Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?
DOI:
https://doi.org/10.1532/hsf.3943Keywords:
adhesions; CorMatrix; expert consensus; expert opinion; extracellular matrix; pericardial closure; pericardial patch; pericardial reconstruction; postoperative atrial fibrillation; ProxiCor.Abstract
Background: As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019.
Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled.
Results: The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured.
Conclusions: Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.
References
Arsenault KA, Yusuf AM, Crystal E, et al. 2013. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev. CD003611. Published 2013 Jan 31.
Asanza L, Rao G, Voleti C, Hartstein ML, Wisoff BG. 1976. Should the pericardium be closed after an open-heart operation? Ann Thorac Surg. 22(6):532-534.
Benedetto U, Gaudino MF, Dimagli A, et al. 2020. Postoperative Atrial fibrillation and long-term risk of stroke after isolated coronary artery bypass graft surgery. Circulation. 142:1320-1329.
Bessissow A, Khan J, Deveareaux P, Alvarez-Garcia J, Alonso-Coellos P. 2015. Postoperative atrial fibrillation in non-cardiac and cardiac surgery: an overview. J Thromb Haemost. 13(Suppl. 1):S304-S312.
Bhatnagar G, Fremes SE, Christakis GT, Goldman BS. 1998. Early results using an ePTFE membrane for pericardial closure following coronary bypass grafting. Published online. 190-193.
Bittar MN, Barnard JB, Khasati N, Richardson S, Raja SG. 2005. Should the pericardium be closed in patients undergoing cardiac surgery? Interact Cardiovasc Thorac Surg. 4(2):151-155.
Bowdish ME, D'Agostino RS, Thourani VH, et al. 2020. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2020 update on outcomes and research. Ann Thorac Surg. 109(6):1646-1655.
Boyd W, Johnson WE III, Sultan P, Deering T, Matheny R. 2010. Pericardial reconstruction using an extracellular matrix implant correlates with reduced risk of postoperative atrial fibrillation in coronary artery bypass surgery patients. Heart Surg Forum. 13(5):E311-E316.
Boyd WD, Tyberg JV, Cox JL. 2012. A review of the current status of pericardial closure following cardiac surgery. Expert Rev Cardiovasc Ther. 10(9):1109-1118.
Brown BN, Badylak SF. 2014. Extracellular matrix as an inductive scaffold for functional tissue reconstruction. Transl Res. 163(4):268-285.
Brown BN, Badylak SF. 2016. Extracellular matrix as an inductive scaffold for functional tissue reconstruction. In: Laurence J, Baptista P, Atala A, Beusekom M Van, eds. Translating Regenerative Medicine to the Clinic. Elsevier Academic Press. 11-29.
Burgess DC, Kilborn MJ, Keech AC. 2006. Interventions for prevention of postoperative atrial fibrillation and its complications after cardiac surgery: a meta-analysis. Eur Heart J. 27(23):2846-2857.
Butt JH, Olesen JB, Gundlund A, Kumler T, Havers-Borgersen PSOE, Aagaard DT. 2019. Long-term thromboembolic risk in patients with postoperative atrial fibrillation after left-sided heart valve surgery. JAMA Cardiol. 4(11):1139-1147.
Cannata A, Petrella D, Russo CF, et al. 2013. Postsurgical Intrapericardial adhesions: Mechanisms of formation and prevention. Ann Thorac Surg. 95:1818-1826.
Cunningham J, Spencer F, Zeff R, Williams C, Cukingnan R, Mullin M. 1975. Influence of primary closure of the pericardium after open-heart surgery on the frequency of tamponade, postcardiotomy syndrome, and pulmonary complications. J Thorac Cardiovasc Surg. 70(1):119-125.
Damen J, Bolton D. 1989. Acute hemodynamic effects of pericardial closure in man. Acta Anaesthesiol Scand. 33(3):207-209.
Dantas CE, SÁ MP, Bastos ES, Magnanini MM. 2010. Pericardium closure after heart operations: A safe option? Brazilian J Cardiovasc Surg. 25(3):365-370.
