OPERATIONS ON THE PERICARDIUM—A Review of Current Surgical Procedures

Improved management of pericardial disease has resulted from a better understanding of the pathological physiology and refined surgical technique.In acute cardiac tamponade from trauma, our experience has shown that simple pericardial aspiration, because it relieves the tamponade, renders open operation unnecessary unless the hemorrhage is unusually severe. However, in chronic tamponade, from prolonged pericardial bleeding or effusion, the “pericardio-pleural window” operation described in this article will safely decompress the pericardium without secondary infection and the necessity of reoperation. With chronic constrictive pericarditis, on the other hand, catheterization studies reveal that left heart constriction is more important than that of the right heart or vena cavae. So it is important to pay more attention to decortication of the left heart than was formerly believed.Excision of pericardial tumors, most often cystic, is indicated because they are indistinguishable from malignant growths, although they in themselves are not of serious import.Fatty and fibrous pericardium have proved to be suitable viable material for various plastic operations on the heart, lung and esophagus. Finally, experience with poudrage to revascularize the myocardium is proving that this is a very satisfactory technique which can be performed with minimal risk.     

A novel technique for measurement of pericardial pressure

To determine whether pericardial liquid pressure accurately measures pericardial constraint, we developed a technique in which a catheter was positioned perpendicular to the epicardial surface. This device, which occupies little or no pericardial space, couples the thin film of liquid to a transducer. In six open-chest dogs, we also measured left ventricular (LV) end-diastolic pressure (LVEDP) and anteroposterior and septum-to-free wall diameters. LVEDP was raised incrementally to approximately 25 mmHg by saline infusion. With the use of the product of the two diameters as an index of area (A(LV)), LVEDP-A(LV) relationships were obtained with the pericardium closed and again after the pericardium had been widely opened to obtain the isovolumic difference in LVEDP (DeltaLVEDP). In all dogs, the technique yielded values of pericardial pressure equal to DeltaLVEDP as well as equal to that measured using a previously placed balloon transducer in the same location and at the same A(LV). We conclude that, when the pressure of the pericardial liquid is appropriately measured, it (in addition to the balloon-measured contact stress) defines the diastolic constraining effect of the pericardium. Furthermore, we suggest that earlier measurements of pericardial "liquid pressure" were low, due to an artifact of measurement.     

MRI-determined left ventricular "crescent effect": a consequence of the slight deviation of contents of the pericardial sack from the constant-volume state

During one cardiac cycle, the volume encompassed by the pericardial sack in healthy subjects remains nearly constant, with a transient +/-5% decrease in volume at end systole. This "constant-volume" attribute defines a constraint that the longitudinal versus radial pericardial contour dimension relationship must obey. Using cardiac MRI, we determined the extent to which the constant-volume attribute is valid from four-chamber slices (two-dimensional) compared with three-dimensional volumetric data. We also compared the relative percentage of longitudinal versus radial (short-axis) change in cross-sectional area (dimension) of the pericardial contour, thereby assessing the fate of the +/-5% end-systolic volume decrease. We analyzed images from 10 normal volunteers and 1 subject with congenital absence of the pericardium, obtained using a 1.5-T MR scanner. Short-axis cine loop stacks covering the entire heart were acquired, as were single four-chamber cine loops. In the short-axis and four-chamber slices, relative to midventricular end-diastolic location, end-systolic pericardial (left ventricular epicardial) displacement was observed to be radial and maximized at end systole. Longitudinal (apex to mediastinum) pericardial contour dimension change and pericardial area change on the four-chamber slice were negligible throughout the cardiac cycle. We conclude that the +/-5% end-systolic decrease in the volume encompassed by the pericardial sack is primarily accounted for by a "crescent effect" on short-axis views, manifesting as a nonisotropic radial diminution of the pericardial/epicardial contour of the left ventricle. This systolic drop in cardiac volume occurs primarily at the ventricular level and is made up during the subsequent diastole when blood crosses the pericardium in the pulmonary venous Doppler D wave during early rapid left ventricular filling.     

