Pericardiectomy for constrictive pericarditis.

Chronic constrictive pericarditis results from inflammation and fibrosis of the pericardium. This situation eventually leads to impairment of diastolic filling and right heart failure. Once the diagnosis is made, because the disease is basically irreversible, a pericardiectomy is the mandatory treatment. The standard surgical treatment has been extensively described. The goal of this video tutorial is to render a visual explanation of the described techniques and to provide tips to help make the procedure easier to perform. The standard technique is performed through a median sternotomy, preferably without cardiopulmonary bypass if feasible. The procedure includes the complete removal of the anterior pericardium from phrenic nerve to phrenic nerve and the removal of the diaphragmatic pericardium and of part of the pericardium posterior to both phrenic nerves. Before starting the actual pericardiectomy procedure, it is useful to separate the pericardial rigid shell from the pleurae and from the diaphragm; this step allows the operator to see both phrenic nerves clearly and to give clear boundaries between the pericardium and the diaphragm, which are not often as clear as desirable due to fat, edema, inflammation, and scarring. Once a portion of the pericardium has been detached from the myocardium, it can be excised, making the portion yet to be removed more visible.