Prevention of Postoperative Pericardial Adhesions With a Novel Regenerative Collagen Sheet Hiroyuki Tsukihara, MD, Shinichi Takamoto, MD, PhD, Kazuo.

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Prevention of Postoperative Pericardial Adhesions With a Novel Regenerative Collagen Sheet Hiroyuki Tsukihara, MD, Shinichi Takamoto, MD, PhD, Kazuo Kitahori, MD, PhD, Kazuhisa Matsuda, BS, MS, Arata Murakami, MD, PhD, Richard J. Novick, MD, PhD, Yoshihiro Suematsu, MD, PhD The Annals of Thoracic Surgery Volume 81, Issue 2, Pages 650-657 (February 2006) DOI: 10.1016/j.athoracsur.2005.07.022 Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Twelve weeks after the initial operation, formation of a regenerative membrane was observed (A), the surface of the heart was smooth, and the coronary vessels were clearly identifiable in Group I (B). In Group 2, severe adhesions were observed mainly in the suture line (C). In Group 3, severe adhesions that were difficult to dissect were observed in all cases (arrowhead); the surface of the heart was covered with fibrous tissue and the coronary vessels were obscure (D). In Group 4, marked adhesion formation was observed (arrowheads); the retrosternal space was completely obliterated (E), and the coronary arteries were completely obscured. The Annals of Thoracic Surgery 2006 81, 650-657DOI: (10.1016/j.athoracsur.2005.07.022) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Twelve weeks after the initial operation, in group 1 (A and B), the surface on the epicardial side was covered with a mesotheliumlike cell layer, fibroblasts, and collagen fibers (A: hematoxylin and eosin [H&E] stain; B: elastica von Gieson stain). In group 3, (C) granulation and fibrous tissue were seen near the pericardium and the ePTFE sheet, surrounded by an inflammatory reaction (H&E stain). In group 4 (D), dense adhesions consisting of connective tissue, fibroblasts, and inflammatory cells were observed (H&E stain). (A, B: magnification ×200; C, D: magnification ×50.) The Annals of Thoracic Surgery 2006 81, 650-657DOI: (10.1016/j.athoracsur.2005.07.022) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) Four weeks after the initial operation, the whitish implanted collagen sheet could still be visualized. (B) Twenty-four weeks after the initial operation, the thickness grade had increased and new capillary vessels were observed. The Annals of Thoracic Surgery 2006 81, 650-657DOI: (10.1016/j.athoracsur.2005.07.022) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A and B) Four weeks after the initial operation, light-microscopic examination revealed the presence of cells and collagen fibers in the regenerated membrane (A: hematoxylin and eosin [H&E] stain; B: elastica von Gieson stain [EVG]). (C and D) Twenty-four weeks after the initial operation, light-microscopic examination revealed that the collagen sheet became integrated with native tissue having a mesotheliumlike cell layer, dense collagen fibers, and capillaries (C: H&E stain; D: EVG stain). (E) A mesothelial cell layer, dense collagen fibers, capillaries, and fatty tissue were observed in the native pericardium (H&E stain). (A–E: magnification ×200.) The Annals of Thoracic Surgery 2006 81, 650-657DOI: (10.1016/j.athoracsur.2005.07.022) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Scanning-electron-microscopic findings of the surface of the regenerated membrane at (A) 12 weeks and (B) 24 weeks after the operation. The mesotheliumlike layer was preserved, and the surface consisted of native pericardial tissue. The Annals of Thoracic Surgery 2006 81, 650-657DOI: (10.1016/j.athoracsur.2005.07.022) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions