Should the pericardium be closed in patients undergoing cardiac surgery?
Date First Published:
May 3, 2005
Last Updated:
May 13, 2005
Report by:
Mohamed N. Bittar, James B. Barnard, Noman Khasati, and Steven Richardson, Registrars in Cardiothoracic Surgery (Department of Cardiothoracic Surgery, Wythenshawe Hospital)
Search checked by:
Joel Dunning, Department of Cardiothoracic Surgery, Wythenshawe Hospital
Three-Part Question:
In [patients undergoing cardiac surgery] does [pericardial closure] affect [outcome]?
Clinical Scenario:
You have been trained to leave the pericardium open after a routine cardiac surgery procedure because in the early postoperative period the patient's haemodynamic performance is better and there is less incidence of graft failure. In addition there is also said to be a reduced incidence of cardiac tamponade. You begin to question this teaching, especially in view of the benefit of a closed pericardium when it comes to re-do surgery. You decide to scrutinise the published literature with regard to the pitfalls of closing the pericardium.
Search Strategy:
Medline 1966–Nov 2004 using the OVID interface
Search Details:
[exp thoracic surgery OR exp cardiac surgical procedures OR heart surgery.mp] AND [exp pericardium OR pericardial.mp] AND [clos$.mp]
Outcome:
Using the above search strategy 240 publications were found of which 8 were deemed to be relevant. Two of the publications were not directly included as they were letters commenting on the identified studies. One study was in an animal model and was excluded on this basis. No additional papers were identified by widening the search strategy or by looking in the references section of the identified papers. These papers are included in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Should the pericardium be closed routinely after heart operations? Rao V, Komeda M, Weisel RD, Cohen G, Borger MA, David TE. 1999 Canada | 42 patients undergoing elective, isolated coronary artery bypass grafting were randomized into two groups: 20 patients underwent closure of the pericardium (closure group) and the pericardium was left open in 22 patients (open group) |
Prospective randomised controlled study (Level 1b) | Distance between the epicardial surface and the posterior table of the sternum on CXR | Larger in the closure group compared to the open group at 1 week and 3 months postoperatively (P<0.001). | The patients involved in this study were low-risk, elective patients with preserved preoperative left ventricular function |
| Cardiac index and stroke work | Cardiac index and stroke work index in the early postoperative period was lower in the Closure group compared to the Open group (P<0.001) despite similar filling pressures. | ||||
| Early results using an ePTFE membrane for pericardial closure following coronary bypass grafting. Bhatnagar G, Fremes SE, Christakis GT, Goldman BS. 1998 Canada | 302 patients having coronary artery bypass graft surgery. Pericardium closed with a gortex membrane [GM] n=138 Pericardium left open [PO] n=164 |
Prospective randomized controlled study (level 1b) | Mortality | GM n=2, PO n=2 | Post operative bleeding was not defined |
| Complication | GM 14%, PO 21% P = not significant | ||||
| Post operative ischaemic event | GM 2.9%, PO 4.9% P = not significant | ||||
| Bleeding | GM 0, PO 1.2% p = not significant | ||||
| Hemodynamic effects and echocardiographic consequences of tension-free pericardial closure after heart valve surgery. Izzat MB, Anderson M, Wilde P, Wisheart JD, Bryan AJ, Angelini GD. 1994 UK | Patients undergoing an open heart valve procedure. N = 10 Effects of a tension-free pericardial closure technique were studied. Opening the pericardium (1.5 to 2 h after the end of the operation) while the chest remained closed |
Prospective Case Series (level 2b) | Cardiac output | 8% reduction, p = not significant | Small study Pericardial opening was performed 2 h after the end of surgery No control group |
| Systematic vascular resistance | 15% reduction, p = not significant | ||||
| Mean arterial pressure | 13% reduction (p = 0.03) | ||||
| Ejection fraction | no change | ||||
| Systolic and diastolic left ventricular dimensions | Decreased by 6% and 4% respectively p = not significant | ||||
| Opening the pericardium (1.5 to 2 h after the end of the operation) | Not followed by significant change in any of the hemodynamic or echocardiographic variables | ||||
