İhsan Alur Yrd. Doç. Dr.İHSAN ALUR PAMUKKALE ÜNİVERSİTESİ TIP FAKÜLTESİ CERRAHİ TIP BİLİMLERİ-KALP VE DAMAR CERRAHİSİ

1. 12TH INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND
CARDIOVASCULAR SURGERY
MARCH, 10 - 13, 2016 / SUENO BELEK CONVENTION CENTER,
ANTALYA - TURKEY
THE DIFFICULTY OF CORONARY ARTERY
BYPASS GRAFTING IN A PATIENT WITH
CONCRETIO CORDIS
İhsan Alur1, İbrahim Gökşin1, Bekir Serhat Yıldız2, Gökhan Yiğit
Tanrısever1, Tevfik Güneş1
1Department of Cardiovascular Surgery, Pamukkale University, Denizli,
Turkey
2Department of Cardiology, Pamukkale University, Denizli, Turkey

2. Case
 A 57-year-old male patient presented with
the complaints of sweating and respiratory
distress on effort
 Anamnesis included hospitalization in the
cardiology clinics with the diagnosis of
supraventricular tachycardia (SVT) attack.

3. Case
 ECG: AF and
 NYHA was functional class 3 heart failure
 Echocardiographical findings were mild
mitral regurgitation (MR), left ventricular
ejection fraction (EF) 50-55%.
 Diffuse pericardial calcification was
observed in the telecardiography (Fig.
1A,1B).

4. Case
Figure 1A,1B. Diffuse pericardial calcification in the
telecardiography, anteroposterior (A) and lateral (B) views.

5. Case
 CAG: revealed complete obstruction at the
origin of the circumflex (Cx) coronary
artery (100%), a lesion causing 70%
stenosis in the proximal part of the left
anterior descending (LAD) coronary artery
and significant diffuse pericardial
calcification (Fig. 2A,2B).

6. Case
Figure 2A,2B. Significant diffuse pericardial calcification on the
coronary angiography

7. Case
 Coronary artery bypass grafting and
pericardiectomy were planned for the
patient.
 Median sternotomy was performed. The
pericardium was observed to be calcified,
highly cohesive, completely ossified and
to have invaded into the myocardial tissue
(Fig. 3A,3B).

8. Case
Figure 3. A view of the calcification in the operation

9. Case
 The calcified pericardium were
respectively resected from the ascending
aorta, anterior face of the left ventricule,
pulmonary artery and right ventricles.
 Aorta-LAD distal anastomosis was
performed with the saphenous graft.

10. Case
 Cx coronary artery anastomosis could not be
performed, since the heart could not be
elevated due to the pericardial cohesiveness
covering the lateral wall of the left ventricle,
and the posterior wall of the heart could not
be accessed.
 Approximately 8-10 mm size of the
pericardium was sent for histopathological
examination. The surgical specimen was
examined and reported as a calcific
constrictive pericarditis.

11. Discussion
 Pericardium is a serous membrane with a
thickness of less than 2 mm under normal
conditions.
 If it has a thickness of more than 4 mm,
the ‘’pericardial constriction’’ term is
suggested (1).
 (1). Talreja DR, Edwards WD, Danielson GK, Schaff HV, Tajik AJ,
Tazelaar HD, et al. Constrictive pericarditis in 26 patients with
histologically normal pericardial thickness. Circulation.
2003;108(15):1852-7.

12. Discussion
 Because of both ventricular limitation in CP,
biventricular end-diastolic pressure is increased, and
ejection volumes of both ventricles are decreased
(2).
 Furthermore, thickened and calcified pericardium is
often in direct contact with the myocardium, reducing
the contractility of the cardiac muscle and impairing
the diastolic input synchronization and coordination
of the ventricles (2).
 (2). Yetkin U, Kestelli M, Yilik L, Ergunes K, Kanlioglu N,
Emrecan B, et al. Recent surgical experience in chronic
constrictive pericarditis. Tex Heart Inst J. 2003;30(1):27-30.

13. Discussion
 The definitive treatment of calcified CP is
pericardiectomy. The reported methods for
pericardiectomy in the literature are
micropneumatic saw (3), Waffle procedure
(4) and direct pericardial resection.
 (3). Casha A, Chandrasekaran V.Pericardiectomy using an
oscillating saw. Ann Thorac Surg. 2000;69(2):613-4.
 (4). Shiraishi M, Yamaguchi A, Muramatsu K, Kimura N, Yuri K,
Matsumoto H, et al. Validation of Waffle procedure for constrictive
pericarditis with epicardial thickening. Gen Thorac Cardiovasc
Surg. 2015;63(1):30-7.

14. Discussion
 The ideal resection is to completely
remove the site of the parietal pericardium
between the right and left phrenic nerves.
 Due to coronary artery disease we
performed CABG and partial pericardial
resection accompanying CPB in our case.

15. Discussion
 Pericardiectomy may have some
complications.
 These include myocardial or coronary artery
injury and related bleeding, atrial/ventricular
injury, tamponade, arrhythmia, low cardiac
output syndrome, acute renal insufficiency
and acute respiratory distress syndrome (2).
 (2). Yetkin U, Kestelli M, Yilik L, Ergunes K, Kanlioglu N, Emrecan B, et
al. Recent surgical experience in chronic constrictive pericarditis. Tex
Heart Inst J. 2003;30(1):27-30.

16. Conclusion
 In conclusion, although the surgery of
Concretio cordis is difficult, the patient
benefits considerably from the operation.
 Pericardiectomy may contribute to these
patients symptomatology.