Pericardiectomy is the surgical removal of part or most of the

pericardium The pericardium (: pericardia), 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 inelastic connective tissue (fibrous pericardium), ...

. This operation is most commonly used to relieve

constrictive pericarditis Constrictive pericarditis is a 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 a good ...

, 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 Mat ...

and

fibrous Fiber (spelled fibre in British English; from ) is a natural or artificial substance that is significantly longer than it is wide. Fibers are often used in the manufacture of other materials. The strongest engineering materials often inco ...

. 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 tissue, connective membrane and an inner two-layered serous membrane ...

. 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 ...

digoxin Digoxin (better known as digitalis), sold under the brand name Lanoxin among others, is a medication used to treat various heart disease, heart conditions. Most frequently it is used for atrial fibrillation, atrial flutter, and heart failure. ...

steroid A steroid is an organic compound with four fused compound, fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes t ...

s, NSAIDs, or

antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...

s 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 Arrhythmias, also known as cardiac arrhythmias, are irregularities in the cardiac cycle, heartbeat, including when it is too fast or too slow. Essentially, this is anything but normal sinus rhythm. A resting heart rate that is too fast – ab ...

, low cardiac output syndrome, and

myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when Ischemia, blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom ...

(in rare cases). There is some risk of damage to the pleural cavities around the

lung The lungs are the primary Organ (biology), organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the Vertebral column, backbone on either side of the heart. Their ...

s, which can lead to

pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...

, 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 kilog ...

. It also presents typical surgical risks, such as

infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...

anaesthesia Anesthesia (American English) or anaesthesia (British English) 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 prev ...

complications,

blood clots A thrombus ( thrombi) is a solid or semisolid aggregate from constituents of the blood (platelets, fibrin, red blood cells, white blood cells) within the circulatory system during life. A blood clot is the final product of the blood coagulati ...

, 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, urethr ...

. 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, vag ...

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 In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...

left ventricle A ventricle is one of two large chambers located 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 t ...

, 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 Statistical population, population, scaled to the size of that population, per unit of time. Mortality rate is typically ...

, initially between 5% and 15%. The 5-year survival rate is around 80%. The most common complication after surgery is reduced

cardiac output In cardiac physiology, cardiac output (CO), also known as heart output and often denoted by the symbols Q, \dot Q, or \dot Q_ , edited by Catherine E. Williamson, Phillip Bennett is the volumetric flow rate of the heart's pumping output: tha ...

, 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 In medicine, a surgeon is a medical doctor who performs surgery. Even though there are different traditions in different times and places, a modern surgeon is a licensed physician and received the same medical training as physicians before spec ...

makes an incision in the skin over the

breastbone The sternum (: sternums or sterna) 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 ve ...

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 pr ...

. Alternatively, a larger incision known as a

thoracotomy A thoracotomy is a surgical procedure that involves cutting open the chest wall to gain access into the pleural cavity, It is mostly performed by specialist cardiothoracic surgeons, although emergency physicians or paramedics occasionally also ...

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 (biology), organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrie ...

, 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 nerve The phrenic nerve is a mixed nerve that originates from the C3–C5 spinal nerves in the neck. The nerve is important for breathing because it provides exclusive motor control of the diaphragm, the primary muscle of respiration. In humans, t ...

s 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 to remove

pericardial fluid Pericardial fluid is the serous fluid secreted by the Serous membrane, 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 t ...

. Hospital recovery takes several days, with

surgical suture A surgical suture, also known as a stitch or stitches, is a medical device used to hold Tissue (biology), body tissues together and approximate wound edges after an injury or surgery. Application generally involves using a Sewing needle, needle w ...

removed after a week. After pericardiectomy, the heart takes on a more rounded shape due to the lack of stretch with the

diaphragm Diaphragm may refer to: Anatomy * Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen * Pelvic diaphragm or pelvic floor, a pelvic structure * Urogenital diaphragm or triangular ligament, a pelvic structure Other * Diap ...

. This does not appear to cause any cardiac issues, but may be detected with

echocardiography Echocardiography, also known as cardiac ultrasound, is the use of ultrasound to examine the heart. It is a type of medical imaging, using standard ultrasound or Doppler ultrasound. The visual image formed using this technique is called an ec ...

References