The Zamvar pericardial fold
Zamvar Journal of Cardiothoracic Surgery
The Zamvar pericardial fold
Vipin Zamvar 0
0 Royal Infirmary of Edinburgh , Edinburgh EH14 1JJ , UK
This paper describes a pericardial fold that has not yet been mentioned in the Anatomy or Surgery literature. The “Zamvar” pericardial fold is formed by the parietal pericardium and the overlying fibrous pericardium folding back onto themselves over the left-sided pulmonary veins; it is 1 to 3 mm wide, and runs from the inferior edge of the left inferior pulmonary vein, to the superior edge of the left superior pulmonary vein. A similar fold is not seen on the right side. The presence of this fold allows for the safe placement of the deep pericardial retraction suture used during off-pump coronary artery surgery.
The serous pericardium is enclosed within the fibrous
pericardium. The serous pericardium is divided into two
layers: the outer parietal layer, and the inner visceral
The outer parietal layers lines the internal surface of the
fibrous pericardium and the internal visceral layer forms
the outer layer of the heart (also known as the epicardium).
Each of the layers of the serous pericardium is made up of
a single sheet of epithelial cells, known as “mesothelium”.
During development, the heart invaginates the serous
pericardium, and it is thus that the two layers of the
serous pericardium are formed.
The parietal and visceral layers of the pericardium are
in continuity at the points at which the great vessels
traverse the pericardial cavity.
Between the visceral and parietal layers of the serous
pericardium is the pericardial cavity. It contains a small
amount of lubricating serous fluid. This fluid minimises
the friction generated by the heart as it contracts and
moves about within the pericardial cavity.
PERICARDIAL SINUSES: (Fig. 1).
As described earlier, the visceral layer of the serous
pericardium (also called epicardium) surrounds the heart and
great vessels, and the parietal layer lines the fibrous
component. The reflections of the serosal layers of the
pericardium are arranged around two tubes. One tube encloses
the aorta and the pulmonary artery. The second tube
encloses the superior vena cava, the inferior vena cava, and
the four pulmonary veins.
The Transverse Pericardial Sinus is the passage
between these two tubes.
It is located
a) Posteriorly to the aorta and the pulmonary trunk,
b) Anteriorly to the superior vena cava, and
c) Superiorly to the left atrium
The Transverse Pericardial Sinus is also called the
Theile canal after the German anatomist, Friedrich
The Oblique Pericardial Sinus is a recess in the
pericardial cavity situated posteriorly to the heart, and is
bounded laterally by the pericardial reflections on the
pulmonary veins and the inferior vena cava and
posteriorly by the pericardium overlying the anterior aspect of
The vestigial fold of the Pericardium: Between the
left pulmonary artery and the left superior pulmonary
vein, is a triangular fold of the serous pericardium, also
called as the vestigial fold of Marshall (named after John
Marshall, British anatomist and surgeon, 1818 to 1891).
It is formed by the serous pericardium folding back
upon itself over the remnant of the lower part of the left
superior vena cava. (also known as the duct of Cuvier,
named after Georges Cuvier, French Naturalist, and
Zoologist, 1769 to 1832).
The ZAMVAR pericardial fold (Fig. 2)
As mentioned earlier, the serous pericardium is made up
of two layers, the visceral pericardium which lines the
surface of the heart, and the parietal pericardium which
lines the under-surface of the fibrous pericardium.
These two layers are continuous with each other over
the major arteries and veins as they enter/exit the heart.
The visceral pericardium covers the heart, and where
the major vessels enter/exit the heart, it becomes the
A special situation arises over the left-sided pulmonary
As shown in in Fig. 2, the transition zone is the region
where the visceral pericardium becomes the parietal
pericardium. After becoming the parietal pericardium,
the serous pericardium lies on the under-surface of the
fibrous pericardium. The serous pericardium is quite
fused with the fibrous pericardium. The serous
pericardium and the fibrous pericardium fold onto themselves
over a distance of 1 to 3 mm (Fig. 3), and this forms the
newly described “Zamvar” pericardial fold. This fold
runs longitudinally from the inferior edge of the inferior
pulmonary vein, to the superior edge of the superior
Figure 4 is an intra-operative photograph, and Fig. 5 is
the corresponding line-diagram explaining the various
landmarks. Figures 4 and 5 show the pericardial fold.
