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Eur J Cardiothorac Surg 2000;18:727
© 2000 Elsevier Science NL

Letter to the Editor

An unusual experience with posterior pericardiotomy

Cem Yorgancolu, Bora Farsak, Hilmi Tokmakolu, Serdar Günaydn

Department of Cardiovascular Surgery, Bayndr Medical Center, Ankara, 06520 Turkey

Received 5 July 2000; accepted 11 September 2000.

Corresponding author. Tel.: +90-312-287-9000; fax: +90-312-285-0733
e-mail: yorgancioglu{at}isbank.net.tr

There are some recent reports on the effect of posterior pericardiotomy to the postoperative supraventricular tachyarrythmias (SVT). Although controversy still exists on its effect on atrial fibrillation, its clinical benefit on pericardial tamponade is satisfactory [1–3]. To test its effectiveness on SVT we started performing posterior pericardiotomy where we experienced an unusual case on the 29th patient.

A 55 year old man with left main coronary stenosis besides two vessel disease, normal ventriculography and ejection fraction 65% was operated in standard fashion with a roller pump, non-pulsatil flow (2.0–2.4 l/min), Polystan^® membrane oxygenator, 32°C systemic hypothermia, single cross clamp, initial antegrade + retrograde cold blood cardioplegia, repeated cold retrograde blood cardioplegia every 20 min, and a hot shut before the removal of the cross clamp. LIMA grafting to the LAD and sequantial saphenous graft to first diagonal, intermediate and obtuse marginal arteries were performed.

After an uneventful operation (x clamp time 42 min, total perfusion time 58 min) the patient was placed in the ICU ward where the patient deteriorated with lateral ST elevation and multifocal ventricular arrhythmias, which did not respond to the medical therapy, continued with ventricular fibrillation (VF), which also did not respond to defibrillation. The patient returned to the operating room urgently and re-explored. After reopening the sternum VF had been over come following the first defibrillation with internal paddles. The hemodynamia returned to normal in a short time with positive inotrops followed by ST normalisation. All the bypass grafts were patent, nothing unusual was observed. Following haemostasis sternum was wired again. But by the time of cutaneous sutures, the ST elevation relapsed, the hemodynamia failed quickly, VF re-occurred. The sternum was reopened in a short time and the heart was defibrillated again. Grafts were patent again, but an ischaemic colour change was observed on the lateral and posterior aspect of the heart. On careful examination we had observed that a segment of saphenous graft (just before and after the intermediate artery anastomosis) and left atrial appendage protruded from the posterior pericardiotomy. The saphenous graft was squeezed by the edges of the posterior pericardiotomy incision. After closing the posterior pericardiotomy incision by primary sutures, and insertion of an intra-aortic balloon from left femoral artery the patient was taken to the ICU ward again. Reperfusion arrhythmia was controlled by amiodorone infusion. Postoperative peak CK-MB (mass) value was 42 ng/ml and Troponin T was 4.85 ng/ml, no Q waves were noted in electrocardiograms. Following an uneventful 5 days in the ICU the patient was discharged in his 10th postoperative day with lateral hypokinesia in echocardiography taken on the 8th day postoperatively.

Posterior pericardiotomy is effective on early and late pericardial tamponade, can be effective on the incidence of SVT, but after this case in our opinion, should carefully be used with patients in whom posterior wall revascularization was performed especially by sequential grafting.

References

1. Mulay A., Kirk A.J., Angelini G.D., Wisheart J.D., Hutter J.A. Posterior pericardiotomy reduces the incidence of supraventricular arrythmias following coronary artery bypass surgery. Eur J Cardio-thorac Surg 1995;9:150-152.[Abstract]
2. Asimakopoulos G., Santa R.D., Taggart D.P. Effects of posterior pericardiotomy on the incidence of atrial fibrillation and chest drainage after coronary revascularization: a prospective randomised trial. J Thorac Cardiovasc Surg 1997;113:797-799.[Free Full Text]
3. Kuralay E., Özal E., Demrkilç U., Tatar H. Effect of posterior pencardiotomy on postoperative supraventricular arrythmias and late pericardial effusion. J Thorac Cardiovasc Surg 1999;118:492-495.[Abstract/Free Full Text]

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