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The Use of Autologous Pericardium for Ventricular Aneurysm Closure
HOW TO DO IT
The Use of Autologous Pericardium for Ventricular Aneurysm Closure Andrew C. Fiore, M.D., Peter P. McKeown, M.B., B.S., F.R.C.S.(C), Gregory A. Misbach, M.D., Margaret D. Allen, M.D., and Tom D. Ivey, M.D. ABSTRACT Closure of the ventriculotomy following ventricular aneurysm resection usually requires buttressing material to provide strength and hemostasis. Although Teflon felt has usually been used, this material is bulky, noncompliant, and prone to infection. Autologous pericardium appears to offer an ideal substitute without the disadvantages of artificial material. A simple technique is described to apply pericardial tissue as a natural buttressing agent for ventriculotomy closure. Ventricular aneurysms develop in 5 to 10% of patients who survive a transmural myocardial infarction. Resection of the aneurysm may be required because of embolism, angina, or hemodynamic compromise. Aneurysms occur in the posterior or anteroapical regions of the heart as necrotic myocardium is replaced by scar tissue. Ventriculotomy closure following aneurysm resection has often required the use of parallel strips of Teflon felt to serve as support for friable tissue and to aid in hemostasis. Unfortunately, any artificial tissue has the disadvantage of being a site for infection. Looser and colleagues [l]have described infection along the cardiac suture line in patients with Teflon felt closure of the ventricle following aneurysm resection. Teflon is rather thick, bulky, noncompliant, and multifilamented. Its multifilamentous nature means that it can harbor bacterial organisms over a protracted period should infection occur, and eradication of infection then becomes difficult. The ideal material to support closure after aneurysmectomy should be compliant, readily available, and inexpensive; assist hemostasis; and conform to the edges of the ventriculotomy while strengthening and securing to the closure. Autologous pericardium appears to fulfill all of these criteria. The use of pericardium as a hemostatic pledget for aortic repair has been described previously [2]. In the present report, a technique using autologous pericardium for ventriculotomy and ventricular aneurysm closure is described, and we believe this material possesses advantages over Teflon felt.
From the Department of Surgery, St. Louis University, St. Louis, MO, and the Department of Surgery, University of Washington, Seattle, WA. Accepted for publication Dec 29, 1987 Address reprint requests to Dr. h e y , Department of Surgery, RF-25, University of Washington, Seattle, WA 98195.
Technique When the ventriculotomy is ready for closure, strips of pericardium on both sides are prepared by dissecting away excess adipose tissue and the pleura. Care should be taken to avoid inadvertently entering the pleural cavity. In the adult patient, it is not difficult to prepare strips of pericardium 2 to 3 cm wide and 10 cm or more in length. Heavy interrupted braided sutures (e.g., 2-0 silk) are placed in a mattress fashion, incorporating the pericardium on the outside edges of the ventriculotomy in the same way one would use felt strips (Figure). After these sutures are tied, a reinforcing layer is placed, using a running 1-0 polypropylene suture. By running this su-
A -
I' . ' I
I
B Interrupted horizontal mattress sutures are passed through excised strips of pericardiurn (A). The closure is completed with a running monofilament suture ( B ) .
570 Ann Thorac Surg 45:57&571, May 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
571 How to Do It: Fiore et al: Autologous Pericardium for Aneurysm Closure
ture down in one oblique direction and running back in a different oblique direction, a crisscross pattern can be used. Excess pericardial tissue can be trimmed once the ventriculotomy closure is completed.
Comment Obtaining a secure and hemostatic closure of a ventriculotomy incision after aneurysm resection or thrombectomy can pose a major challenge. Felt pledgets or strips of Teflon are commonly used to buttress the sutures and to increase hemostasis. By substituting autologous tissue, such as strips of pericardium, the chance of chronic infections at the repair site appears to be diminished. To date this technique has been used in approximately 20 patients over a two-year span. There
have been no instances of suture line hemorrhage or late infection. Pericardium has some distinct advantages: It is easy to use, cost free, readily available, and pliable enough to occlude the interstices, thus, increasing the chances of hemostasis; yet it is strong enough to buttress the sutures. Closure of a ventriculotomy with pericardial strips may prove to be the technique of choice.
References 1. Looser KG, Allmendinger PD, Takata H, et al: Infection of cardiac suture line after ventricular aneurysmectomy. J Thorac Cardiovasc Surg 72:280, 1976 2. Shapira N: An alternative to felt pledgets in cardiac surgery. Ann Thorac Surg 41:219, 1986
Notice from the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the cardiothoracic operations they performed during the year prior to application for recertification. They should also keep a record of their attendance at thoracic surgical meetings, and other continuing medical education activities pertaining to thoracic surgery and thoracic disease, for the two years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS I11 syllabus (Self-EducatiodSelf-Assessmentin Thoracic Surgery). It is not necessary for candidates to purchase
SESATS I11 booklets prior to applying for recertification. SESATS I11 booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1990 may begin the recertification process in 1988. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any Diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is July 1, 1988. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One American Plaza, Suite 803, Evanston, IL 60201.
