1. Intermediate Format: Pericardiectomy/Pericardial Window
Procedures
STST Ch 22 p. 919: Picture above shows pericardial window: approach is thru median sternotomy and decortication begins with left ventricle
Q for Further Study: During a pericardiectomy, what should the STSR be prepared to give the surgeon if calcified portions of the parietal pericardium penetrate the heart’s chambers?
Be prepared to provide a 4-0 or 5-0 pledgeted Prolene suture for the repair.
Type of procedure: Ablative or Palliative
CDC classification I
Intermediate Format:
Pericardiectomy/Pericardial Window

2. Objectives
Assess the related terminology and pathophysiology of the heart.
Analyze the diagnostic interventions for a patient undergoing a pericardiectomy.
Plan the intraoperative course for a patient undergoing_____________.
Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for pericardiectomy.
Describe the care of the specimen

4. Terms and Definitions Pericardium Decortication Pericardial effusion
Cardiac tamponade
Pericardium: the outermost layer of the heart. It is a two-layer membranous sac with a thin layer of serous fluid (normally no more than mL) separating the layers. It protects and cushions the heart and great vessels, provides a barrier to infectious processes in adjacent structurs, prevents displacement of the myocardium and blood vessels, and prevents sudden distention of the heart.
Decortication: removal of the surface layer of an organ or structure, as removal of a portion of the cortex of the brain frm the underlying white matter (Tabers)
Pericardial effusion: abnomral collection of fluid between the pericardial layers that threatens normal cardiac function. The fluid may consist of pus, blood, serum, lymph, or a combination.
Cardiac tamponade: a life threatening condition in which elevated intrapericardial pressures impair the filling of the heart during diastole. Tampanode may result from injuries to the heart or great vessels, or other causes of large pericardial effusions. If fluid accumulates rapidly, as little as 250mL can create an emergency. Slow accumulation and a rise in pressure, as in pericardial effusion assoc w/cancer, may not produce immediate signs and symptoms, as the pericardial sac can gradually stretch to accommodate at much as 1-2 L of fluid. It may be diagnosed by Chest x-ray showing slightly widened mediastinum and enlargement of cardiac silhouette; EKG and pulmonary artery pressure monitoring. A hallmark is paradoxical pulse (markedly decreases in amplitude during inspiration) L & B p. 896

5. Definition/Purpose of Procedure
Partial excision of adhered, thickened fibrotic pericardium to relieve constriction of compressed heart and large blood vessels
Removal of a segment of pericardium, permitting pericardial fluid to drain into the pleural space for treatment of cardiac tamponade
Surgical stripping of the pericardium
Alexanders p This adhered portion of the scarred, thickened pericardium restricts myocardial contractility. As the pericardial space is obliterated and calcification of pericardium occurs, there is even more compression of the heart.
Lemone & Burke p. 897: a rectangular piece of the pericardium or window may be excised to allow collected fluid to drain into the pleural space. Partial or total paricardiectomy is removal of allor part of the pericardium, to relieve the ventricular compression and allow adequate heart filling
May be performed to relieve a pericardial effusion responsible for cardiac tamponade

6. Pathophysiology Chronic pericarditis Tubular Rheumatic Viral
Neoplastic
Constrictive
Pericarditis: Inflammation of the pericardium caused by infection, autoimmune disorders, open heart surgery, etc. It may be a primary disorder or develop secondarily to another cardiac or systemic disorder.
Pericardial tissue damage triggers an nflammatory response. Inflammatory mediators released from the injured tissue cause vasodilation, hyperemia, and edema. Capillary permeability increases, allowing plasma proteins, including fibrinogen, to escape the pericardial space. White blood cells amass at the site of injury to destroy the causative agent. Exuduate is formed, usually fibrinous or serofibrinous. In some cases, the exudate may contain red blood cells or purulent material. The inflammatory process may resolve without long-term effects, or scar tissue and adhesions may form between the pericardial layers. Fibrosis and scarring of the pericardium may restrict cardiac function. Pericardial effusions may develop as serous or purulent exudate (depending on causative agent) collects in the pericardial sac. Pericardial effusion may be recurrent. Chronic inflammation causes the pericardium to be rigid.

