Employing a video thoracoscopic pericardial fenestration constitutes a promising technique for the investigation and treatment of chronic pericardial effusions. It combines the benefit of low invasiveness with the advantages of open biopsy. The procedure simultaneously allows both an accurate diagnosis under visual control (inspection, aspiration, well targeted biopsy of pathological processes) and the performance of effective therapeutic intervention. Without imposing unacceptable stress, it also facilitates rapid symptom relief in patients with advanced malignant disease whose general condition is severely impaire

FURRER, M.

INDERBITZI, R.

LEUPI, F.

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European Heart Journal (1993) 14, 135-137Pericardial biopsy and fenestrationR. INDERBITZI, M. FURRER AND F. LEUPIDepartment of Thoracic and Cardiovascular Surgery, University of Berne, SwitzerlandKEY WORDS: Pericardial effusion, thoracoscopic fenestration, diagnostic, treatment, minimally invasive surgery.Employing a video thoracoscopic pericardial fenestration constitutes a promising technique for the investigation andtreatment of chronic pericardial effusions. It combines the benefit of low invasiveness with the advantages of open biopsy.The procedure simultaneously allows both an accurate diagnosis under visual control (inspection, aspiration, well-targeted biopsy of pathological processes) and the performance of effective therapeutic intervention. Without imposingunacceptable stress, it also facilitates rapid symptom relief in patients with advanced malignant disease whose generalcondition is severely impaired.IntroductionThe treatment of persistent or recurrent pericardialeffusion depends on the underlying disease and on clinicalsymptoms. When there is no response to initial anti-inflammatory treatment with non-steroidal drugs givenunder strict clinical control, the next diagnostic step isaspiration under echocardiographic control followed, ifthe results are negative or unclear, by sub-xiphosternalopen biopsy. A large range of treatments can beemployed, extending from conservative concepts via peri-cardiocentesis'11, thoracoscopic pericardial fenestration'21,and open sub-xiphosternal pericardiotomy'1', to radicalpericardectomy.This paper deals with thoracoscopic fenestrationassisted by video-endoscopy. Owing to the transmissionof visual information from the video camera to a monitor,this method combines the advantage of minimal invasive-ness with the possibilities of surgical techniques.Case historiesCASE 1A 45-year-old woman was referred for diagnosticand therapeutic pericardial fenestration, because of apersistent pericardial effusion and pericardial thickeningassociated with cardiomegaly of uncertain origin knownsince 1980. This procedure was performed on 29 August1990 under endotracheal anaesthesia using the double-lumen technique. Three hundred millilitres of effusionfluid (cytologically and bacteriologically negative)were withdrawn and a pericardial window was mademeasuring 4x4cm (histology: chronic connective tissueproliferation). The postoperative course was uneventful.The drain could be withdrawn after 24 h and post-operative hospitalization lasted 3 days. Eleven monthslater, the patient was symptom-free without medicationand follow-up echocardiography showed normal cardiacperformance.Submitted for publication on 3 January 1992. and in revised form 10 July 1992Correspondence- R. Inderbilzi. MD. Depl. of Thoracic and CardiovascularSurgery, University of Berne, 3010 Berne, Switzerland.CASE 2A 64-year-old man underwent an upper lobe resectionof the left lung in 1984 after discovery of an adeno-carcinoma. On 9 April 1991, a pericardial effusion had tobe evacuated as an emergency due to acute pericardialtamponade. Cytology of the effusion fluid revealedadenocarcinoma cells consistent with the histology ofthe lung carcinoma removed in 1984. Recurrence of peri-cardial effusion required thoracoscopic pericardialfenestration. The pre-operative computer tomogramdemonstrated thickening of the bronchial walls in the leftlower lobe, of the pericardium and of the left pleura. Dueto the presence of pleural scarring, palliative pericardialfenestration was performed through the right pleuralcavity under general anaesthesia using the double-lumentube. Intra-operatively, 500 ml of a blood-tinged effusionfluid