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Overchronic constrictive pericarditis is the involvement of parietal and visceral pericardium, the chronic inflammatory process. Caused by fibrosis and thickening of the pericardium, the heart of the relaxation in restrictions, which reduces cardiac function.
Treatment of constrictive pericarditis has a significant clinical symptoms, after a period of treatment and rest without improved more than their natural prognosis poor. Most of the patients in the conservative treatment of conditions return to normal activity very difficult. Somerville W proposed: Once the symptoms of chronic constrictive pericarditis, and signs. The general movement of patients to survive the loss of life is about 5 to 15 years. When ascites occurs, the disease progresses rapidly, especially in children. Some patients eventually to circulatory failure or liver and kidney dysfunction and death. Therefore, once the diagnosis, surgical treatment is essential, removal of the pericardial constriction, so that the gradual recovery of cardiac function. Recovery of cardiac function depends on: Select the appropriate time operation, before the formation of calcification in the fiber easier to peel, but also less myocardial damage; the scope of pericardial stripping, is able to biventricular thickening of the surface of complete resection of the pericardium . Surgery should be relatively stable in the conditions under implementation. Therefore, before surgery should be carried out fully, the strict m


edical treatment. Constrictive pericarditis caused by tuberculosis, the system should be given anti-TB drug treatment, in body temperature, erythrocyte sedimentation rate and nutritional status of the body close to normal or relatively stable after the surgery.
(A) of the pericardium Endarterectomy Indications and contraindications 1. Indications diagnosed constrictive pericarditis, which should surgery. patient is poor, such as eating less, severe ascites, liver and kidney function is poor, low plasma protein, heart rate 120 times / min or more, and rapid erythrocyte sedimentation rate, should be treated conservatively. Stable condition and the situation improved, undergoing elective cardiac endarterectomy. serious condition, was not improved by conservative treatment, Hu Bingzhong early advocates such as pericardial fenestration line to improve the functional status of the body, and then pericardial resection. 2. Contraindications elderly patients with severe heart and lung disease, can not tolerate surgery. mild symptoms, disease progression-free persons.
(B) before surgery to prepare 1. General supportive therapy, including improved diet, nutritional supplements, low-salt and high protein foods, add a variety of vitamins, Infusion of albumin, a small number of new blood lost. 2. In addition to defining non-tuberculous constrictive pericarditis, the anti-TB treatment should be not less than 6 weeks, preferably 3 months. 3. Hepatomegaly, ascites and peripheral edema were appropriate, given diuretic agents, and potassium to correct water and electrolyte balance disorders. 4. Heart rate too fast may, as appropriate application of small doses of digitalis drugs. 5. After treatment of pleural effusion and ascites volume is still higher, 1 ~ 2 preoperative thoracic cavity puncture drainage should be performed, abdominal pressure bandage to increase lung capacity and reduce intra-abdominal pressure, which is conducive to diaphragmatic breathing exercise. As possible before surgery to achieve the following requirements: circulatory and respiratory function significantly improved; breathing difficulties, orthopnea, edema, pleural effusion and ascites or reduce significantly improved; food situation has improved; heart rate no more than 120 times / min, laboratory Check normal, normal body temperature and activity increased; comparison constant for the daily urine output.
