home Audience 12 Pericarditis. Combined operations. Vascular-atrial resections

Pericarditis. Combined operations. Vascular-atrial resections

The pericardium is a thin two-layer membrane with a small amount of fluid between the sheets that covers the heart and protects it from possible injuries and infections. In addition, the pericardium prevents the chambers of the heart from expanding excessively during diastole, which also allows the heart to work as efficiently as possible. The inflammatory process localized in the pericardium is called pericarditis. Most cases of pericarditis are reported in men.

Pericarditis is always acute illness, which, however, can last up to several months. If the pericardium were accessible to direct inspection, it would be possible to find that it is hyperemic and swollen (as, for example, the skin around a wound looks). In some cases, during inflammatory process a large amount of inflammatory fluid is secreted, which accumulates between the pericardial layers and can even limit the mobility of the heart.

Symptoms of pericarditis

Main symptom pericarditis - sharp pain in the heart, which increases with coughing and movement, and decreases when the patient bends forward.

The main “chest” symptoms include:

Sharp, dagger-like pain behind the sternum. Caused by friction of the heart against the pericardium.
The pain may intensify during coughing, swallowing, deep breath, trying to lie down.
The pain decreases when the person sits forward.
In some cases, the patient holds the chest with his hand or tries to press something against it (for example, a pillow).

Other symptoms may include:

Chest pain radiating to the back, neck, left hand.
, worse when lying down.
Dry cough.
Anxiety, fatigue.

Some people may experience pericarditis. This is usually a symptom of constrictive pericarditis, a very severe form of the disease.

With constrictive pericarditis, the pericardial tissue thickens, hardens and prevents the heart from working normally, limiting its range of motion. In this case, the heart cannot cope with the volume of blood entering it. Because of this, swelling occurs. If such a patient does not receive adequate treatment, then it can develop.

Pericarditis or any suspicion of it is a reason to immediately call an ambulance or get to the hospital yourself (with the help of family and friends), because this condition is very dangerous and requires treatment.

Such autoimmune diseases, like systemic lupus erythematosus, systemic and some others, can also cause pericarditis.

TO rare reasons relate:

Post-traumatic pericarditis (for example, with penetrating chest injury).
Uremic pericarditis in the background.
Pericarditis with tumors.
Pericarditis in familial Mediterranean fever.
Pericarditis while taking immunosuppressants.

The risk of pericarditis also increases after:

and heart surgery (Dressler syndrome).
Radiation therapy.
Such percutaneous types of cardiac examination and treatment as radiofrequency ablation and cardiac catheterization.

In these cases, it is believed that the body begins to mistakenly attack the pericardial cells, which causes inflammation. The difficulty in diagnosing such patients is that after such interventions (catheterization, radiofrequency ablation) it may take several weeks before pericarditis develops.

For many people, the cause of the disease remains unclear. This type of pericarditis is called idiopathic.

Pericarditis often becomes chronic, that is, after a period of exacerbations there is a slight lull, and then after exposure to provoking factors the disease returns.

When should you see a doctor?

If the first symptoms of pericarditis appear, you should immediately seek medical help. If pericarditis is not treated, it can lead to sad consequences up to fatal outcome. Since during inflammation, fluid accumulates between the layers of the pericardium, the volume of which can be advanced cases exceed 1000 ml, there is a high probability of developing such clinical manifestation like cardiac tamponade. This is a condition when the heart is unable to effectively contract and relax, causing pain to occur.

Symptoms of impending cardiac tamponade:

If cardiac tamponade is suspected, emergency medical attention is required.

Signs of constrictive pericarditis:

Dyspnea.
Edema of the lower extremities.
Heart rhythm disturbances.
Enlargement of the abdomen (due to the accumulation of fluid in it due to heart failure).

If you suspect constrictive pericarditis, you should seek help from a cardiology or therapeutic department the nearest hospital.

Diagnosis of pericarditis

During auscultation of pericarditis, the doctor will hear a characteristic noise - a pericardial friction noise.

First of all, the doctor will be interested in the following two symptoms:

Sharp pain radiating to the back, neck and left arm.
Difficulty breathing.

The combination of these signs indicates that the patient has pericarditis rather than acute coronary syndrome.

It is also necessary to tell the doctor in detail what you have been sick with recently, as this will make it easier to identify the cause of the disease (viral, bacterial or autoimmune pericarditis). You cannot hide the fact that you have previously had surgery (especially on the heart) or have chronic ( renal failure) or autoimmune diseases (for example, systemic lupus erythematosus).

During the physical examination, the doctor will listen to heart sounds using a stethoscope. One of the classic auscultatory signs of pericarditis is a pericardial friction rub. This sound resembles rubbing of pieces of paper and occurs when the inflamed pericardium rubs against each other. After liquid accumulates between the leaves, this noise will disappear. If the disease is already advanced, the doctor can listen for moist rales in the lungs, which will indicate decompensation of the process and an increase in heart failure.

