A Simple Technique for Tension-free Pericardial Closure Avraham D. Merav, M.D., Richard Brodman, M.D., Lari A. Attai, M.D., and George Robinson, M.D. ABSTRACT Closure of the pericardium after cardiac operations is desirable but is not always possible to achieve. We describe here a simple technique for tension-free, anterior closure of the pericardium.
Closure of the pericardium after open-heart operation decreases the risk of injury to the heart and great vessels, or to bypass grafts during reoperation. The closed pericardium acts as a barrier in instances of anterior mediastinal infection and reportedly decreases the incidence of both pericardial tamponade and postpericardiotomy syndrome 121. Closure of the pericardium does not alter the early patency of saphenous vein grafts [ll. Occasionally, primary pericardial closure is not possible because it results in cardiac constriction or in compression of aorta-coronary artery bypass grafts. In such cases, we use a simple method for enlarging the pericardial sac to allow anterior closure without cardiac compression. The method obviates the use of pericardial substitutes [31.
If compression of the heart or of bypass grafts occurs, one or more relaxing incisions are made in the pericardium (Figure). Division of the fibrous pericardium is performed by carefully incising its inner surface with a scalpel, without entering the pleural space. The edges of the relaxing incision separate by 1 to 2 cm, thereby permitting tension-free anterior approximation of the pericardium. The relaxing incision is begun anterior to the superior vena cava and is continued inferiorly, anterior to the pulmonary veins. Care is taken to avoid injury to the phrenic nerve. An incision in this area can be made without displacement of the full beating heart and is usually remote from vein grafts that could herniate through a pericardial defect. On one occasion we incised the pericardium overlying the left ventricle (while the patient was still on cardiopulmonary bypass). However, we have not found it necessary to incise both pericardial
Method Following median sternotomy, the pericardium is usually incised in the midline from its aortic reflection superiorly to its diaphragmatic reflection inferiorly. The pericardial edges are then raised over the sternum and stitched to the soft tissues of the chest wall. On completion of the cardiac procedure, the pericardial edges are released from the chest wall and approximated with interrupted sutures.
From the Division of Cardiothoracic Surgery, Montefiore Hospital and Medical Center, and the Albert Einstein College of Medicine, Bronx, NY.
f
I
1
a7fl
Accepted for publication Nov 30, 1978.
A pericardial relaxing incision has been performed on
Address reprint requests to Dr. Merav, Division of Cardiothoracic Surgery, Montefiore Hospital and Medical Center, Bronx, NY 10467.
the right side; the lung can be seen through the intact mediastinal pleura. The dotted lines indicate additional or alternate sites for the incisions.
399
0003-4975/79/100399-02$01.25@ 1978 by Avraham D. Merav
400 The Annals of Thoracic Surgery VoI 28 No 4
October 1979
leaves in order to gain additional relaxation.
References
Comment Three patients in whom a relaxing incision was required after vein bypass operations had early postoperative arteriography. All grafts were found to be patent. The technique described permits tension-free anterior closure of the pericardium. It allows the benefits of pericardial closure without the use of pericardial substitutes, such as fascia lata or pericardial xenografts.
1. Asanza L, Rao G, Voleti C, et al: Should the pericardium be closed after an open-heart operation? Ann Thorac Surg 22:532, 1976 2. Cunningham IN, Spencer FC, Zeff R , et al: Influence of primary closure of the pericardium after open-heart surgery on the frequency of tamponade, postcardiotomy syndrome, and pulmonary complications. J Thorac Cardiovasc Surg 70:119, 1975 3. Kohanna FH, Adams PX, Cunningham JN Jr, et al: Use of autologous fascia lata as a pericardial substitute following open-heart surgery. ] Thorac Cardiovasc Surg 74:14, 1977
Notice from the American Board of Thoracic Surgery
The American Board of Thoracic Surgery now requires that candidates pass both the written and oral portions of the certifying examination. In 1980 and thereafter, a written examination will be given prior to the oral examination. It will be necessary to pass the written examination before the oral examination can be taken.
