Pericardiectomy is the surgical removal of part or most of the

pericardium The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made o ...

. This operation is most commonly used to relieve

constrictive pericarditis Constrictive pericarditis is a medical condition characterized by a thickened, fibrotic pericardium, limiting the heart's ability to function normally. In many cases, the condition continues to be difficult to diagnose and therefore benefits from ...

, or to remove a pericardium that is

calcified Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature Ma ...

and

fibrous Fiber or fibre (from la, fibra, links=no) is a #Natural fibers, natural or Fiber#Artificial fibers, artificial substance that is significantly longer than it is wide. Fibers are often used in the manufacture of other materials. The stronge ...

. It may also be used for severe or recurrent cases of

pericardial effusion A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of t ...

. Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat.

Uses

Pericardiectomy is used to treat

, which is caused by a variety of conditions. It is also used to treat recurring cases of

Contra-indications

Pericardiectomy should not be used if more minor procedures are more appropriate, such as a

pericardial window A pericardial window is a cardiac surgical procedure to create a fistula – or "window" – from the pericardial space to the pleural cavity. The purpose of the window is to allow a pericardial effusion or cardiac tamponade to drain from the sp ...

. Pericardiectomy may not be appropriate for patients who already have a poor prognosis, as its medical benefit is reduced. This is because pericardiectomy has a higher rate of complications and a higher mortality. More conservative treatment may use

diuretic A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics i ...

s, digoxin, steroids, NSAIDs, or antibiotics to change

cardiovascular physiology Cardiovascular physiology is the study of the cardiovascular system, specifically addressing the physiology of the heart ("cardio") and blood vessels ("vascular"). These subjects are sometimes addressed separately, under the names cardiac physiolog ...

without treating the underlying pathology, which is appropriate for those not suitable for major surgery. Some patients may undergo conservative treatment for a number of months before pericardiectomy is considered truly necessary.

Risks

Pericardiectomy can cause a number of cardiac issues, such as arrhythmia, low cardiac output syndrome, and

myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may ...

(in rare cases). There is some risk of damage to the pleural cavities around the lungs, which can lead to

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severi ...

, or

pleural effusion A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per k ...

. It also presents typical surgical risks, such as

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dis ...

anaesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), a ...

complications, blood clots, and

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

. There is a low risk of

haemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...

if the heart is

perforated A perforation is a small hole in a thin material or web. There is usually more than one perforation in an organized fashion, where all of the holes collectively are called a ''perforation''. The process of creating perforations is called perfor ...

whilst removing the pericardium. Outcomes after surgery depend significantly on the underlying cause of illness, and the function of the

kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blo ...

left ventricle A ventricle is one of two large chambers toward the bottom of the heart that collect and expel blood towards the peripheral beds within the body and lungs. The blood pumped by a ventricle is supplied by an atrium, an adjacent chamber in the uppe ...

, and

pulmonary arteries A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and ...

. Recovery from pericardial effusion treated with pericardiectomy is typically very good. However, its use for treating constrictive pericarditis has a fairly high

mortality rate Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality rate is typically expressed in units of d ...

, initially between 5% and 15%. The 5-year survival rate is around 80%. The most common complication after surgery is reduced cardiac output, which occurs in between 14% and 28% of patients.

Technique

Pericardiectomy takes place by removing the infected, fibrosed, or otherwise damaged pericardium. The procedure begins when the surgeon makes an incision in the skin over the

breastbone The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sh ...

and divides the breastbone to expose the pericardium, known as a

median sternotomy Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided using a sternal saw. This procedure provides access to the heart and lungs for surgical pro ...

. Alternatively, a larger incision known as a

thoracotomy A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...

may be used. During the surgery, the surgeon will hold the pericardium, cut the top of this fibrous covering of the

heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to t ...

, drop it into the specimen bag, and re-cover the heart. The breastbone is then wired back together and the incision is closed, completing the procedure. When the portion of pericardium lying between the two phrenic nerves is excised, it is called total pericardiectomy. In cases where total pericardiectomy is not possible, subtotal pericardiectomy is performed or, in extreme cases, a cruciate incision on the pericardium is performed.

Recovery

Heart function often recovers very quickly after pericardiectomy is performed, although the surgery itself can cause reduced cardiac output in the short term. After surgery, many patients will have a

chest drain A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substan ...

to remove

pericardial fluid Pericardial fluid is the serous fluid secreted by the serous layer of the pericardium into the pericardial cavity. The pericardium consists of two layers, an outer fibrous layer and the inner serous layer. This serous layer has two membranes which ...

. Hospital recovery takes several days, with surgical suture removed after a week. After pericardiectomy, the heart takes on a more rounded shape due to the lack of stretch with the diaphragm. This does not appear to cause any cardiac issues, but may be detected with echocardiography.

References