| Effects of the pericardium on left ventricular diastolic filling and systolic performance early after cardiac operations. Daughters GT, Frist WH, Alderman EL, Derby GC, Ingels NB Jr., Miller DC. 1992 | 10 patients between 11 and 15 h after cardiac operations, with the pericardium first closed and then open. | Prospective Case Series (Level 2b) | Haemodynamic studies | End-diastolic volume index, peak positive time derivative of pressure, stroke work index, and cardiac index all increased significantly when the pericardium was opened (P<0.001). At physiological pressures, the pericardium had a significant constraining effect on diastolic filling of the left ventricle, and opening of the pericardium resulted in increased cardiac index and stroke work index | Cardiac output studies were performed at varying time intervals No control group |
| Adverse hemodynamic effects of pericardial closure soon after open heart operation. Hunter S, Smith GH, Angelini GD. 1992 UK | 10 patients who underwent open-heart valve operations. Study of the haemodynamic effect of pericardial closure. Observations were made both while the pericardium was open and after it had been closed, then after closure of the chest after the pericardium had been reopened by removing the pericardial suture through the chest wall. |
Prospective Case Series (Level 2b) | Closing the pericardium before closing the chest: cardiac output | Immediate reduction in cardiac output (thermodilution of 1.39 ± 0.24 l/min from 5.09±0.40 l/min (P<0.001). | Small study. No control group. Patients entered into the study acted as their own control group. |
| Heart rate | Remained stable | ||||
| Stroke volume | Decrease of 29% (P<0.01). | ||||
| Systematic vascular resistance | Increase of 34% (P<0.01) | ||||
| Mean arterial pressure | Increased of 2% (P = not significant) | ||||
| Opening the pericardium (1.5 to 2 h after the end of the operation) while the chest remained closed: cardiac outpupt | Increase in cardiac output of 1.33±0.15 l/min from 4.12± 0.62 l/min (P<0.001). | ||||
| Heart rate | P=not significant | ||||
| Mean arterial blood pressure | P=not significant | ||||
| Stroke volume | Increase of 15±3 ml from 53±5 ml (P<0.01) | ||||
| Systematic vascular resistance | Reduction of 473±83 dynes.s.cm-5 from 1,721±181 dyne.s.cm-5 (P<0.01) | ||||
| Acute hemodynamic effects of pericardial closure in man. Damen J, Bolton DT. 1989 Netherlands | 30 patients with normal left ventricular function undergoing coronary artery bypass surgery |
Prospective Case Series (Level 2b) | MAP, CI, Mean right atrial pressure, Pulmonary Capillary wedge pressure | Closure of the pericardium resulted in decreases in arterial blood pressure (P<0.01), cardiac index (P<0.001), mean right atrial (P<).001), mean pulmonary artery (P<0.001) and pulmonary capillary wedge pressure (P<0.001) | No control group |
| Immediate hemodynamic effects of pericardial closure after open-heart surgery. Jarvinen A, Peltola K, Rasanen J, Heikkila J. 1987 | Acute haemodynamic effects of a routine pericardial closure after cardiopulmonary bypass was studied in 29 patients undergoing cardiac surgery Coronary artery bypass: N=18 Aortic valve+coronary artery bypass: N=6 Mitral valve+coronary artery bypass: N=1 Mitral valve: N=1 Aortic valve: N=2 Aortic valve+Mitral valve: N=1 |
Prospective Case Series (level 2b) | Cardiac output after pericardial closure | 8% decrease (P<0.01) while cardiac index remained normal (2.9 l/min/m2±0.6 S.D.) | Small study No analysis of subgroups Mixed cohort of patients |
| Central venous pressure | Increased from 8±2 mmHg to 9±3 mmHg (P<0.05) after pericardial closure and decreased to 7±3 mmHg (P<0.05) when the pericardium was reopened. | ||||
| Left ventricular end-diastolic cavity diameter by echocardiography | Decreased in 19 patients from 46±6 mm to 41± 5 mm (P<0.01) when the pericardium was closed, and increased to 45±6 mm (P<0.01) after re-opening of the pericardiotomy incision. | ||||
| Closure of pericardium after open heart surgery. A way to prevent postoperative cardiac tamponade. Nandi P, Leung JS, Cheung KL. 1976 UK | 821 patients who underwent open heart surgery. 527 cases of congenital heart disease. 278 cases of acquired heart disease. 596 cases the pericardium was left open. 225 cases the pericardium was closed. | Retrospective Cohort Study (Level 4) | Requirement for reoperation due to bleeding/tamponade | Pericardium open 6.87%. Pericardium closed 1.77%. (No level of significance stated). | Study is limited to patients who have not had coronary artery bypass graft surgery. Restrospective study. Age range 8 months to 61 years. |
