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Ann Thorac Surg 1995;59:770
© 1995 The Society of Thoracic Surgeons
Economopoulos and colleagues provide the surgeon with one more valuable technique for the control of cardiac bleeding when the more conventional suturing techniques prove unfeasible because of tissue friability, edema, or calcification, or because of a tissue gap too large to bring together with sutures. The technique consists of applying to the source of bleeding either the right or left pericardial fat pad after it has been dissected away from the pericardium and phrenic nerve. This fat pad is harvested as a pedicle based on its cephalad blood supply, and led through a pericardial incision appropriately placed to allow the pedicle to reach the bleeding area.
As is the case with most surgical advances, this technique synthesizes from other operations. It recalls Claude Beck's transfer of omentum into the pericardium (but for a very different reason) and the use of packs to apply local control to bleeding. The advantage of the pericardial fat pad used as a pack is the avoidance of a subsequent operation or of any foreign body.
Economopoulos and colleagues noted no adverse consequences of the procedure and were successful in controlling bleeding in all 9 cases. Although no bleeding site distribution is mentioned in the article, in at least 1 case bleeding originated from an aortic suture line. One could surmise that the technique will be more successful in controlling bleeding from low-pressure chambers, and could even lead to false aneurysm formation when used to control aortic bleeding-as indeed occasionally occurs when aortic wrapping is used to control bleeding in a Bentall operation.
Local tamponade from the fat pad and its contained bleeding might be anticipated as a possible complication, but in fact neither tamponade nor coronary graft compression was observed. Another possible drawback of the procedure, and one apparently not seen by Economopoulos and colleagues is devascularization of the phrenic nerve from which the pedicle is dissected, with diaphragmatic palsy occurring as a consequence.
The success of this procedure suggests that the fat pad also could be used as is omentum: to control local infection or to exclude vulnerable territories of the heart (such as aortic suture lines) from contact with mediastinal sepsis. Whether the pericardial fat pad possesses the infection-fighting characteristics ascribed to the omentum has yet to be determined.
As Economopoulos and colleagues mention, in this and other indirect methods of controlling cardiac bleeding, the surgeon must be cautioned not to yield to the temptation to substitute these methods for direct repair of the bleeding source whenever the latter is possible. But in the end, direct repair is not always possible, and the use of the pericardial fat pad just might save the day when focal bleeding appears uncontrollable.
Related Article
Ann. Thorac. Surg. 1995 59: 768-770.
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