The closing date for registration for 1981 is August 1,1980. The exact times and places of these examinations will be announced later. Please address all communications to the American Board of Thoracic Surgery, 14640 E Seven Mile Road, Detroit, MI 48205.
Closure of the pericardium after open-heart operation decreases the risk of injury to the heart and great vessels, or to bypass grafts during reoperation. The closed pericardium acts as a barrier in instances of anterior mediastinal infection and reportedly decreases the incidence of both pericardial tamponade and postpericardiotomy syndrome 121. Closure of the pericardium does not alter the early patency of saphenous vein grafts [ll. Occasionally, primary pericardial closure is not possible because it results in cardiac constriction or in compression of aorta-coronary artery bypass grafts. In such cases, we use a simple method for enlarging the pericardial sac to allow anterior closure without cardiac compression. The method obviates the use of pericardial substitutes [31.
If compression of the heart or of bypass grafts occurs, one or more relaxing incisions are made in the pericardium (Figure). Division of the fibrous pericardium is performed by carefully incising its inner surface with a scalpel, without entering the pleural space. The edges of the relaxing incision separate by 1 to 2 cm, thereby permitting tension-free anterior approximation of the pericardium. The relaxing incision is begun anterior to the superior vena cava and is continued inferiorly, anterior to the pulmonary veins. Care is taken to avoid injury to the phrenic nerve. An incision in this area can be made without displacement of the full beating heart and is usually remote from vein grafts that could herniate through a pericardial defect. On one occasion we incised the pericardium overlying the left ventricle (while the patient was still on cardiopulmonary bypass). However, we have not found it necessary to incise both pericardial
Method Following median sternotomy, the pericardium is usually incised in the midline from its aortic reflection superiorly to its diaphragmatic reflection inferiorly. The pericardial edges are then raised over the sternum and stitched to the soft tissues of the chest wall. On completion of the cardiac procedure, the pericardial edges are released from the chest wall and approximated with interrupted sutures.
From the Division of Cardiothoracic Surgery, Montefiore Hospital and Medical Center, and the Albert Einstein College of Medicine, Bronx, NY.
f
I
1
a7fl
Accepted for publication Nov 30, 1978.
A pericardial relaxing incision has been performed on
Address reprint requests to Dr. Merav, Division of Cardiothoracic Surgery, Montefiore Hospital and Medical Center, Bronx, NY 10467.
the right side; the lung can be seen through the intact mediastinal pleura. The dotted lines indicate additional or alternate sites for the incisions.
399
0003-4975/79/100399-02$01.25@ 1978 by Avraham D. Merav
400 The Annals of Thoracic Surgery VoI 28 No 4
October 1979
leaves in order to gain additional relaxation.
References
Comment Three patients in whom a relaxing incision was required after vein bypass operations had early postoperative arteriography. All grafts were found to be patent. The technique described permits tension-free anterior closure of the pericardium. It allows the benefits of pericardial closure without the use of pericardial substitutes, such as fascia lata or pericardial xenografts.
1. Asanza L, Rao G, Voleti C, et al: Should the pericardium be closed after an open-heart operation? Ann Thorac Surg 22:532, 1976 2. Cunningham IN, Spencer FC, Zeff R , et al: Influence of primary closure of the pericardium after open-heart surgery on the frequency of tamponade, postcardiotomy syndrome, and pulmonary complications. J Thorac Cardiovasc Surg 70:119, 1975 3. Kohanna FH, Adams PX, Cunningham JN Jr, et al: Use of autologous fascia lata as a pericardial substitute following open-heart surgery. ] Thorac Cardiovasc Surg 74:14, 1977
Notice from the American Board of Thoracic Surgery
The American Board of Thoracic Surgery now requires that candidates pass both the written and oral portions of the certifying examination. In 1980 and thereafter, a written examination will be given prior to the oral examination. It will be necessary to pass the written examination before the oral examination can be taken.
The closing date for registration for 1981 is August 1,1980. The exact times and places of these examinations will be announced later. Please address all communications to the American Board of Thoracic Surgery, 14640 E Seven Mile Road, Detroit, MI 48205.