7. Pathophysiology Signs & Symptoms Chest pain Fever Cough Dyspnea
Palpitations
Friction Rub
Signs and symptoms: a. chest pain that varies with respiration is the MAIN symptom. The pain often worsens when the patient lies down and improves when the patient sits up.
Other manifestations: fever, cough, dyspnea, and palpitations
The classic sign is audible friction rub—a multicomponent abnormal heart sound that some describe as scratchy, raspy, or leathery.
Patient care: the pt is observed for symptoms of cardiac tamponade, such as weak or absent peripheral pulses, distended neck veins, decreased BP, and narrowing pulse pressure.
Alexanders p This adhered portion of the scarred, thickened pericardium restricts myocardial contractility. As the pericardial space is obliterated and calcification of pericardium occurs, there is even more compression of the heart. The manifestations are that of Right sided heart failure: (blood backs up in the liver causing abdominal fluid retention and distention) ; Blood returning to the RT heart dos not sufficiently empty into the heart snce the thickened pericardium contrains the RT ventricle from expanding enough to receive the venous blood. Physiological results are: ascites, elevated venous pressure, elevated neck veins, decreased arterial pressure, lower extremity edema, and hepatic enlargement.
Constrictive pericarditis involves scarring of the pericardium after one or more episodes of pericarditis. This limits normal cardiac filling during diastole. Impaired filling of the heart’s chambers reduces the volume of blood ejected by the heart with each contraction.

8. Surgical Intervention: Special Considerations
Patient Factors
anxiety
Room Set-up
For heart surgery
Possibly cardiac bypass on standby

9. Surgical Intervention: Positioning
Position during procedure
Supine, arms on armboards at 90 degrees
Supplies and equipment
Special considerations: high risk areas

10. Surgical Intervention: Special Considerations/Incision
State/Describe incision
Median sternotomy
# 10, # 15 blades
Alexanders p. 1143: skin incision for full sternotomy extends from the sternal notch to the linea alba below the xiphoid process.
The sternum is divided with a saw, and a sternal retractor is inserted. The pericardium is incised and retracted with sutures.
For ministernotomy, the sternum is partially divided starting from either the sternal notch or the xiphoid process (depending on the cardiac structures to be exposed).

11. Surgical Intervention: Supplies
General: Cardiac pack
Specific
Suture
4-0 & 5-0 Prolene, wire for sternum
Pledgets
Medications on field (name & purpose)
Heparinized saline solution and other meds as indicated on preference card (may have protamine on standby)
Catheters & Drains: Chest Tubes

12. Surgical Intervention: Instruments
General: Chest and Heart sets
Specific
Have all cardiac bypass instrumentation available if needed

13. Surgical Intervention: Equipment
General
Specific
Cardiac defibrillator on standby with internal and external paddles
Cardiac bypass on standby

14. Surgical Intervention: Procedure Steps
The lungs are displaced laterally, and the right and left phrenic nerves are identified and protected
The pericardium is incised
Decortication begins with the left ventricle
To prevent development of pulmonary edema and Rt Side Heart Failure, which could happen if one starts w/right ventricle
A plane is developed between parietal & visceral pericardium
Caution must be taken to prevent calcified portions of the parietal pericardium from penetrating the heart’s chambers, esp the atria.
The outer, thickened pericardium is removed as indicated
Have cartilage scissors ready

15. Surgical Intervention: Procedure Steps
Fibrous portions adhering to the atria and ventricles are carefully dissected w/dry dissectors and scissors
Extreme caution used to prevent perforation of atria and right ventricle—small areas of adherent pericardium may be retained
STSR is prepared with loaded 4-0 or 5-0 pledgeted Prolene sutures.
Dissection is continued; large blood vessels are exposed and freed as needed; the Atria, Ventricles, and both Cavae are freed
Drainage catheters are placed near the heart or through the pleural spaces
STSR has chest tubes ready with closed drainage system
Sternum is closed w/ stainless steel wire, and remainder of wound closed “usual manner”

16. Counts Initial: Sponges, Sharps, instruments First closing
Final closing
Sponges
Sharps
Instruments

17. Specimen & Care
Identified as pericardium
Handled: routine

18. Resources
STST Ch 22 pp. 918, 919
Taber’s Cyclopedic Medical Dictionary
Alexanders Ch 27, p. 1143,
Lemone and Burke pp

19. The surgical incision most likely for open heart surgery is:
Anterolateral thoracotomy
Posterolateral thoracotomy
Median sternotomy
supraclavicular
Ans C. It provides the most accessible route and patient positioning is simpler

