Minimally invasive limited pericardiectomy: the hybrid approach

The pericardial window: is a video-assisted thoracoscopy approach better than a surgical approach?

OBJECTIVES

The approach to the pericardial window in patients with pericardial effusion (PE) remains undefined as to whether a surgical (transthoracic or subxiphoid) or a thoracoscopic pericardial window is the optimal operative approach to PE. We hypothesized that the window into the pleural space created by the thoracoscopy might improve the outcome.

METHODS

We conducted a prospective study between September 2007 and October 2009. All patients with PE diagnosed by echocardiography who attended the Cardiothoracic Department in King Fahd Hospital are included in this study. They were 30 patients (18 males, 12 females aged 44±1.22 years). Patients were subdivided into two groups. Group A, 15 patients underwent the surgical (transthoracic or subxiphoid) procedure and Group B, 15 patients underwent the video-assisted thoracoscopy procedure. Preoperative, intraoperative and postoperative variables, morbidity, recurrence, and survival were compared in both groups.

RESULTS

Preoperative variables were well-matched for age, sex, preoperative tamponade, echocardiographical characteristics and co-morbidities between both groups. No recurrence of effusion was observed in the two groups. Operative time was statistically highly significant (P<0.001); it was longer in Group B. There was no intraoperative complication in both groups. There was no postoperative complication in both groups except one case of superficial wound infection in Group A. There was no significance difference between both groups as regard duration of chest tube drainage and length of hospital stay. There was no in-hospital mortality in both groups.

CONCLUSIONS

Pericardial window by video-assisted thoracoscopy is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures.

Thoracoscopic Pericardiectomy for Purulent Pericarditis: Experience with 21 Cases

PURPOSE

We present our experience in performing thoracoscopic pericardiectomy for purulent pericarditis in 21 children.

MATERIALS AND METHODS

Pericardiectomy was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at 2-4 mm Hg. Anterior pericardiectomy was performed from the left phrenic nerve to the right border of the sternum to free the anterior part of the heart, notably the cardiac apex and the original area of the great vessels. Purulent debris was removed prior to detaching the epicardial peel.

RESULTS

This study included 21 patients. Their mean age was 8 years. The time from onset of the disease to surgery ranged from 4 to 34 days (average, 15.2 days). Operative times ranged from 50 to 180 minutes (average, 100 minutes). There were no intraoperative or postoperative complications. All symptoms of cardiac tamponade disappeared immediately postoperatively. Follow-up ranged from 4 to 15 months and showed normal clinical manifestations, echocardiographs, and chest x-rays in all children.

CONCLUSION

Thoracoscopic pericardiectomy with removal of a generous amount of the pericardium is feasible and safe for purulent pericarditis.

Comparative study of subxiphoid versus video-thoracoscopic pericardial "window"

BACKGROUND

It remains undefined whether surgical subxiphoid drainage or thoracoscopic pericardial "window" is the optimal operative approach to pericardial effusion. We hypothesized that the true window into the pleural space created by the latter might improve the duration of freedom from recurrent effusion.

METHODS

We conducted a retrospective chart review of indications, preoperative and intraoperative variables, morbidity, recurrence, and survival.

RESULTS

Fifty-six patients underwent the subxiphoid procedure and 15 underwent the thoracoscopic procedure. Echocardiographic evidence of tamponade was present before 8 of 10 thoracoscopic procedures (80%) and 43 of 56 subxiphoid procedures (81%) for which descriptions of hemodynamics were available. In addition, non-pericardial procedures were performed in 10 (67%) and 18 (32%) patients, respectively (p = 0.020). Anesthesia time was longer at thoracoscopy (117.1 +/- 32.4 vs 81.1 +/- 25.5 minutes; p < 0.001). Procedural morbidity was higher after thoracoscopy (4 [27%] vs 1 [2%]; p = 0.006), but was generally minor. Hospital mortality tended to be higher after the subxiphoid procedure (7 [13%] vs 0 [0%]; p = 0.332), but none of the deaths was procedure-related. Follow-up was complete for 65 patients (92%). Recurrence occurred in 1 thoracoscopy patient (8%) and 5 subxiphoid patients (10%) (p = 1.000). Mean time to recurrence by Kaplan-Meier analysis trends were longer after thoracoscopy (36.1 vs 11.4 months; p = 0.16), and multivariate analysis identified the thoracoscopic approach as an independent predictor of freedom from recurrence (relative risk, 0.41; p = 0.014).

CONCLUSIONS

Operative time and minor procedural morbidity are higher with thoracoscopic pericardial window, but long-term control of effusion seemed to be better than after subxiphoid surgical drainage.