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Alternative for primary pericardial closure: sentry for re-entry
Nitin Ghorpade1, David Hill, Morteza Mohajeri
1Department of Cardiothoracic Surgery, The Geelong Hospital, P.O. Box 281, Geelong, Vic. 3220, Australia.
Insights
Covering the heart with a pedicled pericardial fat pad during cardiac surgery provides a protective barrier, preventing sternal adhesions without adverse hemodynamic effects. This technique offers a safe alternative to primary pericardial closure for future re-sternotomy.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Techniques
Background:
- Redo cardiac surgery carries high risks due to potential accidental injury to major vessels and cardiac chambers.
- Cardiac chamber adherence to the sternum increases injury risk during re-sternotomy.
- Primary pericardial closure can prevent adherence but may lead to cardiac tamponade.
Purpose of the Study:
- To evaluate the efficacy of using a pedicled pericardial fat pad to cover the heart in cardiac surgery.
- To determine if this technique prevents sternal adhesions and avoids adverse hemodynamic effects.
- To compare outcomes with primary pericardial closure or leaving the pericardium open.
Main Methods:
- Forty patients undergoing elective cardiac surgery were randomized into two groups: pedicled pericardial fat pad cover (Closure Group, n=23) and no cover (Open Group, n=17).
- Hemodynamic parameters (heart rate, CVP, PAP, MAP, CI) were monitored post-operatively.
- Retrosternal space depth was measured using a radiopaque marker at 6 days and 6 months post-surgery.
Main Results:
- No significant differences in early post-operative hemodynamic parameters were observed between the groups.
- The Closure Group showed a significantly larger retrosternal space at 6 days (17.5 vs 13.4 mm) and 6 months (12.3 vs 6.0 mm) post-surgery (P<0.001).
- No mortality occurred in either group.
Conclusions:
- Pedicled pericardial fat pad cover is a safe and effective alternative to primary pericardial closure.
- This technique avoids early adverse hemodynamic effects and provides long-term protection against sternal adhesions.
- It is a beneficial strategy for patients undergoing cardiac surgery, particularly those anticipating re-sternotomy.
Background:
Redo cardiac surgery is considered high-risk surgery as accidental injury to the aorta, the innominate vein, the ventricles and the atria is a possibility. Such accidental injury occurs when the cardiac chamber is adherent to the undersurface of the sternum. Closure of pericardium at the time of primary surgery can prevent adherence of cardiac chambers to the sternum, but may increase the risk of tamponade. This study aimed to show that covering heart with a pedicled pericardial fat pad not only serves the purpose of cover but also avoids the adverse haemodynamic effects of primary pericardial closure.
Methods:
Forty patients undergoing elective cardiac surgery were randomised into two groups depending on the way pericardium was managed. Both techniques were already in routine use in our unit and in other units around the country. One method is to leave the pericardium widely open, the other is to loosely oppose the pericardial fat pad over the surface of the aorta and right ventricle. Twenty-three patients had a pedicled pericardial fat pad covering the heart: Closure Group. Seventeen patients had no pericardial fat pad cover over the heart: Open Group. A haemostasis clip was used as a radio-opaque marker over the epicardium in both groups. Post-operation heart rate, central venous pressure, pulmonary artery diastolic pressure, mean arterial pressure and cardiac index were measured and recorded 1, 3 and 8h after surgery. The distance between the haemoclip and the posterior table of the sternum was measured at 6 days and 6 months post-operation. Haemodynamic parameters and the retrosternal space depth were compared between the two groups.
Results:
There were no important differences in haemodynamic parameters between the two groups. Post-operative lateral chest Roentgenograms showed that the distance between epicardial surface and the posterior table of sternum was larger in the Closure Group compared to Open Group on post-operative day 6, 17.5+/-1.0mm versus 13.4+/-1.3mm (P=0.0013) and 6 months later, 12.3+/-0.8mm versus 6.0+/-1.2mm (P<0.001). There was no mortality in either group.
Conclusion:
Pedicled pericardial fat pad cover is a good alternative to primary pericardial closure as there are no adverse haemodynamic effects in early post-operative period and the long-term benefit of protection of heart at the time of re-sternotomy can be expected.