Diagnostic examination includes:

X-ray examination of the chest: the image clearly visualizes an increase in the shadow of the heart and congestion in the lungs.
Electrocardiogram: the ECG may show characteristic signs of cardiac dysfunction and pericardial damage. With constrictive pericarditis, typical changes are also revealed on the film.
Echocardiography: EchoCG allows not only to “see” the inflammatory process, but also to measure the amount of fluid in the pericardial cavity. This is especially important for determining the need surgical intervention– puncture of the pericardium with subsequent removal of excess fluid.
Computed tomography and magnetic resonance imaging: these studies help to visualize the presence of fluid in the pericardial cavity, but also to determine the presence of inflammation using a special substance gadolin. CT and MRI can assess the degree of pericardial thickening and the risk of cardiac tamponade.
Cardiac catheterization: this one invasive method diagnostics makes it possible to determine the efficiency of the heart, pressure in the atria and ventricles.
Laboratory tests: special blood tests will help accurately differentiate heart attack from pericarditis, as well as establish the nature of the disease (viruses or bacteria). Level determination C-reactive protein will help confirm inflammation and determine its activity.

Other tests will also be done to rule out autoimmune diseases.

How is pericarditis treated?

Before starting treatment, it is necessary to establish the cause of pericarditis; the treatment regimen will depend on this.

In all cases, the patient will be prescribed (ibuprofen, diclofenac, etc.) to reduce pain and as an anti-inflammatory treatment. large doses in combination with proton pump blockers (omeprazole) to protect the gastric mucosa. This treatment will help relieve pain and reduce swelling of the pericardial tissue.

If pericarditis has become chronic and the exacerbation lasts a very long time (2 weeks or more), then the patient is prescribed colchicine. This drug has been successfully used as an anti-inflammatory agent for a very long time. Sometimes colchicine is combined with ibuprofen, this helps achieve best result in treatment.

If pericarditis infectious, antibiotics are prescribed when determining the bacterial nature of the pathogen.

If pericarditis caused by fungi, then an appropriate antifungal agent is prescribed.

Other drugs prescribed for pericarditis

Glucocorticosteroids (for example, Prednisone). These substances have a strong anti-inflammatory effect; in addition, without them it will not be possible to cure pericarditis caused by an autoimmune process.
Diuretics. These drugs remove excess water from the body, reduce swelling and stress on the heart, and alleviate the patient’s condition.
Narcotic analgesics. In case of special severe pain that are not relieved by non-steroidal anti-inflammatory drugs, the patient may be prescribed narcotic analgesics. Unfortunately, strong effect pain relief is combined with a high risk of drug addiction.

If fluid continues to accumulate in the pericardium

Pericardiocentesis may be performed. Surgeon after treatment skin in the area of the sternum and applying local anesthesia (lidocaine) will insert a needle into the pericardial cavity and withdraw excess liquid. Sometimes this procedure is performed under echocardiography guidance.
Sometimes patients are given a so-called pericardial window. The surgeon makes a small incision in the pericardium and creates a shunt into the abdominal cavity, allowing accumulated fluid to drain into the abdomen.
In particular severe cases for constrictive pericarditis it is carried out surgical treatment. During surgery, the surgeon removes part of the pericardium (pericardiotomy), which allows the heart to pump normally.

Possible complications of pericarditis

Constrictive pericarditis

This is a very severe form of pericarditis, in which the pericardial layers become calcified and scarred due to inflammation. All this leads to the fact that the heart becomes compressed and can no longer perform its functions fully. Patients with constrictive pericarditis develop heart failure, which is manifested by swelling of the extremities, stagnation of fluid in the lungs, accumulation of fluid in the abdominal cavity(ascites), severe shortness of breath, cardiac arrhythmia.

Constrictive pericarditis is treated as therapeutic methods, and surgical. If diuretics and drugs to maintain a normal heart rhythm are ineffective, then pericardiotomy is performed.

Cardiac tamponade

If inflammatory fluid accumulates between the layers of the pericardium very quickly and there is a lot of it, then this can lead to this clinical condition like cardiac tamponade. In this case, the heart becomes so compressed that it cannot contract. Cardiac tamponade is a condition that threatens the patient’s life and requires emergency medical care.

Life after pericarditis

For most people, pericarditis resolves within a maximum of 3 months and does not cause any complications. Therefore after rehabilitation period the person can return to work and usual activities.

IN in rare cases pericarditis may recur. Then you will again need to seek medical help. It will be necessary to undergo repeated examination and treatment.

Prevention of pericarditis

Severe ARVI suffered on the legs can lead to viral pericarditis.

Since in most cases pericarditis develops after a history of viral infection, then you need to carefully monitor your health and receive timely treatment. You shouldn’t suffer another cold on your feet; it can be very costly in the future.

The heart is located in a kind of sac, which is commonly called the cardiac sac. An inflammatory process that is localized in the pericardium or cardiac sac ( outer shell), called pericarditis. The pathology, which is quite common, is treated by cardiologists, often cardiac surgeons and oncologists.

Very often, the disease can only be identified after the patient’s death and autopsy. The prevalence of the pathology does not depend on the area of residence and gender, although in women the problem is slightly more common.

IN different periods life, patients are diagnosed with pericarditis of different nature. Pericarditis can be an independent disease, in which case its clinical picture comes to the fore.