was again withdrawn from the pericardial cavity.Through a T-shaped incision, a triangular-shapedwindow measuring 5 x 4 x 4 cm was created by removal ofa corresponding pericardial flap. Postoperative drainagecontinued for 24 h, and the patient was discharged after 4days. Two months later the patient was free of cardiacsymptoms and shows no signs of cardiomegaly.CASE 3A 65-year-old patient with recurrent myopericarditisshowed signs compatible with pericardial effusion atechocardiography. To confirm the diagnosis, a left-sidedthoracoscopic pericardial biopsy was planned underendotracheal anaesthesia using the double-lumen tech-nique. Endoscopic exploration demonstrated that peri-cardial movements were synchronous with the heartaction. The thickened pericardium could not be graspedwith the endoscopy forceps. Open transthoracic perimyo-cardial biopsy was then performed showing completeobliteration of the pericardical space in the area visualisedby endoscopy. The histological preparation revealed thediagnosis of active, non-specific, fibrinous, constrictivepericarditis. One month later, peri-epicardectomy had tobe carried out in order to release the severly constrictedright ventricle.0I95-668X 93 010135 + 03 S08.000 © 1993 The European Society of Cardiology136 R. fnderbitzi eta\.Figure 1 Portal placements.Operative techniqueThe operation is performed with the patient in thelateral position under general anaesthesia using a double-lumen endobronchial tube. Three incisions are made inthe axillary triangle formed by the axilla, the lower borderof the major pectoralis muscle and the anterior border ofthe latissimus dorsi muscle, in the third, fourth and fifthintercostal spaces, with a distance of at least 6 cm betweeneach portal (Fig. 1). A trocar is placed into the first skinincision and then the straight telescope connected to thevideo camera is inserted. The endoscopic procedure istransmitted to a TV monitor. The other two trocars arethen inserted with the aid of endoscopic viewing. Afterinduction of the pneumothorax, routine diagnostic in-spection of the whole thoracic cavity is carried out.Any pathological finding should be submitted to biopsy.The external surface of the pericardium is inspected andthe phrenic nerve identified. Fenestration is plannedanteriorly or posteriorly to the nerve, depending on itsanatomical course. The pericardium is carefully graspedand elevated using atraumatic forceps. After incision ofthe pericardial sac using scissors or a scalpel with arounded tip, the effusion fluid is carefully evacuatedand sent for bacteriological, cytological and chemicalanalysis. Suction of the epicardium should be avoidedto prevent serious disturbances of cardiac rhythm.Incidental supraventricular extrasystoles due to surgicalmanipulation can, however, hardly be averted. Followingopening of the pericardial cavity, a flap of the desired sizeis prepared (Fig. 2). The fenestration terminates after ameticulous check for haemostasis. Through the createdwindow, a considerable section of the pericardial cavitycan be carefully sounded and explored for adhesions,using an angled, blunt probe. At the end of the procedurea (24-gauge Charriere) chest tube is inserted through theFigure 2 Endoscopic view. A pericardial flap is created usingforceps and scissors. Note the diaphragm (on the left), the medias-tinum (on the top) and the pericardium with the phrenic nerve.most distal incision of the thoracic wall and positionedunder visual control with the tip ventro-basally in theangle between the pericardium and the diaphragm. Thesubsequent evacuation of the pneumothorax is performedas the telescope is gradually withdrawn, finally togetherwith the trocar. Postoperatively, the catheter is connectedto a water-seal drainage bottle and a pressure of — 15 cmof water is applied for 12 h. The chest tube is removedwhen subsequent X-ray control has shown the lung to befully re-expanded.DiscussionThe timing of therapeutic intervention is primarilydictated by the clinical symptomatology. Special atten-tion has to be directed to the development of the effusion,since a rapid increase can lead to acute tamponade'4'.The decision to intervene is supported by the echocardio-graphic findings. Thoracoscopy not only enables aspir-ation of recurrent pericardial effusion under visualcontrol, the procedure also facilitates an accurate