Ann Thorac Surg 2000;69:613-614
© 2000 The Society of Thoracic Surgeons
Case Reports
Pericardiectomy using an oscillating saw
Aaron Casha, FRCSa,
Venkat Chandrasekaran, FRCS(C/Th)a
a Department of Cardiothoracic Surgery, Leeds General Infirmary, Leeds, United Kingdom
Address reprint requests to Dr Casha, Department of Cardiothoracic Surgery, Castlehill Hospital, Castle Rd, Cottingham, Hull HU16 5JX, UK
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Abstract
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We describe the use of a microoscillating saw on the heart to remove calcific pericardium. This microoscillating saw proved indispensable to achieve a safe pericardiectomy in a 55-year-old woman with thick, severe idiopathic calcific constrictive pericarditis.
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Introduction
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Pericardiectomy for severe calcific constrictive pericarditis can be a difficult operation and can be complicated by profuse bleeding [1, 2] as a result of injury to the myocardium and coronary vessels. We encountered a patient with a thick, severely calcified pericardium involving most of the parietal pericardium, which was not removable with scissors or scalpel but was successfully decorticated with the use of a microoscillating saw.
A 55-year-old woman presented to us with a 12-year history of ankle swelling and breathlessness. Two years previously, she developed ascites that responded to diuretics. She had developed atrial fibrillation a year previously presenting with a cerebral infarct and significant right hemiparesis. She made a good functional recovery from this, albeit with considerable neurologic deficit.
On admission, she had significant shortness of breath on minimal exertion, raised jugular venous pulse, and hepatomegaly. Initial investigation showed an iron deficiency anemia with a hemoglobin of 8.8 g/dL and hypoalbuminemia. Gastroesophogoscopy was normal apart from congested duodenal mucosa. Echocardiography showed mild mitral regurgitation and mild right-sided dilatation of the heart. Magnetic resonance imaging of the heart showed 1-cm thick calcified pericardium involving all surfaces of the heart (Fig 1). Cardiac catheterization showed a left ventricular end-diastolic pressure of 20 mm Hg with equalization of pressure in both ventricles, with characteristic dip and plateau waveforms. Chest roentgenogram showed massive pericardial calcification.
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Fig 1. Preoperative magnetic resonance imaging scan of the chest showing extensive pericardial calcification.
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The heart was approached through a median sternotomy with cardiopulmonary bypass on standby. The pericardium was densely adherent and was approximately 1 cm thick, up to 1.5 cm in some areas, completely calcified without any soft areas in between. The calcification enveloped on most of the surface of the heart, except over the ascending aorta and pulmonary artery, such that there was no visible cardiac pulsation, and was so dense that tapping the pericardium was sonorous. The calcified pericardium was not amenable to resection with conventional instruments and a microoscillating saw (Micro E Sagittal saw; Zimmer Ltd, Swindon, UK) was used to cut through the pericardium, going down in depth to the surface of the heart. Multiple radiating cuts were placed from the center of the anterior surface of the pericardium to produce triangular segments. The edges of these segments thus produced allowed the use of bone nibblers and cutters to remove the calcific pericardium. The calcific shell of pericardium was removed in radiating triangles to produce a phrenic nerve to phrenic nerve subtotal anterior pericardiectomy [3] with virtually no blood loss or myocardial injury. Cardiopulmonary bypass was kept on standby but was not used. There was an intraoperative hemodynamic improvement with a decrease in the central venous pressure from 20 to 12 mm Hg and a decrease in the right ventricular end-diastolic pressure from 14 to 9 mm Hg. The chest was closed in a routine fashion (Fig 2) and the patient remains well with complete relief of symptoms 9 months after her operation and has returned to work. Echocardiography at 9 months showed improved right and left ventricular contraction with mild mitral regurgitation.
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Comment
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We describe a case of constrictive pericarditis with completely calcified and very thick pericardium, encasing the heart like a skull, where the use of the microoscillating saw was the only method that was available to deal with an otherwise extremely difficult and awkward situation. The microoscillating saw works by its rapid vibration fragmenting brittle nonelastic material like the calcification present in calcific pericarditis. Elastic tissues, for example, vessels and cardiac muscle, however, absorb the energy from the device and do not tear. The principle is very similar to that used in redo sternotomy saws, but blades are smaller and finer. As with orthopedic plaster saws, application of the microoscillating saw to one’s hand does not break the skin, although it may cause a burn after some time.
The technique of pericardiectomy with a microoscillating saw has not been previously described in the literature. We have shown that the use of microoscillating saws on the heart is safe in the setting of calcific constrictive pericarditis. Constrictive pericarditis with calcified pericardium remains a surgical challenge [4] as a result of injury to the myocardium and coronary vessels where no plane of cleavage between the pericardium and myocardium exists. The use of microoscillating saws as described here may make operations for grossly calcified pericarditis safer and indeed possible.
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References
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De Chaumaray T.D., Menasché P. Ultrasonic dissection. Ann Thorac Surg 1995;59:1243-1244.[Abstract/Free Full Text]
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Adebo O.A., Adebonojo S.A., Osinowo O., et al. Chronic constrictive pericarditis. Haemodynamic changes following pericardiectomy. J Natl Med Assoc 1980;72:461-466.[Medline]
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Nataf P., Cacoub P., Dorent R., et al. Results of subtotal pericardiectomy for constrictive pericarditis. Eur J Cardiothorac Surg 1993;7:252-255.[Abstract]
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Ninan M., Treasure T. Pericardiectomy using an ultrasonic dissector. Ann Thorac Surg 1994;58:233-235.[Abstract]
Accepted for publication June 17, 1999.
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Abstract
Introduction