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But if the disease is a consequence of another pathology, cardiac, infectious or systemic disease, then the symptoms of this disease will be most pronounced, and the signs of pericarditis will fade into the background.

Pericarditis belongs to the group of polyetiological diseases precisely because it can be caused for various reasons, one of which is tumor formation. It is not difficult to detect using cardiac ultrasound, x-ray, echocardiography, MRI.

In this case, as in many others, treatment should be aimed at eliminating the cause, if the inflammatory process is relieved with the help medications, this will bring temporary relief, but there will be an even greater risk of relapse.

Tumor pericarditis refers to diseases of a non-infectious (aseptic) nature that are not caused by microorganisms. But at some stage of development, the disease can be complicated by microbes, then its course will take on an infectious character.

Most often, pericarditis caused by a tumor can be characterized by:

intense pain in the chest;
general increasing weakness in the body;
shortness of breath;
unproductive cough.

Flow mechanism

The development of the inflammatory process in the pericardium during tumor formation is influenced by direct mechanical compression of the pericardial tissue, which is subsequently destroyed and thickened.

Tumor-like formations have two types of lesions:

Primary

appear as a result of pericardial cells mutating;
detection of such pathology in patients during life is insignificant, therefore very often (in 75% of cases) it is determined by autopsy;
only 3–5% are diagnosable;
the tumor can be benign (fibroma, angioma) or malignant (mesothelioma, sarcoma).

Metastatic

in this case, cancer cells from other organs enter the pericardium;
the spread of metastases is helped by blood flow, so it moves in the body, like an infection;
Once in the pericardium, the cell begins to divide and a malignant neoplasm is formed;
metastases in the cardiac sac appear due to lung cancer(40%), breast (22%), leukemia (15%), gastrointestinal tract (4%), melanoma (3%), other organs (16%).

The clinical signs of pericarditis are not affected by whether the lesion is primary or metastatic because the pathology occurs later than the neoplasm. Due to the growth of the tumor, the inflammatory process mechanism can affect the coronary (heart) vessels and its own tumors, squeezing and damaging them, the pericardial layers, and the tissues surrounding the tumor.

A healthy heart contains 5–30 ml of pericardial fluid in the pericardium, which reduces friction between the layers of the cardiac sac when contractions occur. When inflammation occurs in the pericardium, the process is disrupted.

First, it is customary to consider the development of exudative pericarditis, when additional fluid “sweats” into the cavity of the heart sac, where the pressure increases, which leads to compression of the heart from the outside. The diastolic function of the heart muscle is impaired and the heart cannot relax completely.

With the slow development of the inflammation process, the patient may not have complaints until the body’s compensatory capabilities are exhausted, which will subsequently lead to the development of heart failure.

If the process develops quickly (several hours or days), this will lead to tamponade, a deadly complication.

At the second stage, when a small amount of fluid has accumulated in the pericardium, dry pericarditis develops. In this case, the patient may also not notice the development of the inflammatory process, after which subsides, the amount of fluid in the pericardium will return to its original state. But the protein that was part of the additional fluid will remain in the cavity of the heart sac.

Having been deposited in some areas of the pericardium, it will lead to their adhesion and fusion, resulting in the formation of fibrin adhesions. They will not only interfere with the functioning of the heart, but can lead to serious complications.

The method of treating tumor pericarditis depends on the inflammatory process caused by the tumor, the location and nature of the tumor, and the symptoms that accompany the pathology.

The inflammatory process, and in some cases the tumor, is eliminated with medications. Surgery is required to remove benign and malignant tumors and the complications they cause.

With drug therapy:

inflammation is removed;
the symptoms of pericarditis are eliminated;
pain syndrome is relieved.

Pericardial mesiothelioma cannot be removed with radiation therapy, so several courses of chemotherapy are necessary. But if the localization of the tumor allows radical treatment, it can be removed surgically.

Otherwise, surgical interventions are aimed at saving the patient from the complications that tumor pericarditis has led to. These include the accumulation of additional fluid (effusion) in the heart sac, tamponade (blood in the cavities of the heart due to vascular damage), purulent damage tissues, chronic development, armored heart. Such complications arise due to tumor growth.

Surgical treatment is usually carried out in two ways:

Pericardectomy

The method allows you to remove the outer layer of the pericardium. It is usually prescribed for constrictive pericarditis, one of the causes of which is malignancy in any organs and metastases in the heart. Resection outer shell heart that has thickened will lead to real therapeutic effect and relieve the symptoms of pericarditis.

Surgery is prohibited in case of respiratory failure, bleeding disorders, chronic diseases at the acute stage.

The surgical procedure involves two types of pericardiectomy:

total, when the cardiac sac is removed, but its posterior part is preserved;
subtotal, when the heart sac is removed in various areas in which inflammation most progresses.

Pericardiocentesis

The technique involves removing fluid from the pericardium using a catheter. In this case, the anterior wall of the chest is pierced with a special needle. Pericardial puncture is indicated for tamponade, as a complication of tumor pericarditis and other forms of pathology.
The second option is the inability of the heart muscle to contract, despite the spread of electrical impulses, which can also be caused by a growing tumor or an inflammatory process. Most often, the technique is used when pericardial effusion has just developed.
The pericardiocentesis technique is fraught with serious complications, so it is rarely used.

