Should the pericardium be closed in patients undergoing cardiac surgery
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《血管的通路杂志》
Department of Cardiothoracic Surgery, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK
Abstract
A best evidence topic in Cardiothoracic Surgery was written according to a structured protocol. The question addressed was in open heart surgery is there any adverse effect to closing the pericardium Altogether 240 publications were found using the reported search of which 8 were deemed to be relevant to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the adverse haemodynamic impact of pericardial closure is confirmed in several studies, however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.
Key Words: Evidence-based medicine; Cardiac surgery; Pericardial closure
1. Introduction
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
You have been trained to leave the pericardium open after a routine cardiac surgery procedure because in the early postoperative period the patient's haemodynamic performance is better and there is less incidence of graft failure. In addition there is also said to be a reduced incidence of cardiac tamponade. You begin to question this teaching, especially in view of the benefit of a closed pericardium when it comes to re-do surgery. You decide to scrutinise the published literature with regard to the pitfalls of closing the pericardium.
3. Three part question
In [patients undergoing cardiac surgery] does [pericardial closure] affect [outcome]
4. Search strategy
Medline 1966–Nov 2004 using the OVID interface
[exp thoracic surgery OR exp cardiac surgical procedures OR heart surgery.mp] AND [exp pericardium OR pericardial.mp] AND [clos$.mp]
5. Search outcome
Using the above search strategy 240 publications were found of which 8 were deemed to be relevant. Two of the publications were not directly included as they were letters commenting on the identified studies. One study was in an animal model and was excluded on this basis. No additional papers were identified by widening the search strategy or by looking in the references section of the identified papers. These papers are included in Table 1.
6. Results
Various institutions have attempted to answer the question we posed. Only two groups implemented a prospective randomized study. Rao et al. [2] randomized 42 patients who were having coronary artery bypass grafting to pericardial closure or leaving the pericardium open. They found that cardiac index and stroke work index were lower in the closure group compared to the open group (P<0.001), however, these difference were only present for one hour post operatively and at 4 h and 8 h post operatively no difference could be determined. Bhatnagar et al. [3] conducted a prospective randomised study to assess the impact of a tension-free pericardial closure with the use of a gortex membrane and found no significant difference with or without its use on early mortality, complications, bleeding or post operative ischaemic events in a cohort of patients who had all had coronary artery bypass graft surgery. Bhatnagar et al. [3] did not report any data regarding differences between groups in terms of their haemodynamic performance in the early post operative period. The adverse impact of pericardial closure haemodynamically was confirmed by several of the other studies [2,4–8]. No study reported an adverse clinical outcome due to the closure of the pericardium.
Daughters et al. [4] measured cardiac output and stroke work index in patients immediately after operation and found that removal of the pericardial suture immediately improved left ventricular haemodynamics. This finding raises concerns about pericardial closure in patients with marginal preoperative left ventricular function or in those patients with postoperative ventricular dysfunction who require high preloads to maintain cardiac output.
Only three studies [2,3,8] concentrated on patients who had coronary artery bypass graft surgery, two studies included a mixture of cases [7,9], and the remainder included only patients who had had valve surgery [4–6,8]. None of the studies followed up patients to find out if the mortality was lower in patients having re-sternotomy with a closed or open pericardium.
7. Clinical bottom line
The adverse haemodynamic impact of pericardial closure is confirmed in several studies; however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.
Appendix A. ICVTS on-line discussion
Author: Shahzad G. Raja (Royal Hospital for Sick Children, Glasgow, UK)
eComment: I read with interest the article by Bittar et al. and appreciate their effort in trying to find the answer to an improtant issue which has implications especially for patients undergoing reoperative cardiac surgery. The authors have looked at the impact of primary closure of pericardium on postoperative cardiac and hemodynamic function and have rightly concluded that despite all studies suggesting adverse hemodynamic sequelae, none have reported adverse clinical outcome. However, they fail to give a definite answer to their original query: Should the pericardium be closed in patients undergoing cardiac surgery
The question raised by the authors has much more significance for patients undergoing cogenital cardiac surgery. Most patients with complex congenital cardiac defects require repeated operations and for them, closure of the pericardium is important so as to ensure a safer entry at the time of repeat sternotomy. In my opinion, in all those patients where a reoperation is anticipated, pericardium must be closed. However, at the same time it is important to realize that primary pericardial closure is not feasible in all instances. The need for increased filling pressures, the anticipation of postoperative bleeding, occasional interference with the course of internal mammary pedicles, and placement of an extracardiac conduit (after congenital cardiac surgery) may preclude primary pericardial closure. In such instances, a loosely applied patch of bioresorbable material would not only serve the purpose of pericardial closure but would lead to satisfactory hemodynamic function in the early postoperative phase and the later development of a free dissection plane for any reoperation.
