Ann Thorac Surg 1995;59:1243-1244
© 1995 The Society of Thoracic Surgeons
How To Do It
Ultrasonic Dissection: A Useful Adjunct to Operation for Calcified Constrictive Pericarditis
Thierry du Roy de Chaumaray, MD,
Philippe Menasché, MD, PhD
Department of Cardiovascular Surgery, Hôpital Lariboisière, Paris, France
Accepted for publication January 4, 1995.
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Abstract
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We describe the use of an ultrasonic surgical dissector to remove calcified pericardium. This device proved to be useful for achieving safe and complete pericardial decortication in 2 patients.
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Introduction
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The operative approach used for the treatment of constrictive pericarditis with calcified pericardium still remains a surgical challenge. In some cases the presence of heavily calcified plaques infiltrating the myocardium prevents the required pericardial resection from one phrenic nerve to the other from being performed [1] because attempts at removing these plaques using standard techniques may cause injury to the underlying myocardium and coronary vessels, which leads to life-threatening bleeding [2]. The elective use of cardiopulmonary bypass can make the dissection easier and safer, but does not consistently prevent the occurrence of postbypass hemorrhage.
To address this question, we used an ultrasonic surgical aspirating device (Ultrasonic Dissector Sonoca II; Medizintechnik, Söring, Quickborn, Germany) in 2 patients operated on for the treatment of severely calcified constrictive pericarditis. The cause of the pericardial disease in both patients was tuberculosis, although 1 of the patients also had a history of receiving chest radiotherapy for breast cancer.
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The Device
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The Sonoca II belongs to the second generation of ultrasonic devices. It is an electrically powered ultrasonic surgical dissector using the technology of the direct transducer supported by the piezoelectric effect. This effect can be summarized as follows: when two faces of a crystal (with a low degree of symmetry) are subjected to different pressures, a variation of potential develops on their other faces. This effect is reversible: a crystal subjected to a variation of potential dilates or contracts depending on the direction of this variation of potential. This effect constitutes the origin of ultrasound.
In the Sonoca II, the transducer is a crystal made of special ceramics discs constructed of zirconium and titanium. This transducer is fed with a 23.5-kHz current. The piezoelectric effect has the advantage of a better output, so that much less heat develops and more ultrasounds are produced. The equipment does not need cooling, and is lighter, more compact, and less expensive than previous devices.
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Operative Procedure
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The technique was uniform in the 2 patients. After the sternotomy was made, a ``softer'' area of the anterior pericardium was sought and easily found at the borders of a calcified plaque. The area was incised with a knife and the incision was deepened until the epicardium was identified. The ultrasonic dissector was then used to create a plane of cleavage between the thick, calcified pericardium and the underlying epicardium. The dissection proceeded step by step and allowed an en bloc removal of the plaque. Calcified nuclei infiltrating the myocardium were then pulverized. The same procedure was repeated for each calcified area. In this way the two venae cavae, the anterior and inferior aspects of the right ventricle, and the pulmonary artery trunk were completely freed from the calcified adhesions. The dissection was extended toward the left side of the heart for as long as the cardiac retraction was well tolerated hemodynamically. The anterior and most of the lateral parts of the left ventricle could be dissected free as a whole. Cardiopulmonary bypass was not used in either patient.
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Results
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The operation was expeditious and uneventful in the 2 patients. The intraoperative blood losses were 120 and 200 mL, respectively. Neither required a blood transfusion. The completeness of the pericardial decortication was reflected by a postoperative hemodynamic improvement, which was dramatic in 1 patient and less pronounced in the other because of a tricuspid regurgitation that was due to an associated right ventricular cardiomyopathy. In the former patient an ultrarapid computed tomographic scan obtained 6 months postoperatively showed normal patterns of right and left ventricular contraction, without any evidence of residual restricted motion. The latter patient was lost to follow-up.
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Comment
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The ultrasonic device used in our patients is commonly employed in other surgical specialities, and, in particular, has become a helpful operative tool for brain or liver tumor resections. Its efficacy is related to its selectiveness in tissue removal, in that calcified structures are disintegrated but soft tissues, including blood vessels, are spared because of their elastic fiber content.
In the setting of cardiac surgery, we and others have used ultrasonic dissection for the debridement of a massively calcified mitral annulus [3, 4] or removal of a cardiac tumor [5]. The results reported here suggest that ultrasonic dissection also makes operation for calcified constrictive pericarditis easier and safer.
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Footnotes
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Address reprint requests to Dr de Chaumaray, Department of Cardiovascular Surgery, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75475 Paris Cédex 10.
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References
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- Nataf P, Cacoub P, Dorent R, et al. Results of subtotal pericardiectomy for constrictive pericarditis. Eur J Cardiothorac Surg 1993;7:252–6.[Abstract]
- Adebo OA, Adebonojo SA, Osinowo O, Falase AO, Grillo IA. Chronic constrictive pericarditis. Hemodynamic changes following pericardiectomy. J Natl Med Assoc 1980;72:461–6.[Medline]
- Brown AH, Davies PGH. Ultrasonic decalcification of calcified cardiac valves and annuli. Br Med J 1972;3:274–7.[Abstract/Free Full Text]
- Schwinger ME, Colvin S, Harty S, Feiner H, Opitz L, Kronzon I. Clinical evaluation of high frequency (ultrasonic) mechanical debridement in the surgical treatment of calcific aortic stenosis. Am Heart J 1990;120:1320–5.[Medline]
- Reyes AT, Kantrowitz AB, Issenberg HJ, Factor SM, Frame R, Brodman RF. Use of neurosurgical techniques for removal of a cardiac tumor. Ann Thorac Surg 1994;57:741–3.[Abstract]
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Abstract
Introduction