If pericardial effusion (filling of the heart sac with fluid) is malignant in nature, but there are no signs of tamponade, doctors, in addition to pericardiocentesis, offer the patient:

Malignant tumors affecting the myocardium are not removed surgical methods, is appointed radiation therapy which can lead to the development of radiation pericarditis

Consequences

Tumor pericarditis, like other forms of this pathology, is treated with modern medical methods. Patients usually make a full recovery. Unless the nature of the disease is malignant. In some cases after past illness, complications develop that can even cause disability.

Thickening of the pericardial layers	Fibrinous inflammation of the pericardium occurs because after the end of the process of inflammation and recovery normal amount fluid in the pericardium, fibrinogen or protein still remains in the heart sac for some time and is not absorbed. A dense plaque forms from it on the walls of the pericardium. When listening to patients until the end of life, there is a noise in the pericardium, behind the sternum after physical activity pain may appear. The heart may become slightly larger because the muscles need to increase their oxygen consumption. In this case, the leaves of the heart sac, which have thickened, fit tightly to each other. The complication does not require treatment.
Cardiac tamponade	The pathological condition is characterized by the accumulation of blood in the pericardial cavity, which is the most dangerous complication. As a result of the filling of the heart sac with blood, pressure is created in it, which greatly compresses the heart. Tamponade occurs due to rupture of blood vessels, which can be injured by the tumor. To prevent the patient from dying from heart failure, urgent cardiac puncture (pericardiocentesis) is required; this increases the risk of developing infectious pericarditis in addition to aseptic pericarditis.
Fistula formation	They are formed during purulent pericarditis. But it, in turn, can be triggered by a tumor that compresses the tissues, leading to their necrosis and biological release active substances. All this can cause inflammation, including purulent inflammation. Due to pyogenic microorganisms, holes are formed in the pericardial tissue through which the heart sac and the pleural cavity or esophagus communicate naturally. After the end of the purulent process, the holes remain, which leads to pronounced pain syndrome and disruption of heart function in the future. This complication must be treated surgically to close the holes in the pericardium.
Cardiac conduction disorder	After pericarditis, the disorder may persist for a long time electrical conductivity hearts. This will be expressed by attacks of rhythm disturbance, especially after physical exertion. The reason lies in damage to the muscles of the outer lining of the heart (pericardium). At normal operation Cardiomycytes conduct electrical impulses evenly. During and after the inflammatory process, their electrical conductivity changes, impulses spread unevenly. There is no treatment for the complication, so the patient long time may use antiarrhythmic drugs. When an arrhythmia significantly impairs the quality of life and affects the ability to work, a person may be assigned a disability group.

It is a disease that requires therapeutic and at the same time - perhaps from the very beginning - surgical intervention. Establishing this fact is important because it serves to prevent those severe complications that in the future pose an increasingly difficult problem for the therapist and surgeon.

Diseases of the pericardium of inflammatory origin, for which there are indications for surgical treatment, are usually divided into four groups:

1. Serous and serous-hemorrhagic pericarditis.

2. Fibrinous pericarditis.

3. Purulent pericarditis.

4. Chronic fibrous, calcifying, constrictive pericarditis.

It is typical for the first and third groups that fluid accumulates in the pericardial cavity in the form of transudate or exudate, and this accumulation of fluid can be so significant that it threatens cardiac tamponade. The purpose of the operation is to release fluid and create the easy way for local treatment.

With fibrinous pericarditis, fibrin is released intrapericardially, which in some cases can occur in such large quantities that it gives a picture of the pathologically well-known “hairy heart”, “cor villosum”.

Surgical opening of the pericardium is indicated:

1. if due to the rapid formation of exudate there is a risk of cardiac tamponade;

2. if the exudate exists for a long time and does not show a tendency to be absorbed;

3. if the exudate is purulent, as a result of which its pumping and continuous local antibiotic treatment are indicated;

4. if removal of the pericardium is indicated to prevent the occurrence of constrictive pericarditis.

Constrictive pericarditis is late complication advanced pericarditis.

In the treatment of pericarditis latest development Heart surgery led to results that, by necessity, changed the old conservative views towards radicalism. Before the discovery of antibiotics and chemotherapeutic drugs, conservative views rightfully dominated in the treatment of pericarditis of tuberculous origin. However, having these medicines, conservatism was replaced by a very successful active look treatment, based on objective criticism of which the old indications and contraindications for surgery needed significant revision.

Puncture treatment of pericarditis is unsafe. Here we are less referring to heart damage due to incorrect technique, but rather to pleural complications (pleurisy, empyema, pneumothorax, etc.), which can undoubtedly be serious and undesirable consequences of punctures.

Surgical opening of the pericardium is a long-known, very simple and completely safe intervention, which should always be preferred to puncture treatment. In old textbooks of surgery, the operation is known as inferior longitudinal pericardiotomy or inferior oblique pericardiotomy. The essence of the operation is that by cutting or removing the base of the xiphoid process or resection of a small sternal part of the VIIth costal cartilage, the area of the diaphragm adjacent to the pericardium is prepared without opening the peritoneum and pleura. Having made a small hole in it, the exudate is gradually released. Donaldson attaches a thin rubber tube inserted into the hole with a catgut suture and closes the several centimeter wound. Through drainage, outflow or suction of the accumulating pericardial fluid is ensured, and local treatment is possible, washing the pericardial cavity with antibiotics and medications.