(C) surgical methods are commonly used surgical approach split median sternotomy incision; bilateral transverse incision chest; left anterior incision. Pericardial resection of the left side of three common incision anterolateral incision A.; B. Bilateral transverse incision chest; C. sternal incisi. Breastbone splitting incision in the middle of such a surgical approach to fully show the front and right side of the heart and easy peel Xinyuan vena cava and right parts of the thickened pericardium, little effect on respiratory function after surgery. The merger with poor pulmonary function and respiratory disease cases, the use of this incision. The disadvantage is that, left phrenic nerve and the apical part of some pericardial revealed poor. Some scholars believe that after the pericardium phrenic nerve without resection. 2. Left anterior chest incision through the fifth intercostal space into the right internal thoracic artery be ligated and cut off the transverse sternotomy, the left side of axillary line. The advantage of such a unilateral thoracotomy incision, little effect on respiratory function, the patient can be worse state. Revealed good left ventricular. On the left ventricle and the inferior vena cava revealed poor. 3. Bilateral transverse incision in the chest incision advantage is a good surgical field exposure can be both right and left heart, the pericardium can be completely removed, surgery is also easy to deal with the accident. The disadvantage is cut longer, more traumatic and postoperative pulmonary function great. 4. The left anterior incision in the pericardium anesthetized endarterectomy patient supine position, the left subscapular set a pillow, under the left hand on the wall. Left fifth intercostal space along the left breast below to make a curved incision. Incision into the chest muscle. Thoracic artery ligation. Disconnect the fifth costal cartilage near the sternum. Thorax revealed pleural distraction. The left phrenic nerve from the sharp separation of the pericardium, as much as possible with some fat and soft tissue, to avoid harming the phrenic nerve. Pericardial incision in the left ventricular area, as far as possible after the lateral side, select no calcification zone. The following can be seen sometimes layered cut, or pericardial effusion. But in most cases, cut the pericardium, which amounts to myocardial surface. Found outside the outer membrane layer in mind, along the stratification of blunt or sharp dissection and gradually expanded in scope. Such as thickening of the parietal and visceral pericardium, there are cavities between, you can make the heart beat before the initial removal of the parietal improved reprocessing fiber thickening of the visceral pericardium. If the dense pericardial adhesions or layered unclear, use scissors or sharp blade to separate the precise anatomical detail. Avoid strong pure stripping device to prevent myocardial injury and myocardial rupture. Operating diagram of the left anterior lateral incision should be along the order of the pericardium strip longitudinal incision of the both sides of the separation of the right front and left rear. Should be cut into pieces, such as myocardial rupture, can be used to stop bleeding has been stripped of the pericardial patch. The right side of the pericardium should be isolated to the left atrioventricular groove, below the upper bound to the thymus. Pericardial patches on the left side of the border should be separate to the main pulmonary trunk, and its narrow ring cut off, to avoid serious postoperative right ventricular pressure is too high; lower bound should be thicker than the diaphragm button or the removal of the pericardium completely free; back boundary as far as possible the performance of cardiac left ventricle completely free. In the separation chamber sulcus is in place, pay particular attention not to damage coronary artery, where the lien should be given if calcification, continued in other parts of the strip. Thickening of the left atrial surface of the pericardial little effect on hemodynamics, are more prone to tearing dissection, bleeding problems, do not forcibly strip. Cut as much as possible and release the left atrium near the inferior vena cava constriction ring, such as the presence of atrioventricular sulcus narrow ring should be cut off. Surgery should be noted that the first part of the pericardium, left ventricular completely stripped, and then peel right ventricular outflow tract, to prevent the occurrence of acute pulmonary edema. After the pericardium to be completely stripped, and then pericardial excision. Myocardial atrophy in critically ill patients significantly. After the spin-off pericardium, myocardial surface lighter in color, peel scope should be in moderation, narrowing the ventricular surface and the main ring can be lifted. Digitalis preparations can be applied peel finish. The end of surgery to completely stop the bleeding, pericardial resection margin electric coagulation. If necessary, in the left atrial appendage or pulmonary vein placement piezometer is conducive to the disease after observation. Two closed chest tube placement. 