Posterior Pericardium Research Articles

Impact of posterior pericardial drain and risk factors on late pericardial effusion after coronary artery bypass surgery

The blood retained in posterior pericardium can trigger an inflammatory response that increases postoperative atrial fibrillations (POAFs), and it can complicate postoperative course. We retrospectively investigated the impact of a posterior pericardial drain (PPD) in reducing late postoperative pericardial effusion (pPE) and POAFs during the first 30 postoperative days. Two hundred and fifty coronary artery bypass grafting patients were divided into two groups according to the presence of a PPD in addition to the anterior one. Perioperative data and the incidence of POAF were compared. Risk factor analysis was used to determine the predictors of pPE and postpericardiotomy syndrome. Late pPE was present in 16% of all patients. It proved to be much more frequent in patients with a posterior drain (odds ratio 2.58; 95% confidence interval 1.23-5.79; P = 0.015) where it seemed to be almost mild and anterior. 'Anterior Drain' patients showed an increased rate of moderate ( P < 0.001) and posterior effusions ( P < 0.001). POAF was much more frequent in patients without a PPD (25.2 vs. 6.3%; P < 0.001). Univariate risk factor analysis revealed a significant association between late pPE and lower preoperative weight ( P = 0.003), lower preoperative and postoperative serum albumin ( P < 0.001) and a greater amount of blood transfusion ( P = 0.02). Even if a PPD is associated with a higher rate of pPE, the patients with only anterior drains were shown to have a greater amount of pericardial effusion and an increased risk of POAFs. Therefore, a PPD should be considered to improve postoperative course.

P305 ACUTE MYOPERICARDITIS IN 2021: COVID19 RELATED?

The term myopericarditis is used when there are primarily pericarditis symptoms with myocardium involvement as evidenced by cardiac biomarker elevation or imaging studies revealing normal wall motion. We report a case of a young 23–years old man, who presented to the Emergency Department with fever and diarrhea lasting 5 days followed by acute chest pain, modified by trunk position. The electrocardiogram (ECG) showed diffuse inferior and anterolateral ST–segment elevation. No signs of hemodynamic instability were detected. Laboratory tests showed WBC 8840/mmc, CRP 53,2 mg/L, TnT 986 ng/L, a mildly altered liver function with AST 92 UI/L, ALT 88 UI/L, GGT 82 UI/L and an altered pancreatic function with amylase 190 UI/L, lipase 267 UI/L. Naso–pharyngeal swab was negative. The patient received COVID–19 mRNA vaccination 4 months before symptoms, with high immune response, detected with IgG dosage (465 BAU/ml). Ecocardiography showed a left ventricle with normal size, function, and segmental contractility. Valvular apparatus in normal range. Hyper–refraction of the posterior pericardium with minimal effusion. The diagnosis of acute myopericarditis was glaring and we treated the patient with high dosage of non–steroidal anti–inflammatory drugs, colchicine and ACE Inhibitors, based on the increased troponin levels (nadir 1439 nl/L), in order to prevent the possible cardiovascular remodeling. On laboratory testing, the deepening of the main causes of viral or autoimmune myopericarditis did not clarify the etiopathogenesis. No arrhythmias occurred on ECG monitoring. Cardiac MRI showed multiple areas of altered signal (T2) and altered uptake in lateral and inferior ventricular segments and in adjacent pericardium. The pain was gone in two days and left ventricle function was still preserved upon discharge. In conclusion we report a successful treatment of acute myopericarditis of unknown pathogenesis, in a healthy young man. As there are described cases of myopericarditis and myositis associated with COVID–19 in the absence of respiratory symptoms, and others related to SARSCoV2 mRNA vaccination, we dutifully excluded both.

A safe area for sternal puncture in children: an MSCT study based on sternal development.

