not is still a debated topic. While many studies favour

pericardial closure after cardiac surgery, many are still not in

favour of the same.

Objective : Objective of this study was to analyse the changes

induced by pericardial closure on the haemodynamic of the

patient using easily measurable variables.

Methods : Data of 30 patients were analysed of which 14

underwent mitral valve replacement, 10 underwent coronary

artery bypass grafting and 6 underwent double valve

replacement.

Results:

There was statistically significant change in cardiac output

(p<0.01), central venous pressure (p<0.05) and left ventricular

end diastolic diameter (p<0.01) after pericardial closure.

Clinically the pericardial closure was well tolerated.

Conclusion: Despite exhaustive experience, the topic of closing

pericardium is still debated. Our study shows that clinically

pericardial closure is well tolerated and in return it also

safeguards the risks associated with re-do operations

Saurabh KS1 , Padhy AK2 , Kumar M3 , Munjal R4 , Gupta A5

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Original ArticleHaemodynamic Effects of Pericardial Closure after CardiacSurgerySaurabh KS1, Padhy AK2, Kumar M3, Munjal R4, Gupta A51,3,4Senior Resident, Cardiovascular Thoracic Surgery, Vardhaman Mahavir Medical College  & Safdarjung Hospital2Assistant Professor, Cardiovascular Thoracic Surgery, Vardhaman Mahavir Medical College  & Safdarjung Hospital5HOD, Cardiovascular Thoracic Surgery, Vardhaman Mahavir Medical College  & Safdarjung HospitalCorresponding author:  Padhy AK Department of Cardiothoracic and Vascular Surgery, VMMC and Safdarjung Hospital, New Delhi.AbstractIntroduction: Whether pericardial closure should be done ornot is still a debated topic. While many studies favourpericardial closure after cardiac surgery, many are still not infavour of the same.Objective : Objective of this study was to analyse the changesinduced by pericardial closure on the haemodynamic of thepatient using easily measurable variables.Methods : Data of 30 patients were analysed of which 14underwent mitral valve replacement, 10 underwent coronaryartery bypass grafting and 6 underwent double valvereplacement.Results:There was statistically significant change in cardiac output(p<0.01), central venous pressure (p<0.05) and left ventricularend diastolic diameter (p<0.01) after pericardial closure.Clinically the pericardial closure was well tolerated.Conclusion: Despite exhaustive experience, the topic of closingpericardium is still debated. Our study shows that clinicallypericardial closure is well tolerated and in return it alsosafeguards the risks associated with re-do operations.Keywords:  Pericardial closure, Cardiac output, Left ventricularend diastolic diameter, Central venous pressureIntroductionIn patients who undergo open heart surgery, the pericardiumis left open in a credence that it lowers the incidence of cardiactamponade post-operatively [1]. However, many studies are ofopinion that for prevention of re-entry entries in re-do cases,pericardial closure lowers its incidence [2-4]. In current scenario,the need for re-operation is increasing progressively [5]. Duringre-intervention, the risk of injury to intrathoracic structuresprimarily the structures lying in the anterior part, particularlythe right ventricle and the great vessels are at highest risk ofinjury if the pericardium was left open in first surgery [6-8].Also, the closed pericardium is suggested to act as infectionbarrier in a post-operative case. The bleeding in the post-operative period is mostly extra-pericardial, the pericardialclosure decreases the occurrence of tamponade and post-pericardiotomy syndrome [9]. In two clinical studies, it isdemonstrated that pericardial closure essentially reduced theincidence of postoperative cardiac tamponade [2,9].Still there is an existing controversy about the effects ofpericardial closure on cardiac function parameters. Drop incardiac output [10-12] and blood pressure [13] has been describedafter pericardial closure. All these studies [10-13] comprised ofpatients who had undergone coronary artery bypass grafting(CABG), and therefore there was the likelihood of a constrictiveeffect of pericardial closure on the grafts along with on theheart. Although the pericardium is routinely closed in ourinstitution, per operative re-opening is occasionally necessaryfor any persistent low arterial blood pressure and low cardiacoutput.Methods-Retrospectively, the data of Thirty patients (12 females and 18males, Table 1) who underwent open-heart surgery, wereincluded in the study. 