5. Sternotomy incision through the pericardium endarterectomy under general anesthesia with endotracheal intubation. Patients with supine position, elevate the chest back shoulder blade elongation zone, split the middle of the sternum. If retrosternal adhesions, separation of adhesions should be edge, while devices with a thoracic distraction both sides of the sternum. First began to peel from the apex pericardium. In addition pericardial adhesions light, pericardial thickening is not obvious, easy to peel. Successive cut open with a blade thickness of the pericardium. Thickening of the pericardium and the outer layer of loose connective tissue between the often, pericardial stripping the correct sub-interface. Thickening of the pericardium open, the beating heart can be seen protruding. Separation of part of the pericardium, the assistant gently lift pericardium with pliers, surgeon to the surface of the left hand soft reduction in the heart, thickening of the pericardium can fully reveal the extent of myocardial adhesions. Such as adhesion loose, the available sets of fingers to be blunt gauze or peanuts clamp separation, separation of the hard parts should be in the pericardial surface. Face cord or ribbon adhesions, the need to use scissors or sharp knife slice separation. If a very strong adhesion of the more, the separation should abandon the original site, and in the other bits to re-cut, separation pericardium, that is, the easier issues first. Cardiac surgery patients according to functional status and scope of pericardial adhesions decided to divest. The basic scope of the general dissection: should be the apex to be fully stripped; the left side close to the phrenic nerve at the left; atrioventricular sulcus and the inferior vena cava constriction at the entrance to the fibrous ring to release. Should be stripped of the order of right ventricular outflow tract ventricular atrioventricular groove the inferior vena cava constriction ring ring ties. Charter of good heart and is very easy to dissection, the pericardium was completely exfoliated best. Such as arrhythmia surgery, circulatory instability or myocardial color white, cardiac enlargement, myocardial contraction and weak, peeling operation must stop, the main site (left and right ventricular surface and the inferior vena cava constriction ring) to stripping. While digoxin and diuretic agents, full operation as soon as possible in order to improve surgical safety. Necessary to dopamine after inotropic drugs.
(D) surgical complications and preventive measures 1. Low cardiac output in the pericardial stripping process, due to acute cardiac expansion, particularly after right ventricular surface of the pericardium strip, in the role of venous pressure, rapid rapid ventricular filling, expansion, Acute low cardiac output produced. Therefore, surgery should be limited to the liquid input, narrow left ventricular lift immediately after the application of cedilanid and furosemide, while the strong heart, the heart line to reduce the burden of too much liquid. Within 12 ~ 48h after application of dopamine and other catecholamines. Drug reactions such as less effective, low cardiac output can not be corrected, you can use intra-aortic balloon counterpulsation. 2. Phrenic nerve injury in the left anterior lateral incision at the beginning before the pericardial stripping, Kirklin JW should be made free on the left phrenic nerve, phrenic nerve to retain as much as possible along with fat and soft tissue. Such as phrenic nerve injury can cause conflicts diaphragm breathing exercise, affect gas exchange. Is not conducive to the discharge of respiratory secretions. 3. Artery injury in isolated parts of the anterior interventricular sulcus, we should pay particular attention, not to damage the coronary arteries. The end of its branches or bleeding, can be sutured to stop bleeding. The site has limited experience calcified plaque, you can not deal with retention, not reluctantly removed. 4. Myocardial rupture the embedded myocardial calcifications, and can be shaped to retain the island, not reluctantly strip. For stripping ill-defined, severe adhesion, the thickening of the pericardium can be made "well" the word cut, tied in part to lift myocardial surface. Case of myocardial rupture, the surgeon with the pressure in the gap left index finger flat on the use of free pericardial patches sewn around the cap in rupture of the mouth, can save the patient's life.
