Ann Thorac Surg 1996;62:1196-1197
© 1996 The Society of Thoracic Surgeons
Case Report
Transdiaphragmatic Drainage of Pericardial Effusion With Severe Pericardial Adhesions
Akihiko Ohkado, MD,
Motoki Sato, MD,
Yasuko Tomizawa, MD, PhD,
Hiroshi Nishida, MD,
Masahiro Endo, MD,
Hitoshi Koyanagi, MD
Department of Cardiovascular Surgery, Heart Institute of Japan, Tokyo Women's Medical College, Tokyo, Japan
Accepted for publication April 18, 1996.
 |
Abstract
|
|---|
We describe a method to perform successful drainage of pericardial effusion by incising the diaphragm via the peritoneal cavity assisted by transesophageal echocardiography. This transdiaphragmatic approach is a remarkably simple and useful method for pericardial drainage when the conventional transsubxiphoid approach is difficult and dangerous because of intractable adhesions between the heart and the pericardium.
|
Introduction
|
|---|
Pericardial drainage is the most effective treatment for pericardial effusion that cannot be controlled conservatively. The conventional approach for this method is usually performed through the subxiphoid space [1, 2]. However, it is sometimes extremely difficult to apply this approach when there are severe fibrotic adhesions between the heart and the pericardium, especially in cases long after a previous cardiac operation. We achieved a satisfying result of pericardial drainage by reaching the pericardial cavity from the peritoneal side of the diaphragm in a case of postoperative local tamponade.
A 72-year-old man who underwent quadruple coronary artery bypass grafting in July 1994 had been followed up after the operation at our outpatient clinic. Edema in the face, scrotum, and legs appeared in August 1995 and progressed afterward. Chest roentgenography and echocardiography showed pleural and pericardial effusions. The cause of the effusion was possibly related to intrapericardial hemorrhage because he was receiving anticoagulation. He underwent surgical drainage of the pericardial effusion because medical treatment by diuretics and water restriction was not successful (Fig 1
).
A short, subxiphoidal median skin incision was made to proceed superior to the diaphragm by pericardiotomy. However, after dissection had proceeded as deeply as 5 cm, fibrous adhesions were found to involve the heart severely and widely, possibly as far as the grafted area. Therefore we decided to choose a more secure method that would not jeopardize the bypass grafts. The incision was extended caudally, and the peritoneal cavity was opened. The pericardial effusion was localized in the posterior region of the heart by palpation of the diaphragm and transesophageal echocardiography. The pericardial cavity was approached through a 1-cm incision on the diaphragm. Complete discharge of the pericardial effusion was confirmed by transesophageal echocardiography after approximately 300 mL of pericardial effusion was obtained.
|
Comment
|
|---|
Pericardial effusion is one of the most frequent complications of cardiac operations. When its quantity is relatively low, it may be controlled by conservative methods such as administration of diuretics, whereas a high quantity often requires quick surgical drainage because it easily causes cardiac tamponade. Usually, the pericardial cavity is reached through the subxiphoid space [1, 2]. However, this approach is extremely difficult in postoperative cases that have severe fibrotic adhesions between the heart and the pericardium, and can be especially harmful in patients who have undergone coronary artery bypass grafting because forceful dissection of the adhesions may jeopardize patent bypass grafts. The transdiaphragmatic approach makes it possible to reach the pericardial cavity in patients who have such severe adhesions that it is risky to use the conventional subxiphoid approach. Transesophageal echocardiography is a remarkably simple and helpful method to reliably localize the pericardial effusion and confirm its complete drainage by this approach [3]. There have been several other approaches reported for pericardial drainage, including a thoracoscopic approach through an intercostal space and a laparoscopic approach without an abdominal incision [4, 5]. However, we think transdiaphragmatic approach with laparotomy guided by transesophageal echocardiography is the safest and the most secure choice in patients who have localized pericardial effusion in the posterior region of the heart, especially patients who have undergone coronary artery bypass grafting, to protect the bypass grafts and achieve complete drainage.
|
Footnotes
|
|---|
Address reprint requests to Dr Ohkado, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical College, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162, Japan.
|
References
|
|---|
- Moores DW, Dziuban SW Jr. Pericardial drainage procedures [Review]. Chest Surg Clin North Am 1995;5:359–73.[Medline]
- Temeck BK, Pass HI. A method to facilitate subxiphoid pericardiotomy. Ann Thorac Surg 1994;57:1015–7.[Abstract/Free Full Text]
- Golub RJ, McNulty CM, McClellan JR, St. Laurent L. Prior MW. Usefulness of transesophageal Doppler echocardiography in the surgical drainage of a loculated purulent pericardial effusion. Am Heart J 1993;126:724–7.[Medline]
- Hurley JP, Subarreddy K, McCarthy J, Wood AE. Video-assisted thoracic surgery for delayed pericardial effusion post-CABG [Review]. Chest 1994;106:1617–9.[Abstract/Free Full Text]
- Mayer HJ. Transdiaphragmatic pericardial window: a new approach. J Cardiovasc Surg 1993;34:173–5.[Medline]
Top
Abstract
Introduction
