*4.2.1 Types of pericardiectomy*

Pericardial stripping is carried out via sternotomy or lateral thoracotomy with or without cardiopulmonary bypass support [49]. Total resection is extremely difficult to perform via a thoracotomy, and median sternotomy is the preferred approach to provide definitive resection and optimise benefit [49, 55].

*Partial pericardiectomy* is defined as incomplete decortication of one or both ventricles because of severe myo-pericardial adhesions.

*Total pericardiectomy* is when wide excision of the pericardium is performed. The anatomical borders consist of the phrenic nerves posteriorly, the great vessels and intra-pericardial portion of the superior vena cava/right atrial junction superiorly and the diaphragm and inferior vena cava/right atrial junction inferiorly.

*Radical resection* is the removal of the pericardium including the anterolateral and diaphragmatic surfaces of the left and right ventricles with careful dissection posterior to the phrenic nerves to leave the left and right phrenic pedicles intact.

Epicardial involvement may be missed at surgery leading to persistent constrictive physiology post-operatively. Reoperation to remove the diseased epicardium or visceral pericardium may be required [49].

The need for cardiopulmonary bypass (CPB) should be individualised per case. Studies suggest that mortality rates are higher in patients who required CPB, but data may be skewed because its use is usually reserved for patients with a poor pre-operative status. Other indications include any coexisting cardiac conditions that may require intervention, previous cardiac surgery or partial pericardiectomy, a heavily calcified pericardial "cocoon" encasing all four cardiac chambers, post mediastinal irradiation and unintentional surgical damage to cardiac structures intraoperatively [49].

Persistent constrictive physiology and abnormal diastolic filling patterns may be seen in a percentage of patients even after successful surgery. In conjunction with symptomatic improvement, normalisation of pressure-volume loops and echocardiographic findings post pericardiectomy are used as markers of successful resection [49, 58].

### *4.2.2 Complications associated with pericardiectomy*

Pericardiectomy is a very technically challenging operation with significant morbidity and mortality performed in high-risk patients [49, 54–57, 59]. Intraoperative complications may contribute significantly to poor outcomes. Sufficient preoperative preparation prior to induction of anaesthesia is paramount to ensuring patient safety, and a multidisciplinary team approach should be used.

Massive haemorrhage should be anticipated with contingency plans in place before the administration of any anaesthetic agents. Timeous activation of a massive transfusion protocol is necessary. Cardiopulmonary bypass support should be immediately available with cannulation of femoral vessels under local anaesthesia

in select patients with severe or decompensated disease. Appropriate IV access and invasive monitoring should be established, and inotropic or vasopressor infusions drawn up and running at the time of induction of anaesthesia. Damage to underlying epicardium, myocardium and coronary vessels poses the most risk to patients contributing to an overall mortality of about 7–18% [4]. Arrhythmias are common and prompt management as per the latest ACLS guidelines.

*Low cardiac output syndrome*, defined as a cardiac index of <2.2 l/min/m, will result in a subset of patients with chronic constrictive pericarditis [49, 60]. This is a form of acute cardiac failure, and there are a number of suggested mechanisms. The underlying myocardium may be affected by prolonged constriction causing myocardial disuse atrophy; residual constriction from partial or incomplete removal of the epicardial layer results in persistent constriction; the disease process itself may affect the myocardium; prolonged abnormal diastolic filling leads to architectural changes with remodelling of the ventricles; worsening of tricuspid regurgitation with progressive right ventricular dysfunction causes volume overload and right ventricular failure; and elongation of the papillary muscles leads to significant mitral regurgitation and left ventricular failure post relief of the constriction.

The incidence of low cardiac output syndrome post pericardiectomy is 28% with an associated mortality rate of up to 70% [60, 61]. Patients demonstrating prolonged symptomatic disease are at greatest risk [60]. This complication should be anticipated peri-operatively and managed with the appropriate haemodynamic and ventilatory support. Some studies suggest that levosimendan may be a pharmacological agent of choice [60].

#### *4.2.3 Anaesthetic management*

Intraoperative haemodynamic goals are to maintain heart rate, maintain systemic vascular resistance, optimise venous return and support myocardial contractility [12, 21, 22, 32, 49, 51–54, 60]. General anaesthesia care including intraoperative acid–base management, correction of electrolyte abnormalities, temperature and glucose control is required and will apply to these patients as mentioned above for pericardial tamponade.

Because CP is a fixed output state, patients have an increased reliance on heart rate and systemic vascular resistance to maintain systolic blood pressures and organ perfusion. Optimisation of preload and venous return preinduction are important to compensate for the decreased filling of the cardiac chambers. The consequences of possible fluid overload must always be considered, and these patients require dynamic assessment of fluid status as they too operate at the lower end of the Frank-Starling curve. This places them at increased risk for volume overload and low cardiac output syndrome, especially after relief of the constriction.