(E) treatment 1 after surgery. Generally deal with conventional oxygen, close observation of blood pressure, respiration, pulse, heart rate and urine volume change. Note drainage tube to maintain patency, such as the higher number of bleeding, blood transfusion may be appropriate. 2. Prophylactic antibiotics in addition to conventional antibiotics, but for tuberculous pericarditis, six months to one year after the regular anti-TB drug treatment. 3. Diuretic cardiac surgery continue to give diuretic drugs to reduce the sodium and water retention, under conditions of full potassium, digitalis preparations. Strict control of liquid input. Surgical results 1. Surgical mortality has declined in recent years, about 4%. McCaughan BC report on the patient's preoperative cardiac function is affected the most important factor in operative mortality. Preoperative cardiac function was grade ~ (NYHA) were operative mortality was 0; cardiac function and , surgical mortality was 10% and 46%. Preoperative ascites, peripheral edema, intracardiac pressure and cardiac index with low degree of mortality to a certain extent. 2. Kirklin JW reported late survival 5 years after surgery and 15 year survival rates were 84% and 59%. McCaughan BC Report 5, 15 and 30 year survival rates were 84%, 71% and 52%. The main factors of late survival is still the state of preoperative cardiac function, but with no significant correlation between surgical approaches. Post-operative follow-up time (years) Figure 3 Late survival after pericardial stripping addition, Kirklin report, the use of sternal incision and the left anterolateral incision, reoperation rate was 2%. 3. Hemodynamics in all patients after surgery in a quiet state, the heart of the hemodynamic parameters were normal. About 10% to 20% of patients in physical activity, a slight increase in pulmonary artery pressure, cardiac output can not be compensatory increase. Such as thickening of the pericardium ventricular surface stripping was incomplete, you can better improve hemodynamics. McCaughan BC Most of the patients reported better long-term, almost all patients can reach the heart function grade ~ . 141 patients with preoperative and postoperative cardiac function diagram Yin Lee Act and other reports constrictive pericardial endarterectomy 132 patients, surgical mortality was 3%. 99 cases were followed up 1 to 25 years with an average of 8.2 years, 73% cure rate, symptom improvement, 22%, no significant improvement in 3%, 2% of those who died in late relapse. And proposed: pericardial resection, to the phrenic nerve on both sides about 1cm to the former. Emphasis on early surgery, duration of less than 1 year were 80% cure rate, duration of 1 year or more in only 52% cure rate, operative death in 5 cases, 4 cases in the course of more than 1 year.
Etiology of chronic constrictive pericarditis is the main cause of TB infection. Bacteriological and histological examination confirmed the change of TB accounted for 30%. About 50% of the cases can not be clear risk factors. But many cases are due to long-term anti-tuberculosis medications, in the event of pericardial constriction, the TB becomes evidence has disappeared. Therefore, people think that most cases of tuberculous pericarditis, followed by purulent infection. Traumatic and non-traumatic hemopericardium caused by constrictive pericarditis by about 10%. In recent years, cardiac surgery complicated by the patients increased.
Pathogenesis of constrictive pericarditis is a major change in the pathophysiology of pericardial constriction limit the normal activities of the bilateral ventricles. Disease early, mainly late diastolic ventricular diastolic limited, with the progress of the disease, but also significantly affected the mid diastole. Diastolic period, the rapid increase in ventricular pressure, left and right ventricular obstruction of blood return, venous pressure is increased, the performance of the jugular vein engorgement, hepatomegaly, ascites, pleural effusion and systemic edema, a small number of patients, there may be splenomegaly large. Slightly lower than normal cardiac output, stroke volume decreased significantly. In physical activity or when in severe narrowing, mainly by increasing heart rate to maintain cardiac output per minute. Large blood vessels in the atrioventricular groove and the ring constriction appears root, it can produce the corresponding parts of the valve noise and signs of dysfunction. The degree of ascites and peripheral edema out of proportion is a major characteristic of this disease. Ascites resulting mechanism has the following 3 points: resistive liver congestion, hepatic venous obstruction; diaphragmatic surface of lymphatic drainage of pericardial adhesions; plasma albumin decreased. Pathological changes general thickening of the pericardium, but the degree of thickening of the different parts of inconsistent performance and diaphragm biventricular more significant pericardial thickening. Thickening of the pericardium by fibrous tissue. Deposition of calcium salts can form calcified plaque or ribbon can also form a complete bony shell. Early pericardial effusion may have the epicardium attached to a thin layer of cellulose or fibrous tissue. With the progress of the disease, visceral pericardial cavity between the progressive development of minor adhesions, tight adhesion, and even closer integration, the latter in the visceral pericardium, the interface between the no. Thickening of the pericardium with diaphragm, pleura and mediastinal structures adhesion. Constrictive pericarditis occur early subepicardial myocardial atrophy, late diffuse atrophy, ventricular wall thickness was significantly thinner than normal. Infiltration may also be due to chronic inflammation, the occurrence of focal myocarditis, causing part of the myocardial fibrosis. A few cases, parts can occur in the atrioventricular groove ring narrow. In addition to the heart, the lungs, liver, spleen and other organs may have a passive hyperemia and fibrosis, with long-term changes of heart failure caused similar.