14 patients underwent mitral valvereplacement with LAA (Left atrial appendage) ligation (eitherinternal or external), 10 patients underwent Coronary ArteryBypass Grafting, while the remaining 6 patients underwentboth mitral valve and aortic valve replacement underCardiopulmonary bypass with cold cardioplegic arrest (Table2). Inclusion criteria –All adult cardiac cases who underwent cardiac surgery usingcardiopulmonary bypass. Exclusion criteria –a)  All the patients who underwent off-pump surgeries.b)  All the re-do cases.c)  All cases requiring excision of pericardium (e.g. chronicconstrictive pericarditis)d)  All congenital cases.The data analysis was carried out intra-operatively after thepatient was taken off cardiopulmonary bypass and in a stablehemodynamic state with filling pressures identical topreoperative values. The patients were under fentanylanaesthesia (5 mics/kg), etomidate (0.2mg/kg) and vecuronium(0.1mg/kg) for muscle relaxation.Normo-ventilation was continued with a mechanical ventilator.81Inotropic agents and/or vasodilators were used as needed.Overfilling of the heart was avoided. Blood was infused torecompense bleeding. Pressure measurements wereperformed with standard transducers.Cardiac output was determined by a cardiac output monitor(Edwards Vigileo Monitor, 2012 model). Cardiac output wascalculated by attaching the radial arterial line to the cardiacoutput monitor. Echocardiography was used for thedetermination of the left ventricular cavity diameter. Ensuingbaseline measurements, the pericardiotomy incision wasclosed with interrupted sutures 2 cm apart in the way usuallyused for pericardial closure which avoids undue tension. Aftera period of 3 to 4 min, the measurements were repeated andResults as described in Table 3. Thereafter the pericardialsutures were removed and the measurements repeated. Thenpericardium was closed again in all but one patient. Recoveryin all patients was uneventful.TABLE -1TABLE -2ProcedureMVR + LAA LIGATIONDVRCABGNumber of patients140610MVR – Mitral valve replacement, LAA – Left atrial appendageDVR – Double valve replacement,CABG – Coronary artery bypass graftingResultsChange in heart rate noted was: 86 + l6 before closure of thepericardium, 89 + 17 after, and 87 + 18 beats/min when thepericardium was re-opened. Cardiac rhythm remainedunchanged: 20 patients showed sinus rhythm, 4 were in atrialfibrillation, 4 had junctional rhythm, and 2 were on temporaryventricular pacing. Since the wedge pressure may undervalueleft ventricular end-diastolic pressure, the left ventricular intra-cavitary pressure was also noted. Left ventricular end-diastoliccavity diameter verified by echocardiogram in patients revealeda statistically significant (p< 0.01) decrease induced by thepericardial closure. Average Mean arterial pressure beforepericardial closure was 82 mmHg and after pericardial closurewas 80 mmHg, average systolic blood pressure beforepericardial closure was 114 mmHg and after pericardial closurewas 111 mmHg, Average diastolic blood pressure beforepericardial closure was 66 mmHg and after pericardial closurewas 64 mmHg. Cardiac output lessened (p<0.01) when thepericardiotomy incision was sutured and returned back to thecontrol level after removing the sutures (p<0.0l). Though, thefall in cardiac output was only 10.9%. The pericardial closureincreased somewhat (p< 0.05) central venous pressure.Clinically, the pericardial closure was well tolerated.Number ofpatientsFemaleMale1218AverageageAverageweightAverageHeightAverageBSA3940.451531551571.41.5TABLE -3Average Value Beforepericardial closureVariableAverage Value afterpericardial closureDifference (in%)Statistical significance/InferenceSBP (mmHg)DBP (mmHg)MBP (mmHg)CARDIACOUTPUTCVP (cm H2O)LVedP (mmHg)LVEDD (mm)11466825.59.213.650.911164804.911.514.0144.42.63.032.410.920(+)2.812.7ReducedReducedReducedp<0.01Reducedp<0.05IncreasedIncreasedp<0.01ReducedSBP – Systolic Blood Pressure, DBP – Diastolic Blood Pressure,MBP- Mean Blood Pressure, CVP – Central Venous Pressure,LVedP- Left ventricular end diastolic pressure, LVEDD- Leftventricular end diastolic diameter82Saurabh KS et alDiscussion –In one randomised clinical trial, brief reduction incardiac index and stroke-work index after pericardial closurehas been documented [14]. Numerous clinical case series havealso stated mild-to-moderate cardiac constriction, drop incardiac output and a decrease in arterial pressure ensuingprimary pericardial closure [4,9, 12, 13, 15, 16]. The findings areconstant due to myocardial oedema and dilatation of both,atria and the right ventricle, with procedures done oncardiopulmonary bypass, in which the normal constrainingeffect of pericardium is embellished [9]. The probable negativeeffects of pericardial closure on haemodynamic of the patientis transient in nature, and no study shows long term pooroutcome. [17].Hence the common consensus prefers primary closureof pericardium, if feasible [15,18] but it may not be suitable forpatients with pre-operative impaired cardiac output orimpaired left ventricular function [9, 12-17] or in peri-operativepatients who entail high preloads to sustain an acceptablecardiac output [14]LV-RV coupling can be modulated by intactpericardium [19]. In anesthetized dogs, Kroeker et al. verifiedthat ventricular coupling is ideal when there is 5 mmHg orhigher intrapericardial pressure. Under those circumstances,an abrupt decrease in RV filling is attended by an immediate,compensatory rise in LV end-diastolic volume and strokevolume.Some reports have proposed that pericardial closureafter coronary artery bypass grafting might lead to ‘kinking’ ofthe bypass grafts or internal mammary artery conduits [4, 20-22].While alternate ‘tension-free’ closure methods have beenprojected as a solution to this likely problem, these methodsmerely offer epicardial cover and do not give the truerestoration of the pericardial covering.In our study, the pericardial closure was performedavoiding undue tension. Over distension of the heart wasavoided at the end of cardiopulmonary bypass. A control forany change of the base-line values was attained in each patientby recordings taken when the pericardium was re-opened, andthe alterations not relating to the pericardial closure could beruled out. The impact of the pericardium on the left ventricularfilling pressure was insignificant.However, a statistically significant (p<0.01) reductionin the left ventricular end-diastolic cavity diameter happenedby the pericardial closure. This imitates smaller left ventriculardiastolic volume which can be due to pericardial compressionof the ventricle or from limited filling of the ventricle.The pericardium obstructs the distension of the freewall even more in the thin right ventricle than the left [23].Fascinatingly, the pericardial closure appeared to result in afall in the left ventricular end-diastolic cavity diameter inpatients operated for aortic stenosis also. This supports theconcept that the pericardial closure may cause compressionof the atria and/or venous return channels to the heart, limitingthe filling of the ventricles.In history, the pericardium was left open because ofthe discernment that its closure could cause fluid accumulation(including blood) around the heart leading to tamponade [1].However, this theory is not supported in the literatureby any randomized, controlled trials, case–control studies oreven case series studies. Recent studies show that closing thepericardium is somewhat protective against cardiactamponade [2,9] which can be attributed to the less amount ofclot formation around the heart by the mediastinal blood [24].Apart from preventing postoperative mediastinaladhesions, closure of the pericardium after cardiac surgeryprovides a dissection plane between the heart and theretrosternal surface. It has been said that the maintenance ofnative cardiac geometry plays a vital part in preserving LVfunction post-operatively [14] while insufficient retrosternalspace is a probable risk factor for injury during re-do surgeries[14,25,26].Post-operative exposure of the heart to pericardialand extra-pericardial blood has been suggested in thedevelopment of adhesions [25] and post-pericardiotomysyndrome [9] Inflammation has also been said to play a role inthe development of postoperative atrial fibrillation [27-29].Pericardial closure re-compartmentalizes the mediastinalcavity. The heart can then be ward-off from the blood and itscomponent cytokines along with pro- inflammatory mediators,and also from the wound infections, that may develop duringthe healing of the sternumConclusion -In our study, pericardial closure after cardiac surgery whichwas done using cardiopulmonary bypass significantly decreasesleft ventricular end-diastolic cavity size and hence somewhatdecreases the pump function. Pre-operative patients withnormal cardiac index, the 10.9% decrease in cardiac outputwas clinically well tolerated.Despite so much studies and experience, whether thepericardium should be closed after cardiac surgery or not hasnot yet been answered definitively.The advantages include protection from adhesions, lesschances of injury during re-do cases, re-compartmentalisationof the mediastinum for proper LV function post-operatively,reduced incidence of post-pericardiotomy syndrome, lesschances of pericardial tamponade, localisation of bleedingsource, improvement in cardiac haemodynamic and someother advantages as discussed before. The potential dis-advantages includes risk of graft kinking or compression,83Saurabh KS et alinflammatory epicardial reactions if pericardial substitutes areused and changes in cardiac output.Statistical analysisThe data were analysed with the patients serving as their owncontrols. Changes found significant in the analysis of variancewere isolated using the Statistical tests for comparisons. Thelevel of statistical significance was taken at p<0.05.Limitation of the study: -As the sample size was small, the average of all the variablesunder observation were taken for analysis.Conflict of interest: - NoneREFERENCES1. Gibbon JH. Surgery of the chest.Philadelphia:WBSaunders;1969. p.143.2. Nandi P, Leung JS, Cheung KL. Closure of pericardium afteropen heart surgery. A way to prevent postoperativecardiac tamponade. Br Heart J. 1976;38(12):1319-23.3. Asanza L, Rao G, Voleti C, Hartstein ML, Wisoff BG. Shouldthe pericardium be closed after an open-heart operation?Ann Thorac Surg. 1976;22(6):532-4.4. Bahn CH, Annest LS, Miyamoto M. Pericardial closure. AnnJ Surg. 1986;151(5):612-5.5. Christakis GT, Ivanov J, Weisel RD, Birnbaum PL, DavidTE, Salerno TA. The changing pattern of coronary arterybypass surgery. Circulation. 1989;80(3 Pt 1):I151- 61.6. 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Shirato K, Kanazawa M, Ishikawa K, Nakajima T, TakishimaT. The effect of pericardium on the diastolic properties ofthe heart. Experimental studies on volume load and onacute ischemia in open chest dogs. Jap Circ J 1982; 46:113-12324. Spodick DH. The Pericardium: A Comprehensive Textbook.Marcel Dekker,NY, USA, 387 (1997).84Saurabh KS et al25. Elahi M, Dhannapuneni R, Firmin R, Hickey M. Directcomplications of repeat median sternotomy in adults.Asian Cardiovasc. Thorac. Ann. 13(2), 135–138 (2005).26. Lahtinen J, Satta J, Lähde S et al. Computed tomographicevaluation of retrosternal adhesions after pericardialsubstitution. Ann. Thorac. Surg. 66(4), 1264–1268 (1998).27. Anselmi A, Possati G, Gaudino M. Postoperativeinflammatory reaction and atrial fibrillation: simplecorrelation or causation? Ann. Thorac. Surg. 88(1),326–333 (2009).28. Boos CJ, Anderson RA, Lip GY. Is atrial fibrillation aninflammatory disorder? Eur. Heart J. 27(2), 136–149 (2006)29. Tselentakis EV, Woodford E, Chandy J, Gaudette GR,Saltman AE. Inflammation effects on the electricalproperties of atrial tissue and inducibility of postoperativeatrial fibrillation. J. Surg. Res. 135(1), 68–75 (2006).How to cite this article :  Saurabh KS, Padhy AK, Kumar M,Munjal R, Gupta A Haemodynamic Effects of PericardialClosure after Cardiac Surgery. Perspectives in  MedicalResearch 2020; 8(1):81-85Sources of Support: Nil, Conflict of interest: None declared85Saurabh KS et al

Haemodynamic Effects of Pericardial Closure after Cardiac Surgery

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Haemodynamic Effects of Pericardial Closure after Cardiac Surgery

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