[HSF] Difficult pericardiectomy

[rwmfglycar at aol.com]

   I have to say that I did not use the pump for constrictive pericarditis. This does not mean that there will never be a case for it. However I had a great experience in my first 2 years out of training when I was allowed to do all of the frequent cases of Tuberculous constriction. 
The plane is everything. I still remember my first case when I proudly showed a senior colleague how well I had stripped the pericardium. He said, after a brief glance, you still have another layer to take off . I learned to be very patient and to keep going in multiple directions, switching from one to  another as soon as progress was slow, until finally the diastolic bulging of the epicardium became evident. As I am sure Prasanna had to do there were parts of the pathology that had to be left behind. There are places where the pathology is in epi- and peri-cardium. 
    I learned that there is absolutely no need to touch the atria in the great majority of cases. I did always free the diaphragmatic surface of left and right ventricles and having done that would then take the constrictive fibrous tissue off the diaprhragm, figuring that if the raw surfaces adhere post op the diaphragmatic walls would still effectively be constricted.
The pathologies were tuberculous, bacterial (staph, hemophilus), viral, radiation, and one case, which was "atypical" and turned out on histology to be mesothelioma. This last case had imperfect relief of the constriction but inevitably recurred and died a couple of years later (not without another useless operation at a famous cancer hospital).  The plane was never good and the results suboptimal in radiation cases. 
    I had an interesting case of recurrent staph constriction. The first op was done in London by median sternototomy He was a local TV announcer and his doctor picked up the recurrence by seeing his distended neck veins when he was presenting the news. I thought it would be smart to do a bilateral anterior thoracotomy across the sternum. Having freed up a short distance behind the sternum and starting to crank the retractor open I suddenly realised that I was in danger of tearing the heart apart transversely. After a lot more freeing up I was able to do a proper pericardiectomy.
   To this day, I never peal an orange except with my thumb and always expect to get the skin off  in one unbroken piece, leaving the orange segments undamaged. Takes a little longer .
Bob
-----Original Message-----
From: msfirst at gmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 10 Apr 2007 5:26 PM
Subject: Re: [HSF] Difficult pericardiectomy


Prasanna, 
That is not fair - I asked you the exact same question a few months back 
when I had back to back similar cases! You were supposed to have the 
answer. 
 
Did you go on pump? The few that I have done recently, having (and using) 
that option can keep your stomach acid levels down 
 
-michael 
 
On 4/10/07, prasannasimha <prasannasimha at gmail.com> wrote: 
> 
> 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 
> _______________________________________________ 
> OpenHeart-L mailing list 
> 
> Send postings to: 
> OpenHeart-L at lists.hsforum.com 
> 
> To UNSUBSCRIBE, to CHANGE email address, or to view archives: 
> http://mmp.cjp.com/mailman/listinfo/openheart-l 
> 
> All messages transmitted by the OpenHeart-L are subject to the policies 
> and 
> disclaimers posted at: 
> http://www.hsforum.com/listdisclaim 
> ----------------------------------------- 
> 
_______________________________________________ 
OpenHeart-L mailing list 
 
Send postings to: 
OpenHeart-L at lists.hsforum.com 
 
To UNSUBSCRIBE, to CHANGE email address, or to view archives: 
http://mmp.cjp.com/mailman/listinfo/openheart-l 
 
All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: 
http://www.hsforum.com/listdisclaim 
----------------------------------------- 
________________________________________________________________________
AOL now offers free email to everyone.  Find out more about what's free from AOL at AOL.com.