Pericardial Window Surgery

The heart is surrounded by a fibrous sac, called the pericardial sac or pericardium. This sac serves to hold the heart in place within the body's chest wall and protects it from infection and injury. The pericardium also keeps the heart functioning properly when blood flow increases due to disease or pregnancy by preventing the heart from over-expanding.

The pericardium is made up of two layers, separated by a small amount of fluid (up to 50cc). The outer layer of the pericardium attaches to the diaphragm to hold the heart in place. The inner layer and fluid lubricate the heart and help decrease friction when the heart beats.

Although some fluid is needed in the pericardial cavity, too much fluid between the pericardial layers and the heart causes excess pressure on the heart and can impair proper heart function. This condition, referred to as pericardial effusion, may result in symptoms such as chest pain or pressure, shortness of breath, low blood pressure, dizziness, or nausea. Other conditions such as pericarditis (a swelling of the pericardium) and cardiac tamponade may also cause fluid build-up and pressure on the heart.

Since there are numerous causes of fluid build-up in the pericardium, treatment is often dependent on what’s causing the condition and how severe it is. In some cases, excess pericardial fluid can be treated with medication. In other cases, when immediate fluid drainage is needed or other treatments are not effective, pericardial window surgery may be performed.

Symptoms of Pericardial Effusion

• Shortness of breath or difficulty breathing
• Discomfort when breathing while lying down
• Chest pain, usually behind the breastbone or on the left side of chest
• Swelling in the legs or abdomen
• Chest fullness

Causes of Excess Pericardial Fluid

It is not always known what causes fluid to build up around the heart. However, some conditions that may result in this condition include:

• Inflammation due to heart attack or prior heart surgery
• Infection of the pericardial sac or heart
• Injury to the pericardium
• Immune system diseases that cause inflammation
• Cancer
• Kidney failure
• Drug reactions

Treatment of Excess Pericardial Fluid

Too much fluid around the heart can be very serious, even life-threatening. If medication alone is not enough to eliminate a build-up of excess fluid in the pericardium, surgery is typically recommended.

One option is catheter pericardiocentesis. This procedure uses a long thin needle inserted through a catheter to drain excess fluid from around the heart. But it is not an option for everyone and may not prevent the fluid from returning. Another option is to perform pericardial window surgery.

During pericardial window surgery, a surgeon removes a small section of the pericardial sac in order to drain excess fluid. The portion of the pericardium that is removed may also be biopsied to determine the reason for the excess fluid build-up.

In order to access the pericardium during surgery, the surgeon will use one of these methods:

Thoracotomy

This is an open heart surgical procedure in which the surgeon makes a cut, a few inches in length, below the breastbone or between the ribs to gain access to the pericardium.

Video-Assisted Thoracoscopic Surgery (VATS)

This is a minimal access surgical procedure in which a small camera (thoracoscope) and tools are inserted through tiny incisions in the side of the patient's chest. The camera shows images of the inside of the chest, guiding the surgeon during the procedure. When compared to open heart pericardial window surgery, VATS typically results in less pain and shorter recovery times. Learn more.

Once the doctor has access to the pericardium using one of the above methods, a small portion of the pericardium is removed, creating a "window" to drain the fluid. A chest tube may also be inserted temporarily to assist in fluid drainage.

Pericardial Window Surgery Risks

As with any surgical procedure, there are risks involved with pericardial window surgery. These risks vary depending upon a patient's overall health, heart health, age, and reason for the surgery. Risks include:

• Infection
• Bleeding
• Heart damage
• Heart attack
• Abnormal heart rhythms
• Blood clots, which can lead to stroke
• Complications from anesthesia

Even with the completion of pericardial window surgery, it is possible that excess fluid build-up around the heart will return. If this happens, the procedure may need to be repeated.

What to Expect After Surgery

After undergoing pericardial window surgery, patients can expect to stay in the hospital for at least a few days. The length of stay will depend on the type of surgery performed (thoracotomy vs. VATS) and the reason a pericardial window was needed.

During this time, breathing, heart rate, oxygen levels, and blood pressure will be monitored. Most people will notice improvements in any prior symptoms after surgery. It is normal for patients to experience soreness at the incision site(s) but not severe pain. About 7-10 days following surgery, any stitches or staples will be removed at the incision site(s).

Patients will likely experience tiredness for a period of time after surgery but will be able to slowly resume normal activities. Once home, patients will be instructed to avoid heavy lifting and may be given some activity restrictions temporarily. A member of the patient’s medical team will go over what to do or avoid before the patient is disc