| Mortality in reoperation group | 17.77% open vs 0% closed | ||||
| Tracheostomy | 22.2% open vs 0% closed | ||||
| Wound infection | 8.8% open vs 0% closed |
Author Commentary:
Various institutions have attempted to answer the question we posed. Only two groups implemented a prospective randomized study. Rao et al randomized 42 patients who were having coronary artery bypass grafting to pericardial closure or leaving the pericardium open. They found that cardiac index and stroke work index were lower in the closure group compared to the open group (P<0.001), however, these difference were only present for one hour post operatively and at 4 h and 8 h post operatively no difference could be determined. Bhatnagar et al conducted a prospective randomised study to assess the impact of a tension-free pericardial closure with the use of a gortex membrane and found no significant difference with or without its use on early mortality, complications, bleeding or post operative ischaemic events in a cohort of patients who had all had coronary artery bypass graft surgery. Bhatnagar et al did not report any data regarding differences between groups in terms of their haemodynamic performance in the early post operative period. The adverse impact of pericardial closure haemodynamically was confirmed by several of the other studies [Rao, Daughters, Hunter, Izzat, Jarvinen, Damen]. No study reported an adverse clinical outcome due to the closure of the pericardium.
Daughters et al measured cardiac output and stroke work index in patients immediately after operation and found that removal of the pericardial suture immediately improved left ventricular haemodynamics. This finding raises concerns about pericardial closure in patients with marginal preoperative left ventricular function or in those patients with postoperative ventricular dysfunction who require high preloads to maintain cardiac output.
Only three studies [Rao, Bhatnagar, Damen] concentrated on patients who had coronary artery bypass graft surgery, two studies included a
mixture of cases [Jarvinen,Nandi], and the remainder included only patients who had had valve surgery [Daughters, Hunter, Izzat, Damen]. None of the studies followed up patients to find out if the mortality was lower in patients having re-sternotomy with a closed or open pericardium.
Daughters et al measured cardiac output and stroke work index in patients immediately after operation and found that removal of the pericardial suture immediately improved left ventricular haemodynamics. This finding raises concerns about pericardial closure in patients with marginal preoperative left ventricular function or in those patients with postoperative ventricular dysfunction who require high preloads to maintain cardiac output.
Only three studies [Rao, Bhatnagar, Damen] concentrated on patients who had coronary artery bypass graft surgery, two studies included a
mixture of cases [Jarvinen,Nandi], and the remainder included only patients who had had valve surgery [Daughters, Hunter, Izzat, Damen]. None of the studies followed up patients to find out if the mortality was lower in patients having re-sternotomy with a closed or open pericardium.
Bottom Line:
The adverse haemodynamic impact of pericardial closure is confirmed in several studies; however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.
References:
- Rao V, Komeda M, Weisel RD, Cohen G, Borger MA, David TE.. Should the pericardium be closed routinely after heart operations?
- Bhatnagar G, Fremes SE, Christakis GT, Goldman BS.. Early results using an ePTFE membrane for pericardial closure following coronary bypass grafting.
- Izzat MB, Anderson M, Wilde P, Wisheart JD, Bryan AJ, Angelini GD.. Hemodynamic effects and echocardiographic consequences of tension-free pericardial closure after heart valve surgery.
- Daughters GT, Frist WH, Alderman EL, Derby GC, Ingels NB Jr., Miller DC.. Effects of the pericardium on left ventricular diastolic filling and systolic performance early after cardiac operations.
- Hunter S, Smith GH, Angelini GD.. Adverse hemodynamic effects of pericardial closure soon after open heart operation.
- Damen J, Bolton DT.. Acute hemodynamic effects of pericardial closure in man.
- Jarvinen A, Peltola K, Rasanen J, Heikkila J.. Immediate hemodynamic effects of pericardial closure after open-heart surgery.
- Nandi P, Leung JS, Cheung KL.. Closure of pericardium after open heart surgery. A way to prevent postoperative cardiac tamponade.