A balanced anaesthetic technique ensuring haemodynamic goals is necessary to avoid sudden decompensation at induction of anaesthesia [54, 60]. Ketamine is often recommended as the anaesthetic induction agent of choice because of its sympathomimetic effects on the cardiovascular system. Midazolam, etomidate and potent opioids such as fentanyl have also been safely used for induction of anaesthesia. Securing a definitive airway is recommended, and the use of muscle relaxants can be used early on, bearing in mind the possible deleterious effects of mechanical ventilation. The institution of positive pressure ventilation may compromise right heart chamber filling, and appropriate settings are needed to optimise ventilation, oxygenation and haemodynamics.

It is highly recommended that inotropic and/or vasopressor infusions are drawn up and running at the time of induction. These should be continued and titrated

**89**

support.

status [56].

may outweigh the benefits.

**5. Conclusion**

*Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

and pharmacological agents that may be required.

conventional surgical and medical management fail.

under local anaesthesia prior to induction of anaesthesia.

*4.2.4 Predictors of outcome following pericardiectomy*

these high-risk patients in the safest way possible.

teams who have this appreciation.

throughout surgery and continued into the post-operative period in anticipation for

Anticipation for massive blood loss, both acute and ongoing, is of vital importance as mentioned above. Monitoring with heightened intraoperative vigilance, regular blood gas and TEG analysis will guide transfusion of blood, clotting factors

Damage to cardiac structures may lead to massive sudden haemorrhage, myocardial ischaemia or significant arrhythmias. Appropriate management must be instituted immediately and may include the need for cardiopulmonary bypass if

The need for elective cardiopulmonary bypass support will depend on the pre-operative condition of the patient, the aetiology of the CP and the underlying myocardial function. The decision for the adjunctive use of bypass should be discussed and decided upon during the multidisciplinary team discussion prior to surgery. If deemed necessary, the femoral vessels should be prepped and cannulated

Post-operatively, patients should be transferred to a high-dependency unit for continuation of care. Ongoing monitoring for persistent bleeding and low cardiac output syndrome is necessary as well as ongoing haemodynamic and ventilatory

Early post-operative mortality rates are in the region of 18% [46, 49, 56, 57, 59]. Peri-operative mortality is highly dependent on the patient's pre-operative NYHA

Because of the high peri-operative morbidity and mortality, patients with mild or very advanced disease, renal failure or post-radiation constrictive pericarditis should be evaluated very carefully pre-operatively as the risk of pericardiectomy

Patients with pericardial disease can be challenging for the attending anaesthesiologist. An in-depth understanding of the pathophysiology of each disease state is necessary to provide optimal care. Careful pre-operative evaluation of the clinical history, examination and diagnostic investigations will allow adequate evaluation of risk and alert the anaesthesiologist to the necessary steps to be taken to manage

An appreciation of how the chosen anaesthetic technique may influence the patient's haemodynamic state is necessary to avoid unwanted anaesthetic complications. This includes a thorough understanding of the effect of pharmacological agents as well as how mechanical ventilation may influence haemodynamics. The potential risk and complications of the surgical procedure should

operatively in order to ensure adequate preparation for any potentially catastrophic events. These patients are best cared for by experienced peri-operative

be examined and discussed with the multidisciplinary team pre-

Predictors of poor long-term outcome include the aetiology of the disease, previous radiation, renal dysfunction, hyponatraemia, old age, low pre-operative left ventricular ejection fraction, right ventricular dilatation, elevated pulmonary

pressures and the severity of tricuspid regurgitation [46, 49, 57, 59].

a persistent low cardiac output state, especially in at-risk patients.

#### *Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

*Inflammatory Heart Diseases*

the constriction.

cological agent of choice [60].

*4.2.3 Anaesthetic management*

mentioned above for pericardial tamponade.

oxygenation and haemodynamics.

in select patients with severe or decompensated disease. Appropriate IV access and invasive monitoring should be established, and inotropic or vasopressor infusions drawn up and running at the time of induction of anaesthesia. Damage to underlying epicardium, myocardium and coronary vessels poses the most risk to patients contributing to an overall mortality of about 7–18% [4]. Arrhythmias are common

*Low cardiac output syndrome*, defined as a cardiac index of <2.2 l/min/m, will result in a subset of patients with chronic constrictive pericarditis [49, 60]. This is a form of acute cardiac failure, and there are a number of suggested mechanisms. The underlying myocardium may be affected by prolonged constriction causing myocardial disuse atrophy; residual constriction from partial or incomplete removal of the epicardial layer results in persistent constriction; the disease process itself may affect the myocardium; prolonged abnormal diastolic filling leads to architectural changes with remodelling of the ventricles; worsening of tricuspid regurgitation with progressive right ventricular dysfunction causes volume overload and right ventricular failure; and elongation of the papillary muscles leads to significant mitral regurgitation and left ventricular failure post relief of