Influence of involvement of anterior leaflet versus posterior leaflet on residual regurgitation as assessed by transesophageal echocardiography in patients undergoing valve repair for mitral regurgitation due to mitral valve prolapse

Cardiac tamponade is the phenomenon of hemodynamic compromise caused by a pericardial effusion. Following a myocardial infarction, the most common causes of pericardial fluid include early pericarditis, Dressler's syndrome, and hemopericardium secondary to a free wall rupture. On transthoracic echocardiography, pericardial fluid appears as an echo-free space in between the visceral and parietal layers of the pericardium. Pericardial fat has a similar appearance on echocardiography and it may be difficult to discern the two entities. We present a case of a post-MI patient demonstrating pseudo tamponade physiology in the setting of excessive pericardial fat.     

Fine Structure of Heart,Pericardium and Glomerular Vessel in Cephalodiscus gracilis M'Intosh, 1882 (Pterobranchia,Hemichordata)

Heart, pericardium and glomerular vessel of Cephalodiscus gracilis have been studied with the electron microscope. The lumen of the heart is lined by a basal lamina and an associated epithelium, composed of myoepithelial cells with well developed thin and thick myofilaments. The heart is located in the pericardial cavity, which is deliminated by the pericardium. The latter is composed of two flat layers of myoepithelia with fused basal laminae. The outer layer of the pericardium is the protocoelomic lining, and the inner layer is the ‘parietal’ pericardial epithelium. The myoepithelium forming the heart wall can be considered to represent the ‘visceral’ pericardial epithelium. The spacious glomerular vessel is lined by a basal lamina, on which typical podocytes rest. These cells indicate that ultrafiltration takes place through the wall of the glomerular vessel. The lumen of the vessel contains fine granular material (presumably precipitated blood proteins), fibrils with a faint cross striation, suggesting that they represent collagen, and stellate cells, which in part line the vessel. Since ultrafiltration requires hydrostatic pressure, it is inferred that the blood flow is from the dorsal region then through the heart and into the glomerular vessel.     

Juxtacardiac pressure in closed-chest dogs

We studied pressure (Ppc)-volume (Vpc) relationships of the pericardial sac by inserting air into it at constant end-diastolic heart volume in six dogs. The lungs were inflated by positive alveolar pressure while pleural pressure was monitored using the esophageal balloon technique. Ppc-Vpc relationships were measured at transpulmonary pressures (PL) of 30, 10, and 5 cmH2O in each of three states: closed chest, open chest with lung separation, and open chest with the pericardium dissected free of its mediastinal attachment. Ppc in the closed-chest condition was more positive than Ppc in the open chest with lung separation, with increase of Vpc and PL, which suggests that the lungs compress the pericardium. Ppc in the open-chest condition with lung separation was also more positive than Ppc in the pericardium after it was dissected free, which suggests that mediastinal attachment compresses the pericardium. It is suggested that lungs in the closed-chest condition as well as mediastinal attachment reduce the heart expansion by a similar magnitude.     

Cardiac tamponade as a presentation of malignant thymoma

Morphologic, cytochemical and immunocytochemical studies of pericardial fluid from a 30-year-old man presenting with cardiac tamponade are described. Based on the results of the immunocytochemical studies and the histologic examination of excised pericardium, a diagnosis of malignant thymoma was made. This is the first documented case in which malignant cells were found in the pericardial effusion in a patient with invasive thymoma. The significance of using a multidisciplinary approach to the study of body fluids is discussed.     

Primary malignant lymphoma of the heart. Antemortem cytologic diagnosis

A case of primary malignant lymphoma of the heart diagnosed cytologically is reported. The patient presented with pericardial tamponade and ventricular arrhythmias and developed rapidly progressive and intractable cardiac failure. Two-dimensional echo-cardiography, which demonstrated the pericardial effusion, showed progressive impairment of the left ventricular contraction. The pericardial fluid contained malignant lymphoid cells. Despite vigorous treatment and chemotherapy, the patient died within 15 days; postmortem examination showed malignant lymphoma confined to the myocardium.     

