Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

A. Rego, W. Boyd, E. Góngora, William E. Johnson, III, N. Munfakh, John P Pirris, R. Wolf
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Abstract

BACKGROUND As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019.  Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. RESULTS The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. CONCLUSIONS Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.
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专家对心血管手术中心包重建之争的意见:闭合还是不闭合?
截至2019年,在每年进行的32万多例心脏手术中,只有一小部分进行了心包闭合手术。然而,关于心包闭合或重建的益处的证据越来越多,特别是随着2019年RECON研究的发表。方法:本小组召集专家就心包重建术达成一致意见。结构化的主题问题最初被用来激发讨论。随后,在作者中对拟议的专家意见声明进行了调查。根据这项调查,汇编了协商一致的专家意见声明和建议。结果专家意见涵盖了与心包重建相关的各种主题,包括定义、获益/风险和技术。观察到的益处包括:(1)粘连的减少;(2)术后心包积液、心房颤动、出血;(3)再入院率和住院时间。有关手术技术的专家意见建议汇编成一个图表。应进行完整的心包重建,如果可用且可行,应使用原生心包组织;如果不可行,可以使用贴片。刺激部位特异性组织原位形成(如天然细胞外基质)的贴片可能还有其他好处(包括生物再生特性和缺乏炎症反应)。闭合应该紧绷,但不要紧张。必须确保闭合心包的充分引流。结论根据现有资料和手术经验,我们支持心包重建术作为适当选择患者的标准入路。我们也支持采用标准化的心包重建技术来优化患者的预后,并在未来的研究中提高证据质量。
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