PurposeMultislice spiral CT (MSCT) was used to investigate the anatomical characteristics of sternal development, and to provide anatomical basis for sternal puncture in children.MethodsWe retrospectively analyzed the thoracic MSCT data of 600 children who received thoracic MSCT from January to June 2020 with their age ranging from 1 month to 19 years. The distribution of sternal ossification centers and adjacent tissues and organs was observed. Subcutaneous soft tissue thickness and the distance between the skin and the posterior margin of the sternum were measured in the central areas of sternal manubrium and mesosternum (segments I and II), and the correlation between the two was calculated using linear correlation.ResultsA total of 600 patients were enrolled, the mean age was 9.87 years and the standard deviation was 8.28 years. The sternal manubrium and ossification centers at the I and II segments of the mesosternum were visible in all cases (100%). There was no ossification in segment III of the mesosternum in 15 cases (2.5%), including 12 cases (80%) adjacent to the posterior pericardium and 7 cases (46.7%) of lung tissue. There were 274 cases (45.7%) of segment IV without ossification, including 204 cases (74.5%) of adjacent pericardium and 95 cases (32.8%) of lung tissue. The xiphoid process was not ossified in 258 cases (43%), including 190 cases (73.6%) adjacent to the pericardium and 97 cases (37.6%) adjacent to the lung tissue. Correspondingly, the thickness of subcutaneous soft tissue of the sternal manubrium and the central region of the I and II segments of the mesosternum had a low positive correlation with age (P < 0.001), the distance between the skin and the posterior margin of the sternum showed a moderate positive correlation with age (P < 0.001), and the distance between the skin and the posterior margin of the sternum showed a high positive correlation with the thickness of subcutaneous soft tissue (P < 0.001).ConclusionsNonossification of the sternal ossification center usually occurs below segment III of the mesosternum and is usually adjacent to heart and lung tissue. Pediatric sternal puncture should be performed at the sternal manubrium and the mesosternum of segments I and II. However, attention should be paid to the space between multiple ossification centers. The thickness of subcutaneous soft tissue is a critical factor that determines the depth of the puncture.

One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft-induced new entry (SINE) tear

Video 1 One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft induced new entry (SINE) tear.

One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft induced new entry (SINE) tear

One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft induced new entry (SINE) tear

Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction

Objective: Surgical operation is the main treatment for advanced adenocarcinoma of esophagogastric junction (AEG). Due to its special anatomic location and unique lymph node reflux mode, the surgical treatment of Siewert II AEG is controversial. Lower mediastinal lymph node dissection is one of the most controversial points and a standard technique has not yet been established. This study is aim to explore the safety and feasibility of five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type II AEG. Methods: A descriptive case series study was conducted. The intraoperative and postoperative data of 25 patients with Siewert type II AEG who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection in Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2019 to April 2021 were retrospectively analyzed. Five-step maneuver was as follows: In the first step, the subcardiac sac was exposed; the right pulmonary ligament lymph nodes and the anterior thoracic paraaortic lymph nodes were dissected cranial to inferior pericardium, left to left edge of thoracic aorta. In the second step, the left diaphragm was opened, and a 12 mm trocar was placed through the 6-7 rib in the left anterior axillary line. The supra-diaphragmatic nodes were dissected through the thoracic operation hole. In the third step, the left inferior pulmonary ligament was severed. The anterior fascia of thoracic aorta was incised to join the anterior space of thoracic aorta formed in the first step and then the lymphatic tissue was dissected upward until the exposure of left inferior pulmonary vein. In the fourth step, the posterior pericardium was denuded retrogradely from ventral side to oral side to the level of left inferior pulmonary vein, right to right pleura, and then the right pulmonary ligament lymph nodes were completely removed. In the fifth step, the esophagus was denuded, and the esophagus was transected 5 cm above the tumor using a linear stapler to complete the dissection of lower thoracic paraesophageal lymph nodes. Results: Operations were successfully completed in 25 patients without conversion, intra-operative complication and perioperative death. Total gastrectomy was performed in 19 cases and proximal gastrectomy in 6 cases. The mean operative time was (268.7±85.6) minutes, the mean estimated blood loss was (90.4±44.2) ml, the mean time of lower mediastinal lymph node dissection was (38.6±10.3) minutes, and the mean harvested number of lower mediastinal lymph node was 5.9±2.9. The length of esophageal invasion was >2 cm in 7 cases and ≤ 2 cm in 18 cases. Eight patients (33.0%) had lower mediastinal lymph node metastasis, including 3 cases with esophageal invasion >2 cm and 5 cases with esophageal invasion ≤ 2 cm. The mean time to postoperative first flatus was (5.5±3.1) days. The average time of postoperative thoracic drainage was (5.9±2.9) days. The mean hospital stay was (9.7±3.1) days. Two patients (8.0%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pancreatic fistula and 1 case of pleural effusion, both of whom were cured by puncture drainage. Conclusions: Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph nodes dissection for Siewert type II AEG is safe and feasible. Which can ensure sufficient lower mediastinal lymph node dissection to the level of left inferior pulmonary vein.