The photograph has been taken during the conduct of
off-pump coronary artery bypass graft surgery. The
pericardium has been opened, and the beating heart has
been lifted off the posterior pericardium, and has been
displaced to the right.
The surgeon is standing on the right side of the
patient, and with his left hand has lifted the heart off the
posterior pericardium. The apex in moved up and to the
right. The surgeon’s left hand covers the posterior
surface of the heart, and the left atrium, The left atrial
appendage is seen in the corner. The two pulmonary veins
are seen exiting the left atrium. The “Zamvar”
pericardial fold is clearly seen running from the inferior edge of
the left inferior pulmonary vein to the superior edge of
the left superior pulmonary vein.
Figure 6 is an intra-operative photograph, and Fig. 7 is
the corresponding line diagram, showing the various
landmarks. These figures show the pulmonary veins on
the right side. There is no similar fold on the right side.
The presence of this fold on the left side is not
dependent on whether the pleura is open or not. Figure 8
Fig. 7 Line diagram corresponding to Fig. 6. It shows the right superior
pulmonary vein. There is no pericardial fold over the right-sided veins
is an intraoperative photograph showing clearly the
“Zamvar” pericardial fold; in this case the left pleura is intact.
Surgical significance of the “Zamvar” pericardial
During conduct of off-pump coronary artery surgery, a
deep pericardial retraction suture is used to lift the
pericardium (and hence the heart) up. Along with other
manoeuvres, pulling the pericardium up with a deep
pericardial retraction stitch is an essential step to achieve
hemodynamic stability and aid access to the deeper parts
of the coronary circulation.
A number of ways of taking the deep pericardial stitch
have been described [
]. These include the Lima stitch
] and its various modifications [
experimenting with various positions for the optimal
positioning of the pericardial stitch, the author serendipitously
came across the anatomical feature of the “Zamvar”
pericardial fold, and found that a stitch placed across the
pericardial fold across the body of the left inferior
pulmonary vein was best able to provide lifting of the
pericardium, which in addition to other surgical manoeuvres
provided optimal hemodynamic stability during beating
heart surgery (Fig. 9).
Over the last 15 years, in more than a thousand
coronary artery bypass graft operations, the author has used a
deep pericardial retraction stitch placed on the “Zamvar”
pericardial fold. He calls it the “Zamvar” pericardial
This stitch placed across the pericardial fold running
over the inferior pulmonary vein allows for the heart to
be stabilised with tissue stabilisers (The Octopus
stabiliser is the stabiliser of choice for the author; but many
other proprietary stabilisers are also available).
The author has found that placing a stitch across the
body of the inferior pulmonary vein is the most optimal
position for placing this stitch. Also, only one stitch is
required, without the need for extra stitches, or gauze
The presence of fibrous pericardium in the pericardial
fold affords strength to the pericardial fold, and
therefore allows the stitch to be taken without the risk of
The presence of this fold through which the stitch is
taken also protects from inadvertent passing of the
needle through the inferior pulmonary vein.
This stitch is also useful in retracting the pericardium
upwards to expose the obtuse marginal arteries, during
on-pump coronary artery surgery.
This paper describes a pericardial fold which has not yet
been described in the Anatomy or Surgery literature.
The presence of this fold allows the placement of a
stitch across the anterior surface of the body of the left
inferior pulmonary vein, which is an important adjunct
to the safe conduct of beating-heart coronary artery
bypass graft surgery. It can also be used to lift the
pericardium up to facilitate exposure of the obtuse marginal
arteries during on-pump coronary artery surgery.
Professor Vipin Zamvar is an Editor-in-Chief of the Journal of Cardiothoracic
No funding source.
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or
analysed during the current study.
VZ made the observation of the pericardial fold, and wrote the manuscript.
Ethics approval and consent to participate
This paper is a description of an anatomical structure. As such it is not a
study. Therefore ethical consent was not required.
Consent for publication
Consent was obtained from patients to obtain photographs during surgery.
The consent form can be made available to the editors on request.
The author is a Consultant for Medtronic.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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