Pericardial window

Associate Editor-in-Chief: Mohammed A. Sbeih, M.D. [mailto:msbeih@perfuse.org]

Overview
Creation of a pericardial window is a cardiac surgical procedure in which an opening is made in the pericardium to drain fluid that has accumulated around the heart by creating a fistula or "window" from the pericardial space to the peritoneal cavity. Flow of fluid into the peritoneal cavity prevents the accumulation of fluid around the heart (a pericardial effusion), which might cause compression and impaired filling of the heart (cardiac tamponade), a dangerous complication. The procedure is performed for both diagnostic and therapeutic purposes. The creation of a pericardial window is usually performed by a cardiac surgeon or thoracic surgeon who makes an incision, commonly sub-xiphoid, and cuts a small hole in the pericardium. This surgery is performed with local anesthesia. An incision is made either below the sternum, or alternately between the ribs of the left chest. The resection can be with scissors, cautery, a stapling device, or a harmonic scalpel, with no one technique demonstrably better than another. It is best to have a combination of techniques available to resect the pericardium adequately. The surgeon may place a catheter in the pericardial window so that fluid can continue to drain for a short period of time after the surgery. Chest tubes are removed in 2-3 days once the drainage is less than 200cc/24hrs.

Indication
The indication for creation of a pericardial window is a pericardial effusion (fluid build-up) that is either symptomatic, or if the patient is on the verge of cardiac tamponade or if cardiac tamponade has developed. A surgical approach is recommended only in patients with very large chronic effusion, for whom repeated pericardiocenteses have been unsuccessful.

The procedure
Performing a pericardial window traditionally required open-chest surgery, resulting in a large scar and a lengthy recovery time. With the advent of minimally-invasive robotic surgery and the thoracoscopic approach to pericardial window, however, a new approach became available resulting in less trauma, less pain and faster recovery, even that Until recently, patients in tamponade were considered unsuitable for a thoracoscopic window.

There are 2 approaches for pericardial window procedure:

1) Subxiphoid approach A short vertical incision (about 5-7 cm long) is made over the xiphoid process extending onto the midline of the abdomen. The linea alba is incised, and the xiphoid is often completely removed. by finger dissection, the surgeon can reach the retrosternal space. the diaphragmatic aspect of the pericardium is visualized by upward retraction. The pericardium can be grasped with the hook or can be incised directly. A sucker is inserted into the pericardial space and the fluid aspirated. Often this or a finger is used for further dissection of any adhesions. After all the fluid has been aspirated, the epicardium is inspected and a biopsy specimen can also be taken from the pericardium. A finger is introduced into the pericardial space to determine if any additional adhesions exist and if any nodules are in the pericardium. Finally, a tube is inserted into the pericardial space and connected through a separate stab wound; the incision is closed in layers. 2) Thoracotomy approach A small anterior thoracotomy is made in the fourth or fifth intercostal space. To expose the chosen intercostal space, an inframammary skin incision (5-7 cm long) is made, which allows division of the pectoralis muscle. The intercostal space is opened over the superior margin of the rib entering the pleural cavity. A retractor is placed and the pericardium is visualized. The pericardium is incised anterior to the phrenic nerve with a scalpel or scissors. A window is created and the pericardium specimen is sent for pathology lab, and samples of pleural effusion are obtained. A chest tube is placed within the pericardium and placed on water seal or suction and the incision is closed in layers.

Recovery
Depending on the underlying disease process, patients usually go home in two days.