This method is suitable for the treatment of acute pericarditis, regardless of its specific or nonspecific nature, and it plays a very important role in the prevention of later developing constrictive pericarditis. Holman recommends after graduation acute stage pericarditis, pericardiectomy. We believe that this proposal should be considered, and we are certainly more willing to perform the operation then than in the late, advanced constrictive stage.

In chronic pericarditis, larger or smaller fusions of the pericardial sheets or cords, as well as fixation of the pericardium to surrounding organs (sternum, diaphragm, mediastinum, spine) sometimes lead only to minor, but very often to severe morphological and functional disorders.

The type of these adhesions and the harm they cause determine the indications and contraindications for the operation, as well as the appropriate method for performing it. In the treatment of pericardial adhesions that cause functional disorders, essentially two surgical methods are known. One of them is pericardiectomy, based on the principle of lung decortication proposed by Sapozhnikov; Another method is Brouwer cardiolysis.

Cardiolysis had the goal, according to the views of that time, of freeing the heart from the bony chest wall. Currently, this operation is performed only very rarely. The essence is that part of the bony chest wall located in front of the heart is removed, as a result of which the heart is freed from its fixed position. This operation can be successful if diastolic expansion is primarily hampered by the fact that the heart is fixed to the chest wall.

With pericardial constriction, results can only be expected from pericardiectomy. Known for penetration different kinds access. We have very good access with the lower mediastinotomy proposed by Holman, at the middle of the lower part of the sternum. Other surgeons open both pleural cavities with a transverse incision in the sternum. We typically use the method proposed by Holman, which provides excellent access to complete pericardiectomy, including the inferior vena cava area. The hemodynamic rule for pericardiectomy is that cardiac release and dissection should begin at the surface of the left ventricle.

When removing the armor, serious difficulties sometimes arise for the surgeon, because the scars can be closely adhered to the muscles, and the thin muscles can easily rupture. Sewing it up is sometimes a very difficult or even hopeless task. It is usually not recommended to peel off the atrium, nor is it particularly necessary. The thin walls of the atria are very easily ruptured. All authors consider the release of the vena cava area to be theoretically correct. I myself have never observed their narrowing in a fairly large amount of material.

From a disease perspective, pericardiectomy is certainly a more radical and desirable solution to the issue. Still, there may be cases in which - even if not definitively - one has to be content with cardiolysis. At postoperative treatment We also have good experience with hibernation and hypothermia. By reducing the work of the heart, they have a very beneficial effect. The heart, freed from its shell, becomes sick as a result of compression, and the surgical load certainly means additional work.

The development of operating technology is unlikely to significantly reduce high mortality during pericardiectomy, but early identification of indications for surgery can do this. Unfortunately, this operation in most cases was used only as a last resort, when the patient subject to surgery was already in a hopeless condition, and the operation was hopeless, when the consequences of a long-existing constriction (ascites, cirrhosis) had already gone very far. The results will be good only if we do not delay in establishing indications for surgery and if we take into account that pericarditis should be considered from the very beginning not only as a therapeutic disease, but also as a surgical disease. After a successful operation, improvement is noticeable general condition. Blood pressure rises, the difference between systolic and diastolic pressure levels out, venous pressure reaches normal, and the formation of ascites stops. The condition, naturally, improves even more as the heart strengthens.

Originated in childhood constriction leads to cardiac infantilism, which, however, gradually disappears after successful surgery. As interesting case Let us point out one of our patients in whom constriction was caused by a large accumulation of fluid located outside the pericardial cavity, in a separate connective tissue sac. The pericardium itself was also thickened, but only on the surface of the right ventricle, in the area of the conus arteriosus, there was a fusion in an area the size of a palm infant. In this area there was scarring of the myocardium.

Out of 1000 operations performed for mitral stenosis, in 8 cases we encountered complete cicatricial fusion of the pericardial layers. However, this change did not cause symptoms of compression in any of the patients. We consider it necessary to point out that pericardiectomy performed simultaneously with commissurotomy almost always led to cardiac arrest. After bringing the patient to life, we reconnected the prepared edges of the pericardium and saw that in these cases the supporting role of the pericardium is very large. Thus, in our experience, a prerequisite for successful resumption of cardiac activity is the preservation of the pericardium.

When setting contraindications, it is necessary to take into account simultaneously existing valve defects, congenital anomalies development of the heart and large vessels. The operation is contraindicated in cases of severe changes in the myocardium and lungs, in cases

Extended combined pulmonary resections of the vascular-atrial type include surgical interventions performed: with resection of the pericardium, pulmonary veins with the wall of the left atrium, superior vena cava, extrapulmonary located sections of the pulmonary arteries and the wall of their common trunk, aorta.

