Pericardiectomy

Keywords and synonyms: Pericardial stripping, pericardial excission

Overview
Pericardiectomy is the surgical removal of part or most of the pericardium. This operation is performed to relieve constrictive pericarditis, or to remove a pericardium that is calcified and fibrous.

Constrictive pericarditis is a progressive disease without spontaneous reversal of pericardial thickening. Some patients can be medically managed for several years. Edema can be controlled with diuretics and slowing the heart rate can maximize the diastolic filling time. Many patients eventually develop significant debility from impaired cardiac output and elevated right and left sided filling pressures. The definitive treatment for constrictive pericarditis is pericardiectomy which is also known as pericardial stripping. This is a surgical procedure where the entire pericardium is peeled away from the heart.

Due to the significant risks involved with pericardial stripping, many patients are treated medically, with judicious use of diuretics.

The Procedure
The procedure begins when the surgeon makes an incision in the skin over the breastbone and divides it to expose the pericardium. During the surgery, the surgeon will grasp the pericardium surrounding the heart, and will remove the fibrous, calcified or infected tissue covering of the heart. Once the pericardium is removed, the surgeon will wire the breastbone back together, the incision is closed, and the procedure is completed.

Complications
This procedure has significant risk involved, with mortality rates of 6%-12% in major referral centers. The procedure can be complicated by perforation or tearing of the heart muscle if the heart muscle is tightly adherent to the pericardium. Stated simply, removal of the pericardium can remove the densely adherent heart muscle itself which is a catastrophic complication.

The high risk of the procedure is attributed to adherence of the thickened pericardium to the myocardium and coronary arteries. In patients who have undergone coronary artery bypass surgery with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium. Given the thin wall of the right ventricle, this can be a dangerous procedure and should only be undertaken if the patient's symptoms are incapacitating.

Prognosis and Long Term Outcomes Following Pericardiectomy
If any pericardium is not removed, it is possible for bands of pericardium to cause localized constriction which may cause symptoms and signs consistent with constriction. Some patients do not have complete relief of symptoms and up to 60% will have at least echocardiographic evidence of a restrictive filling pattern at approximately 2 years. Radiation induced disease seems to have a worse prognosis for improvement in functional class. The 5 and 10-year survival after pericardiectomy is 78% and 57% respectively, but is obviously highly correlated with the underlying illness.

Pericardiectomy in Patients with Tuberculous Pericarditis
Pericardiectomy may be used in treatment of recurrent pericardial efussion due to TB, in tuberculous constrictive pericarditis or if there is no hemodynamic and general improvement after 4-8 weeks following antituberculosis chemotherapy. If it is performed in the early stages of TB pericardial constriction, pericardiectomy has a low mortality rate when compared to advanced stages of the disease where pericardiectomy is poorly tolerated. Mortality rate secondary to this procedure is 3-16%. This surgery should be undertaken under the coverage of antitubercular drugs.

Treatment of effusive constrictive pericarditis is challenging because pericardiocentesis does not relieve the impaired filling of the heart, and surgical removal of the fibrinous exudate coating the visceral pericardium may not be possible. Patients should be started on antitubercular drugs and serial echocardiography should be performed to monitor the changes of pericardium and to make a decision regarding its surgical stripping.