References
Dunning J, Prendergast B, Mackway-Jones K. Towards evidence based medicine in cardiothoracic surgery: best BETS. Interactive CardioVasc Thorac Surg 2003;2:405–409.
Rao V, Komeda M, Weisel RD, Cohen G, Borger MA, David TE. Should the pericardium be closed routinely after heart operations Ann Thorac Surg 1999;67:484–488.
Bhatnagar G, Fremes SE, Christakis GT, Goldman BS. Early results using an ePTFE membrane for pericardial closure following coronary bypass grafting. J Card Surg 1998;13:190–193.
Daughters GT, Frist WH, Alderman EL, Derby GC, Ingels NB Jr., Miller DC. Effects of the pericardium on left ventricular diastolic filling and systolic performance early after cardiac operations. J Thorac Cardiovasc Surg 1992;104:1084–1091.
Hunter S, Smith GH, Angelini GD. Adverse hemodynamic effects of pericardial closure soon after open heart operation. Ann Thorac Surg 1992;53:425–429.
Izzat MB, Anderson M, Wilde P, Wisheart JD, Bryan AJ, Angelini GD. Hemodynamic effects and echocardiographic consequences of tension-free pericardial closure after heart valve surgery. J Heart Valve Dis 1994;3:295–299.
Jarvinen A, Peltola K, Rasanen J, Heikkila J. Immediate hemodynamic effects of pericardial closure after open-heart surgery. Scand J Thorac Cardiovasc Surg 1987;21:131–134.
Damen J, Bolton DT. Acute hemodynamic effects of pericardial closure in man. Acta Anaesthesiol Scand 1989;33:207–209.
Nandi P, Leung JS, Cheung KL. Closure of pericardium after open heart surgery. A way to prevent postoperative cardiac tamponade. Br Heart J 1976;38:1319–1323.(Mohamed N. Bittar, James )
Abstract
A best evidence topic in Cardiothoracic Surgery was written according to a structured protocol. The question addressed was in open heart surgery is there any adverse effect to closing the pericardium Altogether 240 publications were found using the reported search of which 8 were deemed to be relevant to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the adverse haemodynamic impact of pericardial closure is confirmed in several studies, however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.
Key Words: Evidence-based medicine; Cardiac surgery; Pericardial closure
1. Introduction
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
You have been trained to leave the pericardium open after a routine cardiac surgery procedure because in the early postoperative period the patient's haemodynamic performance is better and there is less incidence of graft failure. In addition there is also said to be a reduced incidence of cardiac tamponade. You begin to question this teaching, especially in view of the benefit of a closed pericardium when it comes to re-do surgery. You decide to scrutinise the published literature with regard to the pitfalls of closing the pericardium.
3. Three part question
In [patients undergoing cardiac surgery] does [pericardial closure] affect [outcome]
4. Search strategy
Medline 1966–Nov 2004 using the OVID interface
[exp thoracic surgery OR exp cardiac surgical procedures OR heart surgery.mp] AND [exp pericardium OR pericardial.mp] AND [clos$.mp]
5. Search outcome
Using the above search strategy 240 publications were found of which 8 were deemed to be relevant. Two of the publications were not directly included as they were letters commenting on the identified studies. One study was in an animal model and was excluded on this basis. No additional papers were identified by widening the search strategy or by looking in the references section of the identified papers. These papers are included in Table 1.
6. Results
Various institutions have attempted to answer the question we posed. Only two groups implemented a prospective randomized study. Rao et al. [2] randomized 42 patients who were having coronary artery bypass grafting to pericardial closure or leaving the pericardium open. They found that cardiac index and stroke work index were lower in the closure group compared to the open group (P<0.001), however, these difference were only present for one hour post operatively and at 4 h and 8 h post operatively no difference could be determined. Bhatnagar et al. [3] conducted a prospective randomised study to assess the impact of a tension-free pericardial closure with the use of a gortex membrane and found no significant difference with or without its use on early mortality, complications, bleeding or post operative ischaemic events in a cohort of patients who had all had coronary artery bypass graft surgery. Bhatnagar et al. [3] did not report any data regarding differences between groups in terms of their haemodynamic performance in the early post operative period. The adverse impact of pericardial closure haemodynamically was confirmed by several of the other studies [2,4–8]. No study reported an adverse clinical outcome due to the closure of the pericardium.