Left Mini Thoracotomy as a Method for Epicardial Implantable Cardioverter-Defibrillator Placement in a Child. An Effective Alternative to the Transvenous Approach

In infants and children, the small size of the systemic veins precludes safe and durable transvenous placement of automatic internal cardiac defibrillator (ICD). In such cases, an alternative method of implanting an automatic ICD is via thoracotomy. This report describes the technique used at Onassis Cardiac Surgery Center for the epicardial placement of an ICD system with a transvenous ICD coil placed in the posterior pericardium via a left thoracotomy, producing a stable location and excellent coil-to-can vector for successful defibrillation. To the best of our knowledge, this is the first case in Greece.

Systematic review and meta-analysis of randomized controlled trials assessing safety and efficacy of posterior pericardial drainage in patients undergoing heart surgery

ObjectivesTo investigate the potential beneficial effects of posterior pericardial drainage in patients undergoing heart surgery. MethodsMultiple online databases and relevant congress proceedings were screened for randomized controlled trials assessing the efficacy and safety of posterior pericardial drainage, defined as posterior pericardiotomy incision, chest tube to posterior pericardium, or both. Primary endpoint was in-hospital/30 days' cardiac tamponade. Secondary endpoints comprised death or cardiac arrest, early and late pericardial effusion, postoperative atrial fibrillation (POAF), acute kidney injury, pulmonary complications, and length of hospital stay. ResultsNineteen randomized controlled trials that enrolled 3425 patients were included. Posterior pericardial drainage was associated with a significant 90% reduction of the odds of cardiac tamponade compared with the control group: odds ratio (95% confidence interval) 0.13 (0.07-0.25); P < .001. The corresponding event rates were 0.42% versus 4.95%. The odds of early and late pericardial effusion were reduced significantly in the intervention arm: 0.20 (0.11-0.36); P < .001 and 0.05 (0.02-0.10); P < .001, respectively. Posterior pericardial drainage significantly reduced the odds of POAF by 58% (P < .001) and was associated with significantly shortened (by nearly 1 day) overall length of hospital stay (P < .001). Reductions in postoperative complications translated into significantly reduced odds of death or cardiac arrest (P = .03) and numerically lower odds of acute kidney injury (P = .08). ConclusionsPosterior pericardial drainage is safe and simple technique that significantly reduces not only the prevalence of early pericardial effusion and POAF but also late pericardial effusion and cardiac tamponade. These benefits, in turn, translate into improved survival after heart surgery.

The preventive role of the posterior pericardial window in the development of late cardiac tamponade following heart valve surgery.

It is reported that creating a window from the posterior pericardium into the left pleural cavity during coronary bypass surgeries reduces postoperative late cardiac tamponades. Although late tamponades are more common after heart valve surgeries, this procedure is not generally performed. The present study investigated whether creating a window has a preventive effect on the formation of late cardiac tamponade after heart valve surgeries. The study was conducted on all patients (n = 262) in whom one or more valves were replaced and who fulfilled the study criteria between January 2010 and October 2014 in one centre. We began to create a posterior pericardial window in all valvular patients from March 2012. One hundred and thirty-five patients operated on before this date (Non-Window Group) and 127 patients after this date (Window Group) were compared for the development of late cardiac tamponade. There were no differences between the groups in terms of preoperative and intraoperative characteristics. Late pericardial tamponade was not observed in any patients from the Window Group, whereas it occurred in 7 (5.2%) patients from the Non-Window Group (P = 0.015). Three patients died in total; all 3 were from the Non-Window Group. One of the mortalities was associated with tamponade. Creating a pericardial window may reduce late cardiac tamponade events/episodes, which may be a fatal complication in valve patients. We recommend performing this procedure by allocating some time during the surgical procedure in order to avoid tamponade.