Half of the patients with clinical manifestations of disease is slow, do not consciously symptoms, no episode of acute pericarditis. About 30% of patients with acute pericarditis history a few months ago, after treatment and then gradually increase the relief of symptoms. Course of patients with varying lengths, the elderly for more than ten years. Most patients in the event of major symptoms and diagnosis, there were 1 to 2 years and a half years history. The main symptoms of the common difficulty in breathing, abdominal distension, peripheral edema, fatigue, weakness and cough. All patients are present in varying degrees of difficulty breathing, shortness of breath or mild physical activity, severe cases can be expressed as orthopnea. The causes of dyspnea as pleural effusion or ascites with increased diaphragm caused a decrease in lung capacity. Although pulmonary venous pressure was increased, but the rare pulmonary interstitial edema. Thus, paroxysmal nocturnal dyspnea and acute pulmonary edema are relatively rare. Abdominal distension by the liver, ascites and visceral congestion caused. Renal blood flow reduction, body water and sodium retention, resulting in edema, more performance for the ankle edema. There also may be heart palpitations, fatigue, weakness, loss of appetite and upper abdominal discomfort and other symptoms. In addition, cough, and precordial pain are more common. Patients were chronic tolerance, facial swelling, superficial vein filling, jugular vein engorgement. Friedreich symptoms can be observed. When the JVP showed early diastolic depression. When the narrowing of the right ventricle back to the hard work seriously affect the flow of inspiratory jugular vein engorgement can be observed clearly (Kussmaul sign). If more than the amount of pleural effusion, intercostal space can be widened. Apex beat half of the patients reduced or lost, the heart is normal or slightly increased world percussion. Sometimes observed during systole the apex and left sternal retraction area was changed was in the early diastolic rapid outward movement. Fast heart rate. About 2 / 3 of patients early diastolic third heart sound can be heard is the result of rapid early diastolic ventricular filling due. All patients had abdominal distension, hepatomegaly, ascites positive. About 10% of the patients had splenomegaly. Normal or low blood pressure, expressed as systolic blood pressure. Venous pressure is increased, the size of cycle time were extended. Patients often have odd pulse, the pulse is reduced or lost in when inhaling. Blood pressure measurement, inspiratory expiratory systolic blood pressure lower than 10mmHg above. Some people think that these changes are thickening of the pericardium and diaphragm adhesion fixed together, pull down the diaphragm when inhaling the pericardium, the heart of the tension increase and limit the filling, so that cardiac output is smaller, resulting in systolic blood pressure decreased.