Resections of this type are most often performed during combined operations for lung cancer. Thus, out of 605 patients operated on in the clinic, they were performed on 424, which amounted to 70.1%. Only in 168 (42%) they were single, and in the majority of patients they were multiple. Moreover, only in 82 cases did they include other resections of the same type, and were more often combined with resections of other types (mediastinal-esophageal, tracheobronchial, parietal-diaphragmatic). Of the 424 patients, 401 (94.6%) underwent pneumonectomies and 23 (5.4%) underwent partial pulmonary resections.

In all patients who underwent resections of the vascular-atrial type, multiple metastases were determined in The lymph nodes root of the lung and mediastinum. In only 31 patients they were limited to damage to the lymph nodes of the lung root; in all other patients they affected the lymph nodes of the mediastinum.

Pericardial resection is the most frequent sight resections of extrapulmonary formations and organs of the thoracic cavity in patients with advanced stages of lung cancer. Resection of the pericardium was performed in 362 patients, which was 85.4% among all who underwent resections of the vascular-atrial type and 59.8% among those who underwent combined operations. The need to perform it arises when various localizations tumors, equally often on both the right and left. In our observations, it was less often performed in isolation, more often it was combined with other resections of various extrapulmonary formations and organs of the chest cavity. Pericardial resection is usually mandatory element during resection of the wall of the heart and its vessels, it is often combined with resections of the mediastinal-esophageal and tracheobronchial type.

Invasion of the cardiac membrane by a tumor or its metastases requires its wide excision. The resulting defect in the pericardial wall, especially after pneumonectomy, creates the prerequisites for the development severe complication- "dislocation" of the heart in pleural cavity With a sharp violation his activities (Vishnevsky A.A. et al., 1978; Ivchenko Yu.B., Volotsenko M.A., 1990). After extensive resections of the pericardium, it is rarely possible to close the defect.

More often you have to resort to plastic closure. Many methods of pericardial plastic surgery have been proposed. The most commonly used flap of the parietal pleura, taken on a pedicle or freely along with the intrathoracic fascia, pericardial adipose tissue. However, they are mechanically fragile and it is not always possible after extensive surgical interventions to cut out a sufficiently large area of parietal pleura or adipose tissue to close the resulting pericardial defect. It is much more convenient and reliable to use alloplastic materials for this purpose.

Since 1981, the clinic has been using the Bulgarian antibacterial polycaproamide mesh “Ampoxen” (BAPP) for pericardial alloplasty after resection, created in 1976 at the suggestion of Professor N. Vasilev by a team of employees led by Professor K. Dimov. The mesh is knitted from polyfilament fibers with a thickness of 20 microns, cell size 1 mm. The antibacterial effect is achieved by creating a special chemical bond between the polymer and medicinal substance, which may contain various antibiotics and antiseptics. BAPP has strength, optimal elasticity, does not allergize the body, does not have a blastomogenic effect, has chemical and biological inertness, and hemostatic properties (Vasilev N. et al., 1982; Penchev R. et al., 1984).

To study the fate of the implant and the reaction of surrounding tissues to it, we conducted 29 experimental studies on dogs on the plasticity of the pericardium of the BAPP. After pneumonectomy was performed in 14 animals on the right and 15 on the left, a section of the pericardium with an area of 10 cm was resected and the resulting defect in the BAPP was repaired. Animals were removed from the experiment at 1, 6, 8, 11, 14 days, 1 and 2 months, 1 year, followed by macroscopic and histological examination of the preparations.

It has been established that in the tissues directly adjacent to the mesh, a natural change in the phases of inflammation is detected: unexpressed alterative phenomena in the adjacent epicardium on the 1st day, accompanied by the loss of fibrin on the mesh, are replaced by a picture of alterative-infiltrative inflammation in the subepicardial layers of the myocardium with the formation of adhesions on the 3rd day. day. Subsequently, proliferative changes progress at the site of plastic surgery and tissue contact with the implant, manifested by the formation of a connective tissue scar. In the long term (up to 1 year), complete resorption of the mesh does not occur.

Thus, the Bulgarian antibacterial polycaproamide mesh "Ampoxen" is a good plastic material for closing defects when performing extended combined operations for lung cancer with resection of the pericardium. The resulting inflammatory tissue reaction to the implant is not pronounced and is local in nature and does not cause progressive pericarditis. Subsequently, partial resorption of the mesh occurs with the formation of a soft connective tissue scar at the point of contact of the heart with the plastic material, which does not impede the functioning of the heart.

BAPP "Ampoxen" was used for plastic surgery of pericardial defects in 61 patients during extended combined resections for lung cancer. We did not note the development of complications in any patient. postoperative period, which could be connected with the use of a grid. In our opinion, the Ampoxen BAPP is a convenient, reliable and safe material for alloplasty of pericardial defects after extensive resection.

The second most common type of vascular-atrial resection is resection of the pulmonary veins with a section of the left atrium. Among our patients, they were performed in 64 patients, which amounted to 15.1% of patients who underwent resections of the vascular-atrial type and 10.6% of all operated patients who underwent combined operations.