The Use of Autologous Pericardium for Ventricular Aneurysm Closure Andrew C. Fiore, M.D., Peter P. McKeown, M.B., B.S., F.R.C.S.(C), Gregory A. Misbach, M.D., Margaret D. Allen, M.D., and Tom D. Ivey, M.D. ABSTRACT Closure of the ventriculotomy following ventricular aneurysm resection usually requires buttressing material to provide strength and hemostasis. Although Teflon felt has usually been used, this material is bulky, noncompliant, and prone to infection. Autologous pericardium appears to offer an ideal substitute without the disadvantages of artificial material. A simple technique is described to apply pericardial tissue as a natural buttressing agent for ventriculotomy closure. Ventricular aneurysms develop in 5 to 10% of patients who survive a transmural myocardial infarction. Resection of the aneurysm may be required because of embolism, angina, or hemodynamic compromise. Aneurysms occur in the posterior or anteroapical regions of the heart as necrotic myocardium is replaced by scar tissue. Ventriculotomy closure following aneurysm resection has often required the use of parallel strips of Teflon felt to serve as support for friable tissue and to aid in hemostasis. Unfortunately, any artificial tissue has the disadvantage of being a site for infection. Looser and colleagues [l]have described infection along the cardiac suture line in patients with Teflon felt closure of the ventricle following aneurysm resection. Teflon is rather thick, bulky, noncompliant, and multifilamented. Its multifilamentous nature means that it can harbor bacterial organisms over a protracted period should infection occur, and eradication of infection then becomes difficult. The ideal material to support closure after aneurysmectomy should be compliant, readily available, and inexpensive; assist hemostasis; and conform to the edges of the ventriculotomy while strengthening and securing to the closure. Autologous pericardium appears to fulfill all of these criteria. The use of pericardium as a hemostatic pledget for aortic repair has been described previously [2]. In the present report, a technique using autologous pericardium for ventriculotomy and ventricular aneurysm closure is described, and we believe this material possesses advantages over Teflon felt.
From the Department of Surgery, St. Louis University, St. Louis, MO, and the Department of Surgery, University of Washington, Seattle, WA. Accepted for publication Dec 29, 1987 Address reprint requests to Dr. h e y , Department of Surgery, RF-25, University of Washington, Seattle, WA 98195.
Technique When the ventriculotomy is ready for closure, strips of pericardium on both sides are prepared by dissecting away excess adipose tissue and the pleura. Care should be taken to avoid inadvertently entering the pleural cavity. In the adult patient, it is not difficult to prepare strips of pericardium 2 to 3 cm wide and 10 cm or more in length. Heavy interrupted braided sutures (e.g., 2-0 silk) are placed in a mattress fashion, incorporating the pericardium on the outside edges of the ventriculotomy in the same way one would use felt strips (Figure). After these sutures are tied, a reinforcing layer is placed, using a running 1-0 polypropylene suture. By running this su-
A -
I' . ' I
I
B Interrupted horizontal mattress sutures are passed through excised strips of pericardiurn (A). The closure is completed with a running monofilament suture ( B ) .
570 Ann Thorac Surg 45:57&571, May 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
571 How to Do It: Fiore et al: Autologous Pericardium for Aneurysm Closure
ture down in one oblique direction and running back in a different oblique direction, a crisscross pattern can be used. Excess pericardial tissue can be trimmed once the ventriculotomy closure is completed.
Comment Obtaining a secure and hemostatic closure of a ventriculotomy incision after aneurysm resection or thrombectomy can pose a major challenge. Felt pledgets or strips of Teflon are commonly used to buttress the sutures and to increase hemostasis. By substituting autologous tissue, such as strips of pericardium, the chance of chronic infections at the repair site appears to be diminished. To date this technique has been used in approximately 20 patients over a two-year span. There
have been no instances of suture line hemorrhage or late infection. Pericardium has some distinct advantages: It is easy to use, cost free, readily available, and pliable enough to occlude the interstices, thus, increasing the chances of hemostasis; yet it is strong enough to buttress the sutures. Closure of a ventriculotomy with pericardial strips may prove to be the technique of choice.
References 1. Looser KG, Allmendinger PD, Takata H, et al: Infection of cardiac suture line after ventricular aneurysmectomy. J Thorac Cardiovasc Surg 72:280, 1976 2. Shapira N: An alternative to felt pledgets in cardiac surgery. Ann Thorac Surg 41:219, 1986
Notice from the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the cardiothoracic operations they performed during the year prior to application for recertification. They should also keep a record of their attendance at thoracic surgical meetings, and other continuing medical education activities pertaining to thoracic surgery and thoracic disease, for the two years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS I11 syllabus (Self-EducatiodSelf-Assessmentin Thoracic Surgery). It is not necessary for candidates to purchase
SESATS I11 booklets prior to applying for recertification. SESATS I11 booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1990 may begin the recertification process in 1988. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any Diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is July 1, 1988. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One American Plaza, Suite 803, Evanston, IL 60201.