Robotic Endoscopic Off Pump Total Pericardiectomy In Constrictive Pericarditis
Zewditu Asfaw, MD1, Kimberly Maciolek, BS2, Dorothy Krienbring, BSN1, Susan Arnsdorf, MS1, Husam Balkhy, MD1.
1University of Chicago, Chicago, IL, USA, 2University of Wisconsin, Madison, WI, USA.
OBJECTIVE: Although rare, constrictive pericarditis is a serious condition with debilitating symptoms and often severe heart failure. Total pericardiectomy is the most effective treatment and is traditionally performed via median sternotomy. With the increasing use of minimally invasive techniques there have been reports of partial pericardectomy via thoracoscopy but with suboptimal exposure and difficulty identifying both phrenic nerves. Robotic surgery offers both small incisions and enhanced visualization. We present two cases of robotic endoscopic off pump total pericardiectomy for constrictive pericarditis.
METHODS: Two patients underwent total pericardiectomy with robotic assistance for constrictive pericarditis. Both had constrictive physiology demonstrated by right heart catheterization. One was also found to have CAD and underwent concurrent TECAB LIMA-LAD. Ports were placed in the left second, fourth and sixth intercostal spaces. Left lung was isolated and deflated with CO2, aiding in exposure. Using electrocautery, the pericardium was removed first posteriorly to the left phrenic nerve, then anteriorly to the right phrenic nerve, and caudally from the diaphragmatic reflection to the great vessels cephalad. A stabilizer in the fourth robotic arm was used to assist in the dissection.
RESULTS: Both patients were extubated within 6 hours post operatively and transferred to the floor on post operative day (POD) 1. The TECAB patient developed atrial fibrillation but was discharged on POD 3 in sinus rhythm. In clinic, he was asymptomatic with return to baseline activity. The second patient was discharged home on POD 5 with one chest tube remaining due to high output. In clinic, his chest tube was removed. He reported no longer needing home oxygen and return to baseline activity.
CONCLUSIONS: Total pericardiectomy for constrictive pericarditis can be performed safely and effectively using a robotic approach. In contrast to thoracoscopy, it offers better visualization of both phrenic nerves, avoids injury and allows a thorough pericardial dissection. In our experience the robotic left chest approach has proven more efficacious in removing the posterior pericardium than is allowed with median sternotomy.
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