Off-pump subtotal pericardiectomy using ultrasonic aspirator in constrictive pericarditis

A subtotal pericardiectomy was performed without the use of extracorporeal circulation due to the patient's advanced age and underlying liver cirrhosis. After exposure of the heart, both phrenic nerves were identified and carefully preserved. The pericardium was found to be massively calcified, with extensive involvement extending to the base of the aorta and the diaphragm. The pericardium was divided into multiple diamond-shaped sections, allowing controlled, stepwise resection and facilitating safe handling of the rigid, calcified tissue. Decortication was initiated at the right ventricle and proceeded gradually. The calcified pericardium was removed using a combination of an ultrasonic aspirator, a rongeur and electrocautery. Careful, controlled separation of the pericardium from the epicardium was performed throughout, addressing dense adhesions while preserving the underlying myocardium and epicardial vessels. The ultrasonic aspirator facilitated resection of the calcified tissue without harming the underlying structures. Resection was extended over the right atrium, right ventricle and anterior wall of the left ventricle up to the level of the phrenic nerves. Complete pericardiectomy was not achievable due to extensive adhesions and proximity to critical structures. Intraoperative echocardiographic imaging demonstrated immediate improvement in cardiac filling and function.