[HSF] Difficult pericardiectomy

[prasannasimha]

Yesterday I did a pericardiectomy (Cause not identified preop and tissue 
sent for HPE). It was a sheer nightmare. Thick pericardium , no good 
plane and I managed to do an interphrenic dissection with great 
difficulty. The myocardium had a blotchy petechial appearance even prior 
to cutting it (ie when you lift the pericardial edge and start to cut at 
the plain of "cleavage") and there was calcification extending into the 
myocardium at places and even the atrial wall was calcified !! (I could 
not just delamellate it of from certain areas and it was obvious later 
that it was just one block of rock in those areas. The patients CVP has 
come down from a preop of 24 to 12-13 now and he is stable but gave me 
some more grey hairs.
I would like to know what tips and tricks that the members use for a 
difficult pericardiectomy. I do agree that patience and cruciating 
segments are the common methods used. I also tend to dissect following 
the innominate when things are really difficult (In fact that helped a 
lot in this case) Any tips / tricks ?
Prasanna