically treated infective endocarditis involving the aortic bicuspid valve and ventricular septum revealing aortic regurgitation and a Gerbode defect

A 41-year-old man who had been previously diagnosed with bicuspid aortic valve presented to our hospital with repeating episodes of fever. Echocardiography revealed vegetation in the bicuspid valve as well as left-to-right shunt, making one suspicious of rupture of the sinus of Valsalva. Under the diagnosis of infective endocarditis of the aortic valve and rupture of the sinus of Valsalva, the patient underwent a surgical operation. Operative findings showed normal sinus of Valsalva; but a communication between the left ventricle and right atrium was present, suggesting a Gerbode defect. The patient was treated by autologous pericardial patch closure and aortic valve replacement and was dismissed from the hospital without major complications.

Preliminary Experience With Cardiac Reconstruction Using Decellularized Porcine Extracellular Matrix Scaffold: Human Applications in Congenital Heart Disease

An ideal material for repair of congenitally malformed hearts would encourage tissue regeneration with growth potential. Decellularized porcine small intestinal submucosa extracellular matrix (SIS-ECM) promotes tissue regeneration in animal models and noncardiac human applications. This retrospective review evaluates SIS-ECM for reconstruction of congenital heart defects. From June 2007 to May 2009, SIS-ECM patches were used in 43 operations on 40 patients aged 2 days to 13 years. In 16 cases, the SIS-ECM was used for pericardial closure. The SIS-ECM was used for cardiac or great vessel repair in 37 cases: atrial septal defect repair in 11, pulmonary arterioplasty in 10, right ventricular outflow tract patch in 6, pulmonary monocusp valve creation in 5, superior vena cava patch in 2 and aortoplasty in 2, valve leaflet augmentation in 2, and repair of unroofed coronary sinus in 1. Follow-up was complete. There were 5 deaths, all unrelated to the SIS-ECM. Mean follow-up was 7.85 months (0.5-24 months). No pericardial effusions or intracardiac or intravascular thromboses occurred related to the SIS-ECM. The patches did not shrink or calcify. Four of 5 monocusp valves were competent and none were stenotic. One patient who underwent tricuspid valve anterior leaflet augmentation with SIS-ECM required tricuspid valve replacement 4 months later for severe regurgitation following a catheter-based procedure. Explanted tissue showed resorption of the SIS-ECM, replacement with organized collagen, and re-endothelialization. Repair of congenital heart defects using SIS-ECM is feasible and safe. In valve reconstruction, this procedure shows potential for replacement by autologous tissue. Longer-term follow-up is required to assess the potential for growth.

Use of CoSeal in a Patient With a Left Ventricular Assist Device

A 45-year-old man with end-stage idiopathic dilatated cardiomyopathy had previously undergone two left anterolateral thoracotomies for implantation and explantation of a left ventricular epicardial lead for biventricular pacing. Because of worsening heart failure and a predicted long delay to heart transplantation, a left-ventricular assist device was implanted, with application of CoSeal surgical sealant (Baxter Healthcare Corp, Fremont, CA) on the cardiac surface. At re-sternotomy for heart transplantation, surgical dissection of the left-ventricular assist device was greatly facilitated by the presence of avascular, very loose adhesions. CoSeal (Baxter Healthcare Corp) seems to be useful for the inhibition of adhesion formation after left-ventricular assist device implantation, although further clinical experience with this approach is required.

Closure of pericardium using pericardial fat in primary cardiac operations

Closure of pericardium using pericardial fat in primary cardiac operations

Rotational pericardial flap: An alternative tension-free technique for pericardial closure

Closing the pericardium in patients with preserved ventricular function has been proposed as a protective measure attempting to minimize the hazards of injuring the myocardium, coronary grafts, and great vessels at the time of reoperation. 1 Despite its own set of advantages, in view of the increasing number of cardiac reoperations, classical pericardial closure has not gained increasing acceptance, mainly because of concerns over its attendant adverse hemodynamic effects. In the interim, using alternative techniques deemed as tension-free pericardial closure or pericardial substitutes has been advocated to benefit patients with safer resternotomy while minimizing the adverse effects on immediate postoperative hemodynamics. Following this line of reasoning, we report an alterna tive technique for tension-free pericardial closure that results in layering the right ventricular free wall and infundibulum by means of a rotational pericardial flap while leaving the great vessels unlayered, thereby minimizing the likelihood of compressive effects on the great vessels and top-end anastomosis.

Protecting the Crossover Right Internal Thoracic Artery Bypass Graft With a Pedicled Thymus Flap

The right internal thoracic artery graft is placed in jeopardy during repeat sternotomy as it crosses the aorta anteriorly to reach its left-sided coronary targets. We have devised a way of protecting it by means of a pedicled flap taken from the thymic remnants. The flap is easily developed without unduly increasing operative time and morbidity, and it is expected to prevent inadvertent injuries to the graft in the case of mediastinal reentry. Starting in 1999, suitable flaps were obtained in 955 of 1,034 patients (92.4%) receiving an anteaortic crossover right internal thoracic artery-to-coronary graft in our division.

