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Robotic Endoscopic Off-Pump Total Pericardiectomy in Constrictive Pericarditis

Objective Although rare, constrictive pericarditis is a serious condition with debilitating symptoms and often severe heart failure. Total pericardiectomy is the most effective treatment and is traditionally performed via median sternotomy. With the increasing use of minimally invasive techniques, there have been reports of partial pericardiectomy via thoracoscopy but with suboptimal exposure and difficulty identifying both phrenic nerves. Robotic surgery offers both small incisions and enhanced visualization. We present four cases of robotic endoscopic off-pump total pericardiectomy for constrictive pericarditis. Methods Four patients underwent off-pump total pericardiectomy with robotic assistance for constrictive pericarditis. All had constrictive physiology demonstrated by right heart catheterization and/or echo-cardiogram. One was also found to have coronary artery disease and underwent concurrent totally endoscopic coronary artery bypass grafting left internal mammary artery to left anterior descending artery. Ports were placed in the left second, fourth, and sixth intercostal spaces. The left lung was isolated and deflated with CO2 insufflation, aiding in exposure. With the use of electrocautery, the pericardium was removed first posterior to the left phrenic nerve, then anteriorly all the way to the right phrenic nerve, and caudally from the diaphragmatic reflection to the great vessel cephalad. A stabilizer in the subcostal fourth robotic arm was used to assist in the dissection. Results Two of four patients were extubated within 6 hours after surgery and transferred to the floor on postoperative day 1. Both were discharged home by postoperative day 5. Two of four patients had preoperative sequelae from chronic constriction and necessitated longer hospital and intensive care unit stays but had improvement in symptoms and were discharged home within 3 weeks. Conclusions Total pericardiectomy for constrictive pericarditis can be performed using a robotic approach. In contrast to thoracoscopy, it offers better visualization of both phrenic nerves, avoids injury, and allows a thorough pericardial dissection. In our experience, the robotic left chest approach has proven more efficacious in removing the posterior pericardium than is allowed with median sternotomy.