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Constrictive pericarditis results from chronic fibrous thickening, and occasionally calcified adherence of the pericardium. The inelastic constriction of the pericardium impairs ventricular filling, resulting in increased filling pressures and decreased cardiac output (1). Surgical pericardiectomy is the preferred treatment for constrictive pericarditis and is usually performed via median sternotomy using cardiopulmonary bypass or lateral thoracotomy (2). Both techniques are invasive and are associated with high morbidity and mortality (2). In addition, the traditional approach usually excises the pericardium from phrenic nerve to phrenic nerve and not pulmonary vein to pulmonary vein.
Minimally invasive techniques offer the advantage of reduced pain and enhanced recovery. Thoracoscopic pericardiectomy has been described but has not been shown to be successful for complete or total pericardiotomy (3, 4). Robotic assisted total pericardiotomy has been described for constrictive pericarditis and offers superior vision and more complete excision of the pericardium (5, 6). Total pericardiotomy is more effective than anterior pericardiotomy in relieving symptoms as well as improving long-term survival (7, 8).
Calcified constrictive pericarditis is less common than noncalcified and is more likely to be symptomatic. Surgical pericardiectomy for calcified constrictive pericarditis poses a greater operative risk and has significantly more perioperative deaths than noncalcified. Late survival is similar with calcified and noncalcified disease (9).
This video demonstrates robotic-assisted total pericardiotomy for constrictive pericarditis. Two cases are presented, emphasizing the difference between calcified and noncalcified constrictive pericarditis. The patient who had calcified constrictive pericarditis subsequently required a median sternotomy and cardiopulmonary bypass to complete the total pericardiectomy. It is important to excise the pericardium from pulmonary vein to pulmonary vein rather than phrenic nerve to phrenic nerve.
In conclusion, total pericardiotomy for constrictive pericarditis can be performed robotically with minimal morbidity and mortality. The robotic approach offers superior vision with a stable platform, resulting in more complete excision of the pericardium. The lateral decubitus position and bilateral approach are well tolerated and allow for complete pericardiectomy from pulmonary vein to pulmonary vein. The left pericardiectomy should be performed first to improve intraoperative hemodynamics. Calcified constrictive pericarditis is technically difficult and may require median sternotomy and cardiopulmonary bypass if the pericardium cannot be totally excised robotically.
References
- Kusunose K, Dahiya A, Popovic ZB. Biventricular mechanics and constrictive pericarditis comparison with restrictive cardiomyopathy and impact of pericardiotomy. Circ Cardiovasc Imaging 2013; 6: 390 9-406.
- Raheel FA, Beadle M, Khan MA, et al. Management of Constrictive Pericarditis Due to Calcified Thickened Pericardium of up to 18 mm Thick With Impaired Ventricles. CTSNet.January 2021. doi:10.25373/ctsnet.13640753.
- Sengupta PP, Eleid MF, Kandheria BK. Constrictive pericarditis. Circ J 2008;72:1555-62.
- Liem NT, Tuan T, Dung le A. Thoracoscopic pericardiectomy for purulent pericarditis: experience with 21 cases. J Laparoendosc Adv Surg Tech A 2006;16:518-21.
- Luison F, Boyd WD. Three-dimensional video-assisted thoracoscopic pericardiectomy. Ann Thorac Surg. 2000; 70: 2137-8
- Maciolek K, Asfaw ZE, Krienbring DJ, Arnsdorf SE, et al. Robotic endoscopic off-pump total pericardiectomy in constrictive pericarditis. Innovations 2016;11:134-7.
- Balkhy HH. Robotic assisted pericardiectomy for constrictive pericarditis. Expert analysis. Amer Coll Cardiol.April 11, 2018.
- Chowdhury UK, Subramaniam GK, Kumar AS, et al. Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques. Ann Thorac Surg 2006;81:522-9.
- Ling LH, Oh JK, Breen JF, et al. Calcific constrictive pericarditis: Is it still with us? Ann Intern Med. 2000;132(6):444-50. doi: 10.7326/0003-4819-132-6-200003210-00004.
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5 Comments
The operative time is long, although this will decrease with more experience and better patient selection.
The imaging studies on the first case provided adequate information where the patient would have benefited more with one surgery – median sternotomy with total pericardiectomy.
The second case – noncalcified pericarditis – is better suited for access and dissection of thickened pericardium, and thus less causes for misadventures.
Gid day, excellent work and leaves me wishing! In the third world where I practice, we do median sternotomy and have needed cardiopulmonary bypass only twice, one for associated mitral valve repair and then for an IVC injury repair. I was trained to start with the outflows, then the ventricles finishing with the inflows (atria and veins); this was meant to avoid ventricular distension from relative obstruction of the outflows by the constriction. I commend the presenter for great work!
One further notes that we are a TB disease area and the default diagnosis is tuberculous pericarditis, where the patient completes an anti-TB course before being considered for pericardiectomy. This tends to allow for improved tissue planes for dissection and believed to obviate recurrence. One notes that the histology and microbiology results have never diagnosed the TB pericarditis and the blood serology is meaningless as most of us are exposed to TB. Again wonderful work!
Congrats ro the team!! Dr Jett.
What are the places where you place the trocars to perform this surgery when it is done by robot?
Thank you for the answer.
The patient is placed in the right or left lateral decubitus position. An 8 mm port is placed in the eighth intercostal space at the mid axillary line and a 30 degree camera inserted. The remainig ports are placed under direct vision with the 30 degree camera looking up. Another 8 mm port is placed in the seventh intercostal space at the costal margin. In between the anterior port and the camera port, a 12 mm, 100 mm AirSeal assistant port is placed over the 10th rib and over the diaphragm. A 3rd 8 mm port is placed 8 cm posterior to the camera port and in the same interspace.. A fourth 8 mm port is then placed 6 cm more posterior. The Xi robot is brought into the field and docked. A ProGrasp is placed in arm 1, camera arm 2, a long bipolar grasper arm 3 and a tip-up fenestrated grasper arm 4.
The lateral decubitus postion vs a bump up allows exposure of the pericardium posterior to the phrenic nerve enhancing pulmonoary vein to pulmonary vein pericardiectomy vs phrenic nerve to phrenic nerve.
The port placement is similar to that demonstrated on our CTSNet video “Jett GK, Hafen L. Robotic-Assisted Transmyocardial Laser Revascularization Combined With Left Atrial Appendage Exclusion Using an Atrial Clip. June 2020. doi:10.25373/ctsnet.12490604”.
Hopefully this will help.
Thanks for your comments.
Kimble Jett