Cardiothoracic Resident Hammersmith Hospital London London, England, United Kingdom
Disclosure(s):
Nikhil Sahdev, n/a: No financial relationships to disclose
Please explain the educational or technical point that this video addresses.: • Constrictive pericarditis In TB can often have more than one layer. • In TB, the second layer (inner layer) is more prominent and removing the caseous layer does not free pericardium. • Aggressive removal of the inner layer is required to remove the pericardial constriction.
Please provide a 250 word summary of the surgical video being submitted.: This video describes a 57M with thick, double layer, calcified constrictive pericarditis requiring pericardectomy.
Pre-operative The patient was admitted with worsening dyspnoea, palpitations and oedema (weight 120kg (82kg last year)). The aetiology was unknown but possibly TB, for which he has completed empirical treatment. Attempts at ward-based offloading but were unsuccessful. Initially an operation was felt to be too high risk due to oxygen dependence and extreme fluid overload. He was sent to ICU to further offload with hemofiltration. He achieved a 5kg reduction in weight however became hemodynamically unstable. Therefore, a decision was made to proceed to high risk pericardectomy.
Operation The fibrous pericardium was severely thickened and heavily calcified. On entering the pericardium, purulent fluid and blood-stained caseous material was expressed. 150g of caseous material was removed. However, it was then noted that there was a second layer overlying the heart. This was extremely calcific and was likely the culprit layer causing the pericardial constriction. This inner layer was then incrementally excised in the following order: Anteriorly, LV, RV, SVC, IVC, RA and inferior surface.
Post operative The patient lost 30kg after the operation and was eventually discharged home.
Conclusion In TB constrictive pericarditis there is more than one layer with caseous material in the middle. The second layer (inner layer) is more prominent and only removing the caseous layer does not free pericardium. It is important to aggressively remove the inner layer to remove the pericardial constriction.
Learning Objectives:
Upon completion, participant will be able to understand that constrictive pericarditis in TB can often have more than one layer.
Upon completion, participant will be able to understand that in TB, the second layer (inner layer) is more prominent and only removing the caseous layer does not free pericardium.
Upon completion, participant will be able to have a surgical strategy for performing a pericardiectomy for TB constrictive pericarditis and the importance of aggressive removal of the inner layer.