Thymectomy and transpericardial nodal dissection

Neuroendocrine thymic tumors (NETTs) are rare neoplasms. Surgical resection of the tumor and the involved lymph node remains the treatment of choice. We describe the surgical technique adopted in a patient with preoperative diagnosis of thymic malignant tumor and subcarinal nodal involvement. Through a median sternotomy, an extended thymectomy was performed as a first step. Then, through the transpericardial approach (opening of the anterior and posterior pericardium and isolation of ascending aorta, superior vena cava, and main right pulmonary artery), mediastinal nodal dissection (#2R, #4R, #4L, #5 and #7) was performed. Definitive pathology showed a NETT without nodal involvement. The patient received adjuvant chemotherapy, and is alive without disease 19 months after the surgery. Complete surgical excision and adjuvant therapy appears to offer the best hope for prolonged survival for NETTs. The surgical technique should be individualized according to tumor location. Thoracic surgeons should be familiar with this technique, which provides a good technical and oncological result.

A New Surgical Approach to Scimitar Syndrome

A wide variety of surgical strategies has been described to treat scimitar syndrome. However, the incidence of pathway obstruction remains high. An alternative approach is described, in which the pulmonary venous return is widely connected to the left atrium through a tunnel constructed with the in-situ pericardium.

EComment. Ascending-descending aortic bypass in patients with complex aortic coarctation

We read Ugur et al.'s study with interest [1]. Aortic coarctation surgery may be considered a well established procedure in paediatric congenital heart surgery. However, it becomes a complex and challenging procedure in adulthood, especially in the presence of accompanying anomalies. Until the last decade, ascending-descending aortic bypass with a posterior pericardial approach via a sternotomy has been the gold standard for complex coarctation with excellent outcomes [2]. In the era of endovascular interventions, balloon dilatation and stenting have gradually become a reliable option for the management of isolated aortic coarctation [3]. Recently, a hybrid approach has become an alternative technique for treatment of complex cases with encouraging early results [4]. In our institution, we performed ascending-descending aortic bypass as a concomitant procedure in 11 adult patients (9 patients with aortic coarctation and 2 patients with type C interruption of aorta), who had accompanying cardiac diseases. All procedures were done with a median sternotomy and cardiopulmonary bypass in single stage. We performed simultaneous aortic valve replacement, coronary artery bypass grafting, ascending aorta replacement and the Bentall procedure in 4, 3, 2, and 2 patients, respectively. Ascending-descending aortic bypass was done with an anterior aortic approach. The Dacron graft was anastomosed to the lateral ascending aorta and extended toward the left ventricle lateral border. The posterior pericardium was opened and the descending aorta encircled. Descending aorta anastomosis was done with a side clamp. All patients survived surgery without any major adverse cardiac and neurologic events. One patient was reoperated because of infective endocarditis in the second postoperative month. No major adverse cardiac or cerebrovascular events were found in medical follow-up records. The hybrid approach may provide safe and simple repair of coarctation and shortens operative time in patients with accompanying cardiac diseases. Aortic rupture, aneurysmal dilatation, dissection, pseudoaneurysm, restenosis and stent fracture are infrequent but life-threatening complications. Although balloon dilatation and stenting is a well-established treatment in the paediatric population, long-term outcomes and prospective randomized studies comparing surgery and endovascular approaches are necessary in the adult population. Furthermore, extra-anatomic bypass with median sternotomy is a well known technique facilitating the single stage management of concomittant cardiac problems. Limited posterior pericardial incision usually provides adequate exposure for distal anastomosis and decreases the risk of bleeding from excessive collateral vessels. Briefly, we still consider ascending-descending aortic bypass with median sternotomy to be the preferred approach in patients with complex aortic coarctation. Conflict of interest: none declared

Use of the Posterior Pericardium to Cover the Bronchial Stump After Right Extrapleural Pneumonectomy

Limited tissue is available to cover the bronchial stump after right extrapleural pneumonectomy for malignant pleural mesothelioma. After completing the resection, the pericardial reflection can be freed from the superior vena cava, the right pulmonary artery and veins, and the posterior wall of the pericardial sac between the transverse and oblique pericardial sinuses. The length and mobility from the posterior pericardium can then provide excellent coverage for the right bronchial stump. This technique has the advantage of being easy to perform and requiring limited time and dissection.

