In the UK, pericardectomy is performed at various heart and chest hospitals. Notable centres include Royal Brompton Hospital London, Liverpool Heart and Chest Hospital and Royal Papworth Hospital. Pericardectomy is rarely performed outside of specialist centres in the UK and therefore anaesthetic trainees may have limited experience of this procedure. Those trainees who as part of OOPE or for altruistic reason, plan to go abroad and gain experience in this procedure, are advised to take a look at this article.
Sher Mohammad and anaesthetic colleagues from Peshawar (referral centre not only for residents but for the people from across the border in Afghanistan), regularly perform cardiac procedures and share their experience of pericardectomy.
Erstwhile notable clinicians who mentioned pericardium and related pathologies
- The sac around the heart was known to Hippocrates, but it was Giovanni Morgagni in 1700s, who first associated the symptoms of heart failure with a thickened pericardium on autopsy [1].
- In the first half of 1800s, Jean Nicolas Corvisart and Sir Richard Bright mentioned the relationship between constrictive pericarditis and advanced renal disease. In the 1870s, Richard Volkmann coined the term ‘constrictive pericarditis’ and postulated that thickened pericardium contributed directly to decrease pump performance. Nuanced physical findings were later mentioned by Adolph Kussmaul, Sir William Osler and Hermann Pick.
- Dr.Sauerbruch resected a portion of pericardium in 1913 and the first pericardiectomy is generally attributed to Dr.Wilhelm Rehn in 1920. In the 1950s, invasive haemodynamic features of constrictive pericarditis were described and in 1955, William Dressler reported a case series documenting successful treatment of pericarditis with aspirin and steroids [2-4]. Soon, indomethacin and colchicine were added to the treatment regime [4-7].
- In 1979, echocardiographic criteria for constrictive pericarditis were described and by the end of 20th century, both cardiac MR and cardiac computed tomography emerged as complementary imaging modalities [8-13].
- In 2005, clinical trials of combination of colchicine with conventional therapy for managing acute and recurrent pericarditis [14-18] were studied. In 2009, initial reports of successful treatment of autoimmune-associated recurrent pericarditis using IL-1 receptor antagonist anakinra [21-23].
Anatomy of the pericardium
The normal pericardium is situated in the anterior mediastinum surrounding the heart and proximal parts of great vessels. It consists of an outer fibrous layer and an inner serous layer. The fibrous pericardium contains a dense network of collagen fibres that stabilise the position of the heart and associated vessels within the mediastinum.
The serous pericardium is a two-layered membrane composed of an outer parietal layer and an inner visceral layer. The visceral layer is also known as the epicardium. The potential, fluid-filled space between these two serous layers is the pericardial cavity. In normal states, approximately 15-50 ml of fluid is contained within the pericardial sac. This fluid is produced by visceral mesothelial cells and is drained from the pericardial sac via lymphatics into the right side of the heart.
The pericardial fluid minimises friction exerted on pericardium from normal heart movements during the cardiac cycle and serves to balance hydrostatic pressures over the surface of the heart.
Normal pericardial thickness is 1-2 mm (the thickness of the pericardium before surgery was 7.42±2.31mm and after surgery 5.20±2.15 mm in a Chines study).