diag-nosis, because it offers possibilities for inspection andguided biopsy of pathological processes'251. The accuracyof the latter method should certainly be equivalent toopen biopsy, which provides the correct diagnosis in 90%of the patients suffering from pericardial effusions ofmalignant origin'61.The main benefit of endoscopy in a preexisting anatom-ical cavity is based on the favourable relation betweenminimal surgical access and anatomical oversight. Byemploying the video technique, the intervention can beextended to the target organ without additional enlarge-ment of the access and. if indicated, adequate therapeuticfenestration of the pericardial sac can be performedPericardia! biopsy andfenestration 137simultaneously. The diagnosis (aspiration, biopsy) andtherapeutic (fenestration) manoeuvres can be performedunder visual control, thus clearly reducing the risk of aheart injury. This technique avoids accidental opening ofthe abdomen or possible injury to the anterior abdominalwall by intramuscular bleeding; these complications mayoccasionally occur, however, during surgical proceduresusing the sub-xiphosternal route'31.The anatomically more suitable left pleural cavityshould be used as the standard access. If the pleural spaceis obliterated in the area of thoracostomy, as found inour second case, access through the right thoracic cavityoffers an alternative. However, fenestration of the peri-cardial sac from the right side is difficult for severalreasons, and not without risk; the pericardium does notprotude but lies flat, and the available surface is smallerthan on the left side. Furthermore, on the videoscope theright atrium is hard to differentiate in colour from thebluish shimmering pericardium. Injuries to the thin atrialwall may thus occur. The incision of the pericardial sacshould therefore be made very carefully in the elevatedpericardium. Disorders of cardiac rhythm should be inter-preted as a signal that the forceps could have grasped theright atrial wall together with the pericardium. Afterevacuation of the effusion, step-by-step extension of theincision should be preceded by careful probing of thepericardial cavity, in order to detect potential adhesionsbetween the pericardium and atrium.The exsudative form of constrictive pericarditis canrender the thoracoscopic opening and fenestration im-possible, since the obliterative process frequently does notpermit the pericardium to be grasped and safely elevated.As illustrated by our third example, in this situation theendoscopic technique may not be considered a safealternative to open pericardial biopsy, even if there isechocardiographic evidence of pericardial effusion. Inaddition, the third case emphasizes the importance of thepre-operative echocardiogram, since obliteration of thepericardium is clearly a contraindication to endoscopictechniques.References[1] Callahan JA, Seward JB, Tajik AJ et al. Pericardiocentesisassisted by two dimentional echocardiography. J ThoracicCardiovasc Surg 1983; 85: 877-9.[2] Vogel B, Mall W. Thorakoskopische Perikardfensterung —diagnostische und therapeutische Aspekte. Pneumologie 1990;44: 184-5.[3] Little AG, Kremser PC, Wade JL, Levett JM, DeMeester TR,Skinner DB. Operation for diagnosis and treatment of peri-cardial effusions. Surgery 1984, 96' 738-44.[4] Fraser RS, Viloria JB, Wang NS. Cardiac tamponade as apresentation of extracardiac malignancy. Cancer 1980; 45:1697-1704.[5] Loddenkemper R. Diagnostik des Pleuraergusses. InternistischeWelt 1983, 10: 293-301[6] Kralstein J, Frishman W. Malignant pericardial diseases:Diagnosis and treatment Am Heart J 1987; 113-785-90.

Pericardial biopsy and fenestration

Employing a video thoracoscopic pericardial fenestration constitutes a promising technique for the investigation and treatment of chronic pericardial effusions. It combines the benefit of low invasiveness with the advantages of open biopsy. The procedure simultaneously allows both an accurate diagnosis under visual control (inspection, aspiration, well-targeted biopsy of pathological processes) and the performance of effective therapeutic intervention. Without imposing unacceptable stress, it also facilitates rapid symptom relief in patients with advanced malignant disease whose general condition is severely impaired

Pericardial biopsy and fenestration

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