The incidence of low cardiac output syndrome post pericardiectomy is 28% with an associated mortality rate of up to 70% [60, 61]. Patients demonstrating prolonged symptomatic disease are at greatest risk [60]. This complication should be anticipated peri-operatively and managed with the appropriate haemodynamic and ventilatory support. Some studies suggest that levosimendan may be a pharma-

Intraoperative haemodynamic goals are to maintain heart rate, maintain systemic vascular resistance, optimise venous return and support myocardial contractility [12, 21, 22, 32, 49, 51–54, 60]. General anaesthesia care including intraoperative acid–base management, correction of electrolyte abnormalities, temperature and glucose control is required and will apply to these patients as

Because CP is a fixed output state, patients have an increased reliance on heart rate and systemic vascular resistance to maintain systolic blood pressures and organ perfusion. Optimisation of preload and venous return preinduction are important to compensate for the decreased filling of the cardiac chambers. The consequences of possible fluid overload must always be considered, and these patients require dynamic assessment of fluid status as they too operate at the lower end of the Frank-Starling curve. This places them at increased risk for volume overload and

A balanced anaesthetic technique ensuring haemodynamic goals is necessary to avoid sudden decompensation at induction of anaesthesia [54, 60]. Ketamine is often recommended as the anaesthetic induction agent of choice because of its sympathomimetic effects on the cardiovascular system. Midazolam, etomidate and potent opioids such as fentanyl have also been safely used for induction of anaesthesia. Securing a definitive airway is recommended, and the use of muscle relaxants can be used early on, bearing in mind the possible deleterious effects of mechanical ventilation. The institution of positive pressure ventilation may compromise right heart chamber filling, and appropriate settings are needed to optimise ventilation,

It is highly recommended that inotropic and/or vasopressor infusions are drawn up and running at the time of induction. These should be continued and titrated

low cardiac output syndrome, especially after relief of the constriction.

and prompt management as per the latest ACLS guidelines.

**88**

throughout surgery and continued into the post-operative period in anticipation for a persistent low cardiac output state, especially in at-risk patients.

Anticipation for massive blood loss, both acute and ongoing, is of vital importance as mentioned above. Monitoring with heightened intraoperative vigilance, regular blood gas and TEG analysis will guide transfusion of blood, clotting factors and pharmacological agents that may be required.

Damage to cardiac structures may lead to massive sudden haemorrhage, myocardial ischaemia or significant arrhythmias. Appropriate management must be instituted immediately and may include the need for cardiopulmonary bypass if conventional surgical and medical management fail.

The need for elective cardiopulmonary bypass support will depend on the pre-operative condition of the patient, the aetiology of the CP and the underlying myocardial function. The decision for the adjunctive use of bypass should be discussed and decided upon during the multidisciplinary team discussion prior to surgery. If deemed necessary, the femoral vessels should be prepped and cannulated under local anaesthesia prior to induction of anaesthesia.

Post-operatively, patients should be transferred to a high-dependency unit for continuation of care. Ongoing monitoring for persistent bleeding and low cardiac output syndrome is necessary as well as ongoing haemodynamic and ventilatory support.

#### *4.2.4 Predictors of outcome following pericardiectomy*

Early post-operative mortality rates are in the region of 18% [46, 49, 56, 57, 59]. Peri-operative mortality is highly dependent on the patient's pre-operative NYHA status [56].

Predictors of poor long-term outcome include the aetiology of the disease, previous radiation, renal dysfunction, hyponatraemia, old age, low pre-operative left ventricular ejection fraction, right ventricular dilatation, elevated pulmonary pressures and the severity of tricuspid regurgitation [46, 49, 57, 59].

Because of the high peri-operative morbidity and mortality, patients with mild or very advanced disease, renal failure or post-radiation constrictive pericarditis should be evaluated very carefully pre-operatively as the risk of pericardiectomy may outweigh the benefits.

### **5. Conclusion**

Patients with pericardial disease can be challenging for the attending anaesthesiologist. An in-depth understanding of the pathophysiology of each disease state is necessary to provide optimal care. Careful pre-operative evaluation of the clinical history, examination and diagnostic investigations will allow adequate evaluation of risk and alert the anaesthesiologist to the necessary steps to be taken to manage these high-risk patients in the safest way possible.

An appreciation of how the chosen anaesthetic technique may influence the patient's haemodynamic state is necessary to avoid unwanted anaesthetic complications. This includes a thorough understanding of the effect of pharmacological agents as well as how mechanical ventilation may influence haemodynamics. The potential risk and complications of the surgical procedure should be examined and discussed with the multidisciplinary team preoperatively in order to ensure adequate preparation for any potentially cata*Inflammatory Heart Diseases*