Atrioventricular nonuniformity of pericardial constraint

Physiologists and clinicians commonly refer to "pressure" as a measure of the constraining effects of the pericardium; however, "pericardial pressure" is really a local measurement of epicardial radial stress. During diastole, from the bottom of the y descent to the beginning of the a wave, pericardial pressure over the right atrium (P(pRA)) is approximately equal to that over the right ventricle (P(pRV)). However, in systole, during the interval between the bottom of the x descent and the peak of the v wave, these two pericardial pressures appear to be completely decoupled in that P(pRV) decreases, whereas P(pRA) remains constant or increases. This decoupling indicates considerable mechanical independence between the RA and RV during systole. That is, RV systolic emptying lowers P(pRV), but P(pRA) continues to increase, suggesting that the relation of the pericardium to the RA must allow effective constraint, even though the pericardium over the RV is simultaneously slack. In conclusion, we measured the pericardial pressure responsible for the previously reported nonuniformity of pericardial strain. P(pRA) and P(pRV) are closely coupled during diastole, but during systole they become decoupled. Systolic nonuniformity of pericardial constraint may augment the atrioventricular valve-opening pressure gradient in early diastole and, so, affect ventricular filling.     

Evaluating the role of autologous mesenchymal stem cell seeded on decellularized pericardium in the treatment of myocardial infarction: an animal study

Inappropriate left ventricular remodeling following myocardial infarction (MI) can result in subsequent severe dysfunction. In this study, we tested the hypothesis that decellularized pericardium (DP) or seeded pericardial patch with autologous adipose-derived mesenchymal stem cells (ADMSCs) could be safely used in a MI scar and could improve heart function. Twelve rabbits were randomly divided into three equal groups. Four weeks after MI induction by ligation of the left anterior descending artery in 12 rabbits, animals of G1 (n = 4) received DP patch with labeled ADMSCs. DP patch was implanted in animals of G2 (n = 4). Rabbits of G3 (n = 4) remained without any intervention after MI induction (control group). Serial examinations including echocardiography, electrocardiography (ECG), scanning electron microscopy, histology and immunohistochemistry (IHC) were performed to evaluate the efficacy of the implanted scaffolds on recovery of the infracted myocardium. The results demonstrated that left ventricular contractile function and myocardial pathological changes were significantly improved in rabbits implanted with either DP or ADMSC-seeded pericardium. However, the seeded pericardium was more effective in scar repairing 2 months after the operation, IHC staining with Desmin and CD34 and positive immunofluorescence staining verified the differentiation of ADMSCs to functional cardiomyocytes. This approach may involve the application of autologous ADMSCs seeded on pericardial patch in an attempt to regenerate a contractible myocardium in an animal model of MI.     

Opening the pericardium during pulmonary artery constriction improves cardiac function.

During acute pulmonary hypertension, both the pericardium and the right ventricle (RV) constrain left ventricular (LV) filling; therefore, pericardiotomy should improve LV function. LV, RV, and pericardial pressures and RV and LV dimensions and LV stroke volume (SV) were measured in six anesthetized dogs. The pericardium was closed, the chest was left open, and the lungs were held away from the heart. Data were collected at baseline, during pulmonary artery constriction (PAC), and after pericardiotomy with PAC maintained. PAC decreased SV by one-half. RV diameter increased, and septum-to-LV free wall diameter and LV area (our index of LV end-diastolic volume) decreased. Compared with during PAC, pericardiotomy increased LV area and SV increased 35%. LV and RV compliance (pressure-dimension relations) and LV contractility (stroke work-LV area relations) were unchanged. Although series interaction accounts for much of the decreased cardiac output during acute pulmonary hypertension, pericardial constraint and leftward septal shift are also important. Pericardiotomy can improve LV function in the absence of other sources of external constraint to LV filling.     

The density of myocardial and pericardial rat mast cells in isoproterenol-induced heart failure

Myocardial mast cells (MC) respond to cardiovascular pathology. The behavior of MC population in myocardium and pericardium of rats has been studied 24 h, 14, 28 and 60 days after two isoproterenol injections (at 24 h intervals). The extent of heart failure has been estimated by supersonic inspection 28 and 60 days after isoproterenol injections. The density of MCs of different degrees of maturity was estimated on paraffin sections stained with Alcian blue--Safranin. The MC density in myocardium of intact and experimental rats was relatively low: from 4 to 6 cells/mm2. The MC density in pericardium of intact rats was several times higher than in myocardium: 48.6 +/- 13.0 cells/mm2. In 24 h and 14 days after isoproterenol injections the pericardial MC density was 1.5 times higher than in control rats (P < 0.05) at the expense of increase in the number of mature MCs with Safranine-positive granules without the increase in the number of immature cells with Alcian blue-positive granules. In 28 days the pericardial MC density was 2 times higher than in intact rats (P < 0.05) at the expense of increase in number of immature and mature cells. In 60 days after isoproterenol injections the pericardial MC density and the ratio of immature and mature cells compared with control did not reach statistical significance. The changes in pericardial MC population corresponded to severity of heart failure according to functional indices. The findings show active reaction of pericardial MCs on myocardium dysfunction that stimulates the maturation of resident immature MCs in pericardium and migration of immature cells to pericardium of damage heart.     