Primary Pericardial Mesothelioma: A Rare Entity

Primary pericardial malignant mesothelioma is an extremely rare neoplasm that arises from the pericardial mesothelial cell layers. Clinical symptoms and signs are frequently nonspecific, and the diagnosis is usually made after surgery or at autopsy. There is no standard treatment for pericardial mesothelioma; nonetheless, radical surgery is the mainstay of therapy for localized disease. The neoplasm is highly aggressive and carries a dismal prognosis with an overall survival of less than six months. This paper presents a case study of a 68-year-old patient with a primary pericardial malignant mesothelioma. Radiologic evaluation revealed a small nodule in the posterior pericardium with pericardial and bilateral pleural effusions. The diagnosis was established after surgery by histological and immunohistochemical studies. The patient remained alive and free of disease for about 24 months; however, due to rapid local recurrence, the patient died 27 months after the surgical treatment.

“Closed-Vein” Technique for Primary Sutureless Repair of Anomalous Pulmonary Venous Connection

Deep hypothermic circulatory arrest or low-flow bypass are commonly used in primary repair of total anomalous pulmonary venous connection, or individual veins may be dissected to allow clamp or snare application, in order to provide a bloodless field for anastomosis by the direct or sutureless marsupialization technique. In the described technical modification, the marsupialization of the opened atrium to the posterior pericardium is completed before opening the pulmonary venous confluence, allowing bloodless exposure during full-flow normothermic bypass. In addition, vein branch dissection is avoided.

Primary correction of total anomalous pulmonary venous return with a modified sutureless technique

The objective was to evaluate primary sutureless repair of total anomalous pulmonary venous return (TAPVR) in neonates using a modified technique that minimizes hypothermia and circulatory arrest times. From 2009 to 2011, seven consecutive patients underwent primary sutureless repair for the treatment of TAPVR, by which the prepared posterior pericardium was sutured to an opening in the left atrium. Three patients had the obstructed infracardiac type, and four patients had the unobstructed supracardiac type of TAPVR. Moderate hypothermia was used in all patients with a median temperature of 28°C (26-32). Circulatory arrest was not used except for the opening of the collector, which lasted between 3 and 5 min. The connecting vein was ligated in all seven patients (five during repair and two early postoperatively). The follow-up was 100% complete, with a median duration of 652 (range 370-1023) days. There was no operative mortality and no late death. No patient required reoperation. Postoperative echocardiography showed unobstructed pulmonary venous flow in all patients. Recurrent pulmonary venous stenosis was not seen during the follow-up in any patient. The sutureless technique is an effective technique with potential advantages even for the primary correction of TAPVR. With the described technique, the need for circulatory arrest is substantially reduced. Not handling the pulmonary venous collector by avoiding a direct anastomosis may contribute to better compliance, better growth and the absence of subsequent stenosis.

Long-segment thoracoabdominal aortic occlusions in childhood

Developmental coarctation, hypoplasia, and occlusion of the abdominal aorta is a rare disease encompassing many differing etiologies and diverse methods of treatment. Long-segment thoracoabdominal aortic occlusion, an extreme manifestation of this disorder, has not previously been reported in children. Two pediatric patients with this entity, a 5- and 13-year-old with uncontrolled hypertension, underwent extensive arterial reconstructions for this entity and provided the impetus for this report. An ascending thoracic aorta to infrarenal aortic expanded polytetrafluoroethylene bypass was undertaken in the younger child. A distal thoracic aorto-bi-iliac artery expanded polytetrafluoroethylene bypass, with implantation of the left renal artery to one graft limb and a right renal artery bypass originating from the other limb, was performed in the older child. There were no major perioperative complications. Both patients were discharged with easily controlled blood pressures. They have remained normotensive at 13 and 14 months follow-up.

A mouse model of radiation-induced cardiomyopathy

A mouse model of radiation-induced cardiomyopathy

Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction

Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction

Anesthetic considerations during heart-lung transplantation in a patient with an unresectable pulmonary artery sarcoma

Anesthetic considerations during heart-lung transplantation in a patient with an unresectable pulmonary artery sarcoma