Total Robotic Pericardiectomy for Constrictive Pericarditis

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

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2. 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.
3. Sengupta PP, Eleid MF, Kandheria BK. Constrictive pericarditis. Circ J 2008;72:1555-62.
4. 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.
5. Luison F, Boyd WD. Three-dimensional video-assisted thoracoscopic pericardiectomy. Ann Thorac Surg. 2000; 70: 2137-8
6. Maciolek K, Asfaw ZE, Krienbring DJ, Arnsdorf SE, et al. Robotic endoscopic off-pump total pericardiectomy in constrictive pericarditis. Innovations 2016;11:134-7.
7. Balkhy HH. Robotic assisted pericardiectomy for constrictive pericarditis. Expert analysis. Amer Coll Cardiol.April 11, 2018.
8. 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.
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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