The Effect of Milrinone on the Right Ventriclular Function in Patients with Reduced Right Ventricular Function Undergoing Off-pump Coronary Artery Bypass Graft Surgery

This investigation evaluated the effect of continuous milrinone infusion on right ventriclular (RV) function during off-pump coronary artery bypass graft (OPCAB) surgery in patients with reduced RV function. Fifty patients scheduled for OPCAB, with thermodilution RV ejection fraction (RVEF) <35% after anesthesia induction, were randomly allocated to either milrinone (0.5 µg/kg/min) or control (saline) group. Hemodynamic variables and RV volumetric data measured by thermodilution method were collected as follows: after anesthesia induction (T1); 10 min after heart displacement for obtuse marginal artery anastomosis (T2); after pericardial closure (T3). Cardiac index and heart rate increased and systemic vascular resistance significantly decreased in milrinone group at T2. Initially lower RVEF of milrinone group was eventually comparable to control group after milrinone infusion. RVEF did not significantly change at T2 and T3 in both groups. RV end-diastolic volume in milrinone group consistently decreased from the baseline at T2 and T3. Continuous infusion of milrinone without a bolus demonstrated potentially beneficial effect on cardiac output and RV afterload in patients with reduced RV function during OPCAB. However, aggressive augmentation of intravascular volume seems to be necessary to maximize the effect of the milrinone in these patients.

Letter Regarding the Article by Xue et al, “Functional Integration of Electrically Active Cardiac Derivatives From Genetically Engineered Human Embryonic Stem Cells With Quiescent Recipient Ventricular Cardiomyocytes”

To the Editor: The article by Xue et al1 on human embryonic stem cell-derived pacemakers illustrates that embryonic stem cells differentiated into spontaneously beating cardiocytes may function as biological pacemakers and mentions a potential limitation: The intrinsic pacemaker rate was slower than desirable. They suggest that incorporating HCN pacemaker channel genes might achieve more desirable rates, an idea consistent with our published results using HCN2 in gene- and adult human mesenchymal stem cell (hMSC)-based therapies.2–4 However, certain of the comments by Xue et al misinterpret our own work on HCN-loaded hMSCs. They state that “…these modified, undifferentiated, human mesenchymal stem cells are incapable of pacing quiescent cells because the former are neither electrically active nor genuine cardiac cells” (p 19). This statement suggests a misunderstanding of the rationale and underlying biophysics of the hMSC experiments. In fact, generation of pacemaker activity does not require delivery of an “excitable differentiated cardiac cell,” but only that the delivered cell (1) carry sufficient pacemaker current and (2) make gap junctions; thus, the hMSC-myocyte pair should behave as a pacemaker unit entirely equivalent to a single heart cell with substantial if. We clearly demonstrated both …

Should the pericardium be closed in patients undergoing cardiac surgery?

A best evidence topic in Cardiothoracic Surgery was written according to a structured protocol. The question addressed was in open heart surgery is there any adverse effect to closing the pericardium? Altogether 240 publications were found using the reported search of which 8 were deemed to be relevant to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the adverse haemodynamic impact of pericardial closure is confirmed in several studies, however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.

Alternative for Primary Pericardial Closure: Sentry for Re-entry

Background. Redo cardiac surgery is considered high-risk surgery as accidental injury to the aorta, the innominate vein, the ventricles and the atria is a possibility. Such accidental injury occurs when the cardiac chamber is adherent to the undersurface of the sternum. Closure of pericardium at the time of primary surgery can prevent adherence of cardiac chambers to the sternum, but may increase the risk of tamponade. This study aimed to show that covering heart with a pedicled pericardial fat pad not only serves the purpose of cover but also avoids the adverse haemodynamic effects of primary pericardial closure. Methods. Forty patients undergoing elective cardiac surgery were randomised into two groups depending on the way pericardium was managed. Both techniques were already in routine use in our unit and in other units around the country. One method is to leave the pericardium widely open, the other is to loosely oppose the pericardial fat pad over the surface of the aorta and right ventricle. Twenty-three patients had a pedicled pericardial fat pad covering the heart: Closure Group. Seventeen patients had no pericardial fat pad cover over the heart: Open Group. A haemostasis clip was used as a radio-opaque marker over the epicardium in both groups. Post-operation heart rate, central venous pressure, pulmonary artery diastolic pressure, mean arterial pressure and cardiac index were measured and recorded 1, 3 and 8 h after surgery. The distance between the haemoclip and the posterior table of the sternum was measured at 6 days and 6 months post-operation. Haemodynamic parameters and the retrosternal space depth were compared between the two groups. Results. There were no important differences in haemodynamic parameters between the two groups. Post-operative lateral chest Roentgenograms showed that the distance between epicardial surface and the posterior table of sternum was larger in the Closure Group compared to Open Group on post-operative day 6, 17.5±1.0 mm versus 13.4±1.3 mm ( P=0.0013) and 6 months later, 12.3±0.8 mm versus 6.0±1.2 mm ( P<0.001). There was no mortality in either group. Conclusion. Pedicled pericardial fat pad cover is a good alternative to primary pericardial closure as there are no adverse haemodynamic effects in early post-operative period and the long-term benefit of protection of heart at the time of re-sternotomy can be expected.