Immunolocalization of ANP in mast cells of rat and human pericardium

It is known that many heart diseases are accompanied by a significant increase in the level of atrial natriuretic peptide (ANP), a regulator of cardiovascular homeostasis, in the pericardial fluid. Cellular sources of ANP in pericardial cavity remain uncertain. By EM immunocytochemistry, we have examined the presence and localization of ANP in rat and human pericardium. ANP-immunoreactive material was revealed in granules of mast cells (MCs) situated in connective tissue of the pericardium. MCs have an oval form and measure about 6.5 x 12.5 and 9.1 x 13.6 microm in the rat and human pericardium, respectively. Density of MC population makes up about 50 and 10 cells/mm2 in the rat and human pericardium, respectively. Our data suggest possible participation of the pericardial MCs in endocrine function of pericardium and in control of the ANP level in pericardial cavity.     

Functional analysis of bioprosthetic heart valves

Glutaraldehyde-treated bovine pericardium is used successfully as bioprosthetic material in the manufacturing of heart valves leaflets. The mechanical properties of bovine pericardial aortic valve leaflets seem to influence its mechanical behaviour and the failure mechanisms. In this study the effect of orthotropy on tricuspid bioprosthetic aortic valve was analysed, using a three-dimensional finite element model, during the entire cardiac cycle. Multiaxial tensile tests were also performed to determine the anisotropy of pericardium. Seven different models of the same valve were analysed using different values of mechanical characteristics from one leaflet to another, considering pericardium as an orthotropic material. The results showed that even a small difference between values along the two axes of orthotropy can negatively influence leaflets performance as regard both displacement and stress distribution. Leaflets of bovine pericardium bioprostheses could be manufactured to be similar to natural human heart valves reproducing their well-known anisotropy. In this way it could be possible to improve the manufacturing process, durability and function of pericardial bioprosthetic valves.     

Morphofunctional bases of the choice of nerves for reinnervation of transplanted heart]

In two series of experiments on 61 dogs it was found that from all the nerves approaching the heart, the largest are on the ascending aorta, pulmonary trunk and pericardium transilicual tuck along which they cross the left pulmonary artery on the way to the dorsal surface of this organ. These nerves are able to provide the adequate heart activity under cardiovascular system loading. It is they that should be primarily used for transplanted heart reinnervation.     

Histological, histochemical and ultrastructural studies on the bulbus arteriosus of the sticklebacks, Gasterosteus aculeatus and Pungitius pungitius (Pisces: Teleostei)

The bulbar wall has three layers. Its lining consists of squamous-columnar endothelial cells that store neutral mucopolysaccharides and are PAS-positive. They do not contain large amounts of acid phosphatase, acid mucopolysaccharides, glycogen or lipids. A morphometric analysis shows that 32% of the cell volume in Pungitius and 12% in Gasterosteus is occupied by specific granules, 100–600 nm in diameter. According to X-ray probe micro-analysis, these granules bind chromium ions, even though the endothelial cells do not contain catecholamines. Rootlets, packed with plasmalemmal vesicles, extend from the endothelial cells into the middle layer of the bulbus. Here, smooth muscle cells alternate with elastic fibres. The staining reactions of bulbar elastica are compared with those in the mammalian aorta and the ligamentum nuchae. The outer layer of the bulbus is visceral pericardium and beneath its covering mesothelial cells are numerous collagen fibres, non-myelinated nerves, occasional fibroblasts and melanocytes. Scanning electron microscopy shows that the bulbar lining is thrown into longitudinal folds, but that there are no trabeculae subdividing the lumen.
Many features of the bulbus arteriosus may be related to the low systolic pressures of teleosts and to the proximity of their heart and gills. In contrast to mammals, only a small part of the arterial system can act as a windkessel. The bulbus is thus more distensible than the mammalian aorta and must lie within the pericardial cavity so that its greater excursions can be accommodated. Perhaps because the bulbus is so distensible, it has elastic fibres rather than lamellae. This in turn may affect the organization of the smooth muscle cells which do not form "span muscles" as in some mammalian aortae. Like most cells in the bulbus, they are joined to others by desmosomes. Evidently, firm cohesion is important in highly distensible vessels.     