Resections of the pulmonary veins with the atrium equally often have to be performed for right- and left-sided lung lesions. The need to perform them arises in patients with advanced local spread of the tumor, characterized by the extensiveness and multiplicity of damage to various extrapulmonary anatomical structures and organs of the chest cavity. Therefore, as a rule, they are multiple, often combined. Such surgical interventions are traumatic and have an increased risk of developing severe intraoperative complications.

Resection of the pulmonary veins with a section of the left atrium with a right-sided tumor localization is much more technically complex and dangerous, due to the peculiarities of their anatomical structure. Short, inactive, especially when germinated by tumor tissue, deeply located, flowing into the atrium at back surface, they are, as a rule, inaccessible to typical treatment with separate ligation of vessels. Ligation of a wide, thin-walled common venous trunk poses a significant risk due to the possibility of cutting through it with a ligature.

It is preferable to bring the mechanical suturing device of the cardiac auricle directly to the atrium and apply stapled sutures here. If the local spread of the tumor allows, in order to increase the reliability of the sutures, even before cutting off the vessel, a second one is applied somewhat proximally, at a distance of 3 mm from the first line.

During such resection, a double mechanical hardware suture does not require additional reinforcement and is quite reliable. When performing resection of the atrium from the right-sided approach using mechanical suturing devices, it is necessary, when applying the device, to control the location of the interatrial groove of the heart and suturing the left atrium posterior to it. Involvement in the seam interatrial septum and the area of the anterior wall of the right atrium can lead to severe disorders heart rate and even to mechanical narrowing of the mouth of the superior vena cava (Volodos N.L., 1987).

Suturing the left atrium wall during right-sided resections using hand sutures is difficult and dangerous. Performing a well-adapted manual suture requires prior application of a vascular clamp (such as a Satinsky clamp) and intersection of the atrial wall distal to it. With constant traction on the clamp while making a suture, the thin and mechanically fragile posterior wall of the atrium may rupture or slip out of the jaws of the clamp, which leads to massive, very difficult to stop bleeding.

If such a complication occurs, it seems advisable for us to abandon attempts to capture the damaged atrium deep in the wound filled with blood using a vascular clamp, as this can lead to an increase in the rupture and increased bleeding. It is necessary to press the atrium wall to the spine with a tuffer to temporarily stop or at least reduce the bleeding, drain the surgical field, and then suture the atrial defect with a continuous suture or furrier's suture, be sure to include the section of the dissected posterior pericardial layer in the suture along with the posterior wall of the atrium. The pericardium, acting as a gasket, avoids the cutting of sutures. In such a situation, leading to back wall the atrium of other autologous or alloplastic materials is extremely difficult.

Bisenkov L.N., Grishakov S.V., Shalaev S.A.

Acute or chronic inflammatory disease of the serous membrane of the heart is called pericarditis. The disease is extremely rarely an independent disease and more often acts as a complication of primary infectious and non-infectious pathology.

The morphological essence is expressed in the accumulation of fluid in the pericardial cavity or the development adhesive processes between its leaves. We will talk about what pericarditis is and why this heart disease develops in this article.

The speed of development ranges from several hours to several days. The faster the inflammation develops, the greater the likelihood of acute heart failure and cardiac tamponade. Average appearance time inflammatory reaction from the moment of development of the underlying disease – 1-2 weeks.

Pericarditis affects people of all ages, men more often than women. The age of most patients is from 20 to 50 years.

Pathogenesis

On initial stages Inflammatory fluid leaks into the pericardial cavity. Due to the low extensibility of the serous membrane, the pressure in the cavity increases and is accompanied by compression of the heart. The ventricular chambers are unable to completely relax during diastole.

Incomplete relaxation stimulates an increase in pressure in the cardiac chambers and an increase in the shock force of the ventricles. Further exudation further increases the load on the myocardium. With rapid and pronounced accumulation of fluid, acute heart failure and cardiac arrest (tamponade) develop.

The further course is determined by the subsidence of the inflammatory process. The liquid is gradually adsorbed by the leaves of the pericardial sac, so its amount in the cavity decreases. The fibrin fibers remaining in the pathological focus contribute to the adhesion of the pericardial layers and their subsequent fusion (adhesive process).

Does it affect hemodynamics?

The effect on hemodynamics is expressed in compression of the heart muscle. In this case, the atria experience less pressure than the ventricles due to the low force of contractions. Inadequate relaxation of the ventricles leads to an increase in their striking force while maintaining the original cardiac output.

Violation of diastole causes first an increase and then a decrease in blood pressure. Stagnation develops in big circle blood circulation resulting in heart failure.

Causes

Determining the cause of the disease is usually difficult. Most cases are described as idiopathic, that is, occurring for an unknown reason, or viral. The virus itself, which led to the development of inflammation, usually cannot be isolated.

Other possible reasons inflammation of the pericardium:

Bacterial infection, including tuberculosis.
Inflammatory diseases: scleroderma, rheumatoid arthritis, lupus.
Metabolic diseases: renal failure, hypothyroidism, hypercholesterolemia (increased cholesterol in the blood).
Cardiovascular diseases: myocardial infarction, aortic infarction, Dressler's syndrome (a complication that occurs weeks after a heart attack).
Other causes, including neoplasms, injuries, use of drugs or medications (for example, isoniazid, diphenin, immunosuppressants), medical errors during manipulations in the mediastinum, HIV.