Auxiliary examination ECG: All patients had ECG abnormalities, but no specific ECG changes. Most patients with ventricular complex wave low voltage. About 70% of the patients experienced abnormal P waves, P waves or P waves widened notch, or both of the. Low and flat or inverted T wave. 1 / 3 to 2 / 3 of the patients had atrial arrhythmias, atrial arrhythmias in 75% of atrial fibrillation. Echocardiography: pericardial clearly visible thickening or adhesions, echogenic; in the late diastolic left ventricular wall motion swim was flat shape; mitral early and rapid closure; pulmonary valve opening in advance; septal motion abnormalities and ventricular end-diastolic diameter reduced. Some people think that the early diastolic rapid filling support the diagnosis of pericardial constriction. Dilated inferior vena cava. X-ray examination: heart normal heart shadow ray film or slightly larger, or smaller. Heart irregular contour, stiffness. Widened mediastinum, caused by the expansion of the superior vena cava. Peripheral lung fields clear. 50% to 90% of patients seen pleural effusion, such as unilateral pleural effusion without mediastinal shift is an important sign of constrictive pericarditis. Pericardial calcification is the main evidence for X-ray changes, and clinical features of a clear diagnosis can co-exist. Calcified parts of its extensive features. About 70% of the patients had signs of calcification. Coronal calcification is a common part of the right ventricle and sternum surface and every surface except the apical surface than the left ventricle. X ray tomography also helps to clear pericardial calcification. CT and magnetic resonance imaging: pericardial thickening can be clearly demonstrated that the extent of about 80% positive rate. High-speed CT (UFCT) more accurate. MRI diagnosis of constrictive pericarditis is the best noninvasive, can accurately measure pericardial thickness and the expansion of the right atrium and right ventricle reduced level. Cardiac catheterization: noninvasive methods, such as failure to confirm the diagnosis, it can further the line right heart catheterization. Right atrium, pulmonary artery and left atrial end-diastolic pressure is equal in the diagnosis of the disease signs. Right ventricular pressure decreased rapidly in early diastole, followed by rapid increase, followed by the diastolic, the pressure was high level of advanced lines, known as the "square root sign" (squareroot sign), also supports the diagnosis. Laboratory tests: some patients may manifest as severe hypoproteinemia, and anemia changed. Individual cases may have abnormal liver function and jaundice.
Differential diagnosis of patients based on dyspnea, hepatomegaly, ascites, venous pressure and pulse pressure decreases and the odd pulse, peripheral edema and other clinical manifestations of depression, coupled with X-ray examination, electrocardiogram and echocardiography, etc. auxiliary method, generally reach the right diagnosis. Need to identify the disease with the disease are mainly the following: 1. Congestive heart failure history of previous heart disease, cardiac enlargement, heart valve murmur may be present often, lower extremity edema and abdominal distension was relatively light. Application of pressure significantly decreased after intravenous diuretics, and chronic constrictive pericarditis diuretics have little effect on the venous pressure. 2. Cirrhosis or hepatic vein thrombosis and portal hypertension may have hepatomegaly and (or) ascites. Based on clinical symptoms and the head, upper extremity venous pressure increased availability, easy, and constrictive pericarditis were identified. In addition, patients with portal hypertension esophageal barium meal examination, showing esophageal varices. 3. Primary dilated cardiomyopathy patients with cardiac examination shows significantly increased, the shift to the left apex beat, mitral or tricuspid valve auscultation a systolic murmur can be. ECG left ventricular hypertrophy or left bundle branch block, pathological Q or T wave inversion affected. X-like to both sides of the heart to expand, especially in left ventricular obvious, pulse weakened, no significant expansion of the superior vena cava. RV-and dual-chamber type of restriction and constrictive pericarditis cardiomyopathy hemodynamic changes and clinical performance is quite similar. However, restrictive cardiomyopathy by echocardiography may have myocardial, endocardial thickening and reflective characteristics of enhanced apical chamber cavity narrow and identification of occlusion and so on can be funded. Small number of patients to conduct a comprehensive examination, diagnosis is still hard to determine, you can redo pericardial biopsy. Left fifth intercostal space to do everything by mouth, the removal of a pericardial sent for pathological examination. If proven constrictive pericarditis, the pericardium can expand the original incision surgery. 4. Tricuspid stenosis the murmur with characteristic damage and the valve (aortic and mitral), jugular vein without early diastolic depression, Doppler ultrasound probe and tricuspid diastolic transvalvular pressure gradient. With tricuspid regurgitation can produce systolic JVP, and the whole liver beat systolic murmur.
Outcomes shall be done pericardial stripping surgery, most patients may be satisfied with the results, a longer duration may be due to cardiogenic cardiac atrophy and cirrhosis of the liver, the prognosis is poor. If not treated by surgery, disease progression, a few cases long-term sick, life and work are severely limited.


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