20. Which medication is commonly given IV about 3-5 min prior to cross-clamping the artery during Arteriotomy?
Epinephrine
Protamine sulfate
Papavarine
Heparin
Ans D Arteriotomy is opening into the vascular system—heparin is given to prevent blood clot formation which could later obstruct vessels

21. Polytetrafluoroethylene (PTFE or Gore-Tex) Polyporpylene (Prolene)
All of the following are sutures used in CV surgery to suture vessels or vascular grafts except:
Polytetrafluoroethylene (PTFE or Gore-Tex)
Polyporpylene (Prolene)
Polyester (Dacron)
Surgical gut (chromic)
Ans D Surgical gut is absorbable and not recommended for the suturing of vessels and vascular grafts. A nonabsorbable, swaged suture is used

22. Abdominal Aortic Aneurysmectomy with Graft Pneumonectomy
Which of the following procedures would commonly require the use of extracorporeal circulation (heart-lung bypass)?
Abdominal Aortic Aneurysmectomy with Graft
Pneumonectomy
Coronary Artery Bypass Graft
Vena Cava Umbrella insertion
Ans C.

23. Internal mammary artery
The vessel used to increase the overall blood supply to the heart following CABG is the :
Saphenous artery
Brachial artery
Carotid artery
Internal mammary artery
Ans D. The IMA can be dissected from the chest wall and attached to the coronary circulatory system, increasing the overall volume of blood delivered to supply the heart muscle.

24. Vena Cava Umbrella Filter Placement Arteriovenous Fistula Formation
The creation of a commuication between an artery and a vein for hemodialysis access is called a(n)
Bypass Graft
Aneurysmectomy
Vena Cava Umbrella Filter Placement
Arteriovenous Fistula Formation
Ans D

25. Which of the following bypass grafts would require preclotting?
Knitted polyester (Dacron)
Saphenous vein
Human umbilical cord graft
Polytetrafluoroethylene (PTFE)
Ans A Dacron is porous and enhances in-growth of issue but could allow leakage of blood through its pores if the graft is not preclotted or pretreated

26. Ligation and stripping
The procedure in which a Fogerty Catheter is used to remove blockage of a vessel is referred to as:
Arteriovenous shunt
Endarterectomy
Embolectomy
Ligation and stripping
Ans C Embolectomy is the procedure in which a Fogerty catheter is used to remove blockage of a vessel.

27. In-situ saphenous vein graft Human umbilical cord graft PTFE graft
The autogenous graft which is left in place after destruction of the internal valves and then sutured into the arterial system is:
In-situ saphenous vein graft
Human umbilical cord graft
PTFE graft
ligation and stripping of the saphenous vein
Ans A

28. The artery that carries deoxygenated blood in the adult is the: Aorta
Carotid artery
Pulmonary artery
Coronary artery
Ans C

29. Common artery bypass procedures include all of the following except:
axillo-popliteal
Femoro-femorol
Axillo-femoral
Femoro-popliteal
Ans A Is NOT commonly performed due to the significant distance the graft must travel throught the subcutaneous tunnel which could lead to clot formation in the graft and obstruction of blood flow

30. Bi-polar ESU with its patient return electrode applied to the patient
Specific equipment used during surgery on a pt with a pacemaker in place should include:
A magnet
Mono-polar ESU with its patient return electrode applied to the patient
Mono-polar ESU without its patient return electrode applied to the patient
Bi-polar ESU with its patient return electrode applied to the patient
Ans A the magnet is placed over the pacemaker generator andwill assist in blocking stray electricity from reaching the pacemaker generator, since electricity is able either to reprogram or significantly interterfere with the generator’s function. The use of mono-polar should be limited and should always be used with patient return electrode (grounding pad). The use of bipolar does not require use of a pt return electrode.

31. Suture material used to place vascular grafts would include: PDS
Vicryl/Dexon
Prolene
Stainless steel
Ans C. When vasc grafts are placed, they are sutured to the vessel with nonabsorbable suture material, preferably monofilament. Prolene or polypropylene is a synthetic monofilament, nonabsorbable suture material.

32. A Femoro-popliteal Bypass is scheduled
A Femoro-popliteal Bypass is scheduled. Which self-retaining retractor would be used to facilitate exploration of the femoral artery?
Harken
Debakey
Weitlaner
Gelpi
Ans C. Retracts soft tissues of the groin—(Gelpi is sharp and may cause damage)