Daughters GT, Frist WH, Alderman EL, Derby GC, Ingels NB, Miller DC. 1992. Effects of the pericardium on left ventricular diastolic filling and systolic performance early after cardiac operations. J Thorac Cardiovasc Surg. 104(4):1084-1091.
Duvernoy O, Malm T, Ramstrom J, Bowald S. 1995. A biodegradable patch used as a pericardial substitute after cardiac surgery: 6- and 24-Month evaluation with CT. Thorac Cardiovasc Surg. 43(5):271-274.
Ferraris VA. 2018. Pericardial adhesions and cardiac surgeons’ nightmares. J Thorac Cardiovasc Surg. 156(4):1609-1610.
Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. 2017. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardiothorac Surg. 52(4):665-672.
Hunter S, Smith GH, Angelini GD. 1992. Adverse hemodynamic effects of pericardial closure soon after open heart operation. Ann Thorac Surg. 53(3):425-429.
Izzat M, Anderson M, Wilde P, Wisheart J, Bryan A, Angelini G. 1994. Hemodynamic effects and echocardiographic consequences of tension-free pericardial closure after heart valve surgery. J Heart Valve Dis. 3(3):295-299.
Jarvinen A, Peltola K, Rasanen J, Heikkila J. 1987. Immediate hemodynamic effects of pericardial closure after open-heart surgery. Scand J Thorac Cardiovasc Surg. 21(2):131-134.
Kaneko Y, Hirata H, Achiwa I, Morishita H, Sotos H, Kobayashi J. 2012. Adhesion barrier reduces postoperative adhesions after cardiac surgery. Asian Cardiovasc Thorac Ann. 20(3):257-262.
Kargar F, Aazami MH. 2007. Rotational pericardial flap: An alternative tension-free technique for pericardial closure. J Thorac Cardiovasc Surg. 134(2):510-511.
Kaya M, Satilmisoglu M, Bugra A, et al. 2015. Impact of the total pericardial closure using bilateral trap door incision and pericardial cavity intervention on outcomes following coronary artery bypass grafting: a randomized, controlled, parallel-group prospective study. Interact Cardiovasc Thorac Surg. 21:727-733.
Lin MH, Kamel H, Singer DE, Su YL, Lee M, Ovbiagele B. 2019. Perioperative/postoperative atrial fibrillation and risk of subsequent stroke and/or mortality: A meta-analysis. Stroke. 50:1364-1371.
Ma B, Wang X, Wu C, Chang J. 2014. Crosslinking strategies for preparation of extracellular matrix-derived cardiovascular scaffolds. Regen Biomater. 1(1):81-89.
Matsumura G, Shin’Oka T, Ikada Y, Sakamoto T, H Kurosawa. 2008. Novel anti-adhesive pericardial substitute for multistage cardiac surgery. Asian Cardiovasc Thorac Ann. 16(4):309-312.
Minale C, Nikol S, Hollweg G, Mittermayer C, Messmer B. 1988. Clinical experience with expanded polytetrafluoroethylene Gore-Tex surgical membrane for pericardial closure: A study of 110 Cases. J Card Surg. 3(3):193-201.
Nandi P, Leung J, Cheung K. 1976. Closure of pericardium after open heart surgery: A way to prevent postoperative cardiac tamponade. Br Heart J. 38:1319-1323.
Okuyama N, Wang CY, Rose EA, et al. 1999. Reduction of retrosternal and pericardial adhesions with rapidly resorbable polymer films. Ann Thorac Surg. 68(3):913-918.
Quarti A, Nardone S, Colaneri M, Santoro G, Pozzi M. 2011. Preliminary experience in the use of an extracellular matrix to repair congenital heart diseases. Interact Cardiovasc Thorac Surg. 13(6):569-572.
Rao V, Komeda M, Weisel RD, Cohen G, Borger MA, David TE. 1999. Should the pericardium be closed routinely after heart operations? Ann Thorac Surg. 67(2):484-488.
Rego A, Cheung PC, Harris WJ, Brady KM, Newman J, Still R. 2019. Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions. J Cardiothorac Surg. 14(1):1-10.
Walther T, Rastan A, Dahnert I, et al. 2005. A novel adhesion barrier facilitates reoperations in complex congenital cardiac surgery. Surg Congenit Hear Dis. 129(2):359-363.
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