The cause of pericarditis in infants is most often generalized staphylococcal or streptococcal infection, and in older children - inflammatory diseases or viral infections.

Frequency of occurrence by etiology

Infectious pericarditis (60% of cases):

Non-infectious pericarditis (40% of cases):

Post-infarction – 10.1%;
Postoperative – 7%;
For illnesses connective tissue – 7-10%;
Traumatic – 4%;
Allergic – 3-4%;
Radiation – less than 1%;
For blood diseases – 2%;
Medicinal – 1.4%;
Idiopathic – 1-2%.

The incidence of the disease in children is 5%, of which 80% is dry, and 20% is dry. exudative form. The criteria for diagnosis and treatment tactics do not differ from those in adults.

A detailed classification of pericarditis by etiology and course is presented in.

In adults and children

In different age groups prevail the following types pericarditis.

In newborns:

Viral (60-70%);
Bacterial (22%).

In children:

Viral (55-60%);
Rheumatic (12%);
Postoperative (5.5-7%);
Bacterial (5%).

Nature of pain

The nature of the pain can be aching, stabbing, burning or squeezing.
There is a gradual onset and increase in pain over several hours.
High intensity (pain can be unbearable).
Localization - behind the sternum with irradiation to the epigastrium, neck, back, right hypochondrium.
The pain intensifies with coughing, sneezing, sudden movements and swallowing, and decreases with bending forward and bringing the knees to the chest.
As the exudate accumulates, the pain disappears.
The pain decreases when taking anti-inflammatory drugs and analgesics, but does not change when taking nitrates.

Cough

Character - dry, paroxysmal. Initially, the cough is caused by compression of the lungs by the enlarged pericardial cavity. Subsequently (with the development of heart failure), the cough becomes wet and constant. Streaks of blood are found in the sputum, and the sputum itself may have a “foamy” appearance.

When the trachea and bronchi are compressed, a barking cough develops, which intensifies when lying down.

When to see a doctor?

Most symptoms of pericarditis are nonspecific, they are similar to the manifestations of other diseases of the heart and lungs, so if you experience pain in the sternum, it is important to consult a doctor immediately. Based on the results of the examination, the patient will be referred to a cardiologist for treatment and further observation.

It is impossible to distinguish pericarditis from other conditions without special knowledge. For example, chest pain can also be caused by a myocardial infarction or a blood clot in the lungs (), so timely examination is extremely important for diagnosis and effective treatment.

When going to an appointment, it makes sense to write down all the symptoms. Information about similar cases in the past that resolved on their own or required treatment, and information about heart disease in close relatives is also useful. You will need to tell your doctor about all medications and dietary supplements you are taking.

Establishing diagnosis

An examination for suspected pericarditis begins with listening to the chest through a stethoscope (auscultation). The patient should lie on his back or lean back using his elbows. In this way, you can hear the characteristic sound that inflamed tissue makes. This a noise that sounds like rustling fabric or paper, called pericardial friction.

Among diagnostic procedures, which can be carried out as part of differential diagnosis with other diseases of the heart and lungs:

Electrocardiogram(ECG) - measurement of the electrical impulses of the heart. Characteristic ECG signs with pericarditis will help distinguish it from myocardial infarction.
Chest X-ray to determine the size and shape of the heart. If the volume of fluid in the pericardium is more than 250 ml, the image of the heart in the image is enlarged.
Ultrasound provides an image of the heart and its structures in real time.
CT scan may be needed if detailed images of the heart are needed, for example to rule out pulmonary thrombosis or aortic dissection. CT scans also determine the degree of pericardial thickening to make a diagnosis.
Magnetic resonance imaging- layer-by-layer image of an organ obtained using magnetic field and radio waves. Allows you to see thickening, inflammation and other changes in the pericardium.

Blood tests usually include: general analysis, determination of ESR (an indicator of the inflammatory process), levels of urea nitrogen and creatinine to assess kidney function, AST (aspartate aminotransferase) to analyze liver function, lactate dehydrogenase as a cardiac marker.

Additional laboratory research may be needed to determine the causative agent of infection if a viral or bacterial nature of the disease is suspected. We talked about this in more detail in another article.

Differential diagnosis is made with myocardial infarction. The main differences between the symptoms of these diseases are shown in the table:

	Pericarditis	Myocardial infarction
Nature of pain	Acute, worsens with coughing and inhalation. Location - behind the sternum or on the left.	Pressing, sensation heavy object on the chest
Radiation of pain	In the back ( trapezius muscle) or missing.	In the jaw or left hand. Sometimes missing.
Voltage	Does not affect pain	Usually evades pain
Body position	Pain worsens when lying on your back	No dependency
Start/duration	The pain occurs suddenly, and several hours or days pass before seeking medical help.	The pain occurs suddenly or increases, sometimes pain attacks go away on their own, and it usually takes several hours before you see a doctor.

Treatment tactics and prognosis

Drug therapy is aimed at reducing swelling and inflammation. Suspicion of cardiac tamponade is a reason for hospitalization. If this diagnosis is confirmed, surgical intervention will be required. It is also necessary for hardening of the pericardium.