Pericardiectomy for Chronic Constrictive Pericarditis via Left Anterolateral Thoracotomy

Intraoperative views of the steps of total pericardiectomy via left anterolateral thoracotomy. The chest is opened through the 4th intercostal space. n. = nerve.

Two full-length parallel incisions are made 0.5 cm anterior and posterior to the left phrenic nerve and extended until the level of the pulmonary artery superiorly and the diaphragm inferiorly. Multiple silk stay sutures are placed on the incised edges to achieve adequate exposure. n. = nerve.

Dissection of the pericardium posterior to the phrenic nerve. Posteriorly, the pericardium is gently dissected from the posterolateral surface of the left ventricle and left atrial appendage. The posterior pericardium is subsequently divided to facilitate adequate mobilization until the levels of left-sided pulmonary veins and excised. n. = nerve.

The anterior pericardial flap is held between stay sutures and mobilized from the anterolateral surfaces of right ventricle, right ventricular outflow tract, and pulmonary artery. n. = nerve.

The left phrenic pedicle containing the phrenic nerve and accompanying vessels is gently dissected from the underlying left ventricle and pulmonary artery and two vascular loops are passed around it for atraumatic traction.

Using cautery dissection, a new plane is developed between the posterior surface of the sternum and anterior surface of the pericardium to extend the area of pericardial excision. APF = anterior pericardial flap; RV = right ventricle.

The anterior pericardial flap is divided into two halves between stay sutures and the thickened pericardium, including the epicardium, is excised until the right atrioventricular groove. APF = anterior pericardial flap; D = diaphragm; DP = diaphragmatic pericardium; RV = right ventricle.

Using cautery, a new cleavage plane is made to develop between the diaphragm and thickened diaphragmatic pericardium all along its length. The diaphragmatic surface of the right ventricle including the left ventricular apex is completely freed from pericardial adhesions. Subsequently, the entire width of diaphragmatic pericardium is excised in toto. APF = anterior pericardial flap; D = diaphragm; DP = diaphragmatic pericardium; RV = right ventricle; LV = left ventricle.

Intraoperative pictures of the decorticated heart with an intact phrenic pedicle. LAA = left atrial appendage; LV = left ventricle; n. = nerve; PA = pulmonary artery; RV = right ventricle. (Color version of figure is available online at http://www.optechtcs.com.)