Percutaneous Pericardial Resection

Abstract

Background People with heart failure and preserved ejection fraction (HFpEF) develop increases in left ventricular (LV) end-diastolic pressures (LVEDP) during exercise that contribute to dyspnea. In normal open-chest animal preparations, the pericardium restrains LV filling when central blood volume increases. We hypothesized that resection of the pericardium using a minimally-invasive epicardial approach would mitigate the increase in LVEDP that develops during volume loading in normal and diseased hearts with the chest intact. Methods and Results Invasive hemodynamic assessment was performed at baseline and following saline load before and after pericardial resection in normal canines with open (n=3) and closed chest (n=5) and in a pig model with features of human HFpEF with sternum intact (n=4). In closed-chest animals, pericardiotomy was performed using a novel subxiphoid procedure. In both experimental preparations of normal dogs, pericardiotomy blunted the increase in LVEDP with saline infusion, while enhancing the saline-mediated increase in LV end-diastolic volume (LVEDV). With chest intact in the pig model, percutaneous pericardial resection again blunted the increase in LVEDP secondary to volume expansion (+4±3 vs +13±5 mmHg, p=0.014) while enhancing the saline-mediated increase in LVEDV (+17±1 vs +10±2 ml, p=0.016). Conclusions This proof of concept study demonstrates that pericardial resection through a minimally-invasive percutaneous approach mitigates the elevation in LV filling pressures with volume loading in both normal animals and a pig model with diastolic dysfunction. Further study is warranted to determine whether this method is safe and produces similar acute and chronic hemodynamic benefits in people with HFpEF.

Heart failure with preserved ejection fraction: an update on pathophysiology, diagnosis, treatment, and prognosis

“…Patients with HFpEF characteristically develop marked increases in filling pressures with exercise or volume loading owing to diastolic dysfunction (6). Further study is required to determine whether pericardial restraint or enhanced diastolic ventricular interaction contributes to the pathophysiology of HFpEF, which would then raise the question as to whether surgical approaches to remove pericardial restraint might improve symptoms related to venous congestion (25). One recent study demonstrates that pericardial resection through a minimally-invasive percutaneous approach mitigates the elevation in LV filling pressures with volume loading in both normal animals and a pig model with diastolic dysfunction (25).…”

“…Further study is required to determine whether pericardial restraint or enhanced diastolic ventricular interaction contributes to the pathophysiology of HFpEF, which would then raise the question as to whether surgical approaches to remove pericardial restraint might improve symptoms related to venous congestion (25). One recent study demonstrates that pericardial resection through a minimally-invasive percutaneous approach mitigates the elevation in LV filling pressures with volume loading in both normal animals and a pig model with diastolic dysfunction (25). Further study is warranted to determine whether this method is safe and produces similar acute and chronic hemodynamic benefits in people with HFpEF.…”

A Feline HFpEF Model with Pulmonary Hypertension and Compromised Pulmonary Function

“…Another limitation of the study is that once the aortic constriction surgery is performed, the band is in place for the entire duration of the study since it cannot easily be removed. Furthermore, the pericardial sack is dissected during both the sham and aortic constriction procedures, which could have potentially resulted in an underestimation of the left-sided filling pressures 76 .…”

Pericardiectomy to Treat Heart Failure With Preserved Ejection Fraction

“…In the accompanying proof of principle paper by Borlaug et al (30), a subxyphoid, minimally invasive percutaneous method similar to that used for arrhythmia ablation procedures was successfully adapted along with a specially designed cutting device to achieve resection of the anterior pericardium. After testing this method ex vivo and in open chest dogs, the procedure was employed in normal, intact dogs and in an intact pig model combining a high fat diet with renovascular hypertension.…”