Daughters et al. [4] measured cardiac output and stroke work index in patients immediately after operation and found that removal of the pericardial suture immediately improved left ventricular haemodynamics. This finding raises concerns about pericardial closure in patients with marginal preoperative left ventricular function or in those patients with postoperative ventricular dysfunction who require high preloads to maintain cardiac output.
Only three studies [2,3,8] concentrated on patients who had coronary artery bypass graft surgery, two studies included a mixture of cases [7,9], and the remainder included only patients who had had valve surgery [4–6,8]. None of the studies followed up patients to find out if the mortality was lower in patients having re-sternotomy with a closed or open pericardium.
7. Clinical bottom line
The adverse haemodynamic impact of pericardial closure is confirmed in several studies; however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.
Appendix A. ICVTS on-line discussion
Author: Shahzad G. Raja (Royal Hospital for Sick Children, Glasgow, UK)
eComment: I read with interest the article by Bittar et al. and appreciate their effort in trying to find the answer to an improtant issue which has implications especially for patients undergoing reoperative cardiac surgery. The authors have looked at the impact of primary closure of pericardium on postoperative cardiac and hemodynamic function and have rightly concluded that despite all studies suggesting adverse hemodynamic sequelae, none have reported adverse clinical outcome. However, they fail to give a definite answer to their original query: Should the pericardium be closed in patients undergoing cardiac surgery
The question raised by the authors has much more significance for patients undergoing cogenital cardiac surgery. Most patients with complex congenital cardiac defects require repeated operations and for them, closure of the pericardium is important so as to ensure a safer entry at the time of repeat sternotomy. In my opinion, in all those patients where a reoperation is anticipated, pericardium must be closed. However, at the same time it is important to realize that primary pericardial closure is not feasible in all instances. The need for increased filling pressures, the anticipation of postoperative bleeding, occasional interference with the course of internal mammary pedicles, and placement of an extracardiac conduit (after congenital cardiac surgery) may preclude primary pericardial closure. In such instances, a loosely applied patch of bioresorbable material would not only serve the purpose of pericardial closure but would lead to satisfactory hemodynamic function in the early postoperative phase and the later development of a free dissection plane for any reoperation.
References
Dunning J, Prendergast B, Mackway-Jones K. Towards evidence based medicine in cardiothoracic surgery: best BETS. Interactive CardioVasc Thorac Surg 2003;2:405–409.
Rao V, Komeda M, Weisel RD, Cohen G, Borger MA, David TE. Should the pericardium be closed routinely after heart operations Ann Thorac Surg 1999;67:484–488.
Bhatnagar G, Fremes SE, Christakis GT, Goldman BS. Early results using an ePTFE membrane for pericardial closure following coronary bypass grafting. J Card Surg 1998;13:190–193.
Daughters GT, Frist WH, Alderman EL, Derby GC, Ingels NB Jr., Miller DC. Effects of the pericardium on left ventricular diastolic filling and systolic performance early after cardiac operations. J Thorac Cardiovasc Surg 1992;104:1084–1091.
Hunter S, Smith GH, Angelini GD. Adverse hemodynamic effects of pericardial closure soon after open heart operation. Ann Thorac Surg 1992;53:425–429.
Izzat MB, Anderson M, Wilde P, Wisheart JD, Bryan AJ, Angelini GD. Hemodynamic effects and echocardiographic consequences of tension-free pericardial closure after heart valve surgery. J Heart Valve Dis 1994;3:295–299.
Jarvinen A, Peltola K, Rasanen J, Heikkila J. Immediate hemodynamic effects of pericardial closure after open-heart surgery. Scand J Thorac Cardiovasc Surg 1987;21:131–134.
Damen J, Bolton DT. Acute hemodynamic effects of pericardial closure in man. Acta Anaesthesiol Scand 1989;33:207–209.
Nandi P, Leung JS, Cheung KL. Closure of pericardium after open heart surgery. A way to prevent postoperative cardiac tamponade. Br Heart J 1976;38:1319–1323.(Mohamed N. Bittar, James )