The pericardium and cardiac transmural filling pressure in the fetal sheep

Fetal pericardial physiology may be important for understanding normal and abnormal circulatory states. Right atrial, pericardial, thoracic, and amniotic fluid pressures were measured simultaneously in chronically-instrumented, near-term fetal sheep. Fourteen experiments were performed in 8 fetuses 4-21 days after surgery. The pressure gradient from the right atrium to the amniotic fluid and its components (transatrial, transpericardial and transthoracic pressures) were measured during control and with rapid infusion and withdrawal of blood. Under control conditions, right atrial minus amniotic pressure was 3.2 +/- 1.8 (SD) torr, right atrial minus pericardial pressure 2.5 +/- 1.7, pericardial minus thoracic pressure 0.6 +/- 0.7, and thoracic minus amniotic pressure 0.1 +/- 1.4. At right atrial pressures above control, pericardial minus thoracic pressure rose linearly with right atrial minus thoracic pressure. The average regression coefficient was 0.50 with an intercept of -1.5 torr. Administration of dextran-saline solution (121% of estimated blood volume) over 2-4 hs in 10 experiments did not reduce the pericardial minus thoracic to right atrial minus thoracic pressure relationship. Fluid added to the pericardium of three lambs progressively shifted the pericardial minus thoracic to right atrial minus thoracic pressure relationship up and to the left. The pericardial minus thoracic to right atrial minus thoracic pressure relationship was unaffected by fetal growth. Thus, the fetal pericardium affects cardiac filling pressures. The affect of the pericardium is increased markedly by pericardial liquid but is unchanged during growth.     

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

Morphological analysis of the hagfish heart. II. The venous pole and the pericardium

The morphological characteristics of the venous pole and pericardium of the heart were examined in three hagfish species, Myxine glutinosa, Eptatretus stoutii, and Eptatretus cirrhatus. In these species, the atrioventricular (AV) canal is long, funnel‐shaped and contains small amounts of myocardium. The AV valve is formed by two pocket‐like leaflets that lack a papillary system. The atrial wall is formed by interconnected muscle trabeculae and a well‐defined collagenous system. The sinus venosus (SV) shows a collagenous wall and is connected to the left side of the atrium. An abrupt collagen‐muscle boundary marks the SV‐atrium transition. It is hypothesized that the SV is not homologous to that of other vertebrates which could have important implications for understanding heart evolution. In M. glutinosa and E. stoutii, the pericardium is a closed bag that hangs from the tissues dorsal to the heart and encloses both the heart and the ventral aorta. In contrast, the pericardium is continuous with the loose periaortic tissue in E. cirrhatus. In all three species, the pericardium ends at the level of the SV excluding most of the atrium from the pericardial cavity. In M. glutinosa and E. stoutii, connective bridges extend between the base of the aorta and the ventricular wall. In E. cirrhatus, the connections between the periaortic tissue and the ventricle may carry blood vessels that reach the ventricular base. A further difference specific to E. cirrhatus is that the adipose tissue associated with the pericardium contains thyroid follicles. J. Morphol. 277:853–865, 2016. © 2016 Wiley Periodicals, Inc.     

FIRST HEART SOUND ALTERNANS IN MASSIVE PERICARDIAL EFFUSION

First heart sound alternans in the absence of pulsus alternans, or variation in heart rate (i.e., variation in PR interval), occurring in a patient with massive neoplastic pericardial effusion is described. The mechanism appears to be similar to that in electrical alternans and is shown by echocardiography to be related to the cardiac position within the pericardium, with the first heart sound intensity varying according to the distance of the heart from the chest wall. First heart sound alternans, electrical alternans, and alternating cardiac motion within the pericardium disappeared following pericardiocentesis.