Definition & Overview
Pericardiectomy, also known as pericardial stripping, is a medical procedure where the pericardium, or a portion of it, is surgically removed. The pericardium is the double-layered sac that envelops the heart. Although the heart can survive without it, pericardium offers an extra layer of protection against infections.
Aside from protecting and lubricating the heart while it pumps blood to tissues and organs of the body, the pericardium also keeps the heart from over-expanding. This is especially true in cases when the supply of blood to the heart increases due to certain conditions such as pregnancy and kidney failure.
Pericardiectomy is performed when the heart has become so calcified and stiff due to a condition called constrictive pericarditis. When the pericardium stiffens, it puts pressure on the entire heart, specifically its chambers. When that happens, the heart will not be able to function properly, and there’s a possibility that blood would flow back. This causes the heart to swell and some parts to atrophy or waste away and die.
Patients with an advanced case of constrictive pericarditis are usually the candidates for pericardiectomy. Other indications for this procedure include effusive disease (pericardial effusion) that causes various symptoms including chest pains.
Patients can opt for other alternative medications for the treatment of pericarditis. If detected early or within 3-6 months, the condition can be treated using conservative methods. The surgical option is only recommended for advanced cases.
In pericardiectomy, the breastbone is cracked open allowing surgeons to easily resect (cut out) a part of the pericardium or remove it all together.
Who Should Undergo and Expected Results?
Pericardiectomy is particularly useful for patients suffering from recurrent pericarditis and those who have developed complications from regularly taking anti-inflammatory medications that contain steroids.
The development of pericarditis is usually attributed to tuberculosis, or any bacterial or fungal infection that invades the pericardium. Some of these are complications of a previous surgery or a kind of cancer called mesothelioma, which typically develops due to exposure to asbestos.
The operative mortality rate for patients who undergo pericardiectomy for pericardial effusion and tamponade and constriction is low, usually between 4% and 5%. Patients who underwent such procedure manage to survive even without the use of steroids.
After the surgery, patients are required to stay in the hospital for up to a week. This is important because surgeons need to carefully monitor the patient for immediate postoperative infections that may occur within that waiting period.
Patients are expected to feel significant improvement shortly after the surgery as long as they do not suffer from other diseases. However, full recovery may take about six to eight weeks. Patients are generally able to resume normal activities after that time except lifting heavy objects for a certain period. For older patients or those who were already too sick even before the surgery, recovery may take longer.
A study that monitored pericardiectomy patients over a 24-year period showed that those who have idiopathic constrictive pericarditis and those who developed the condition due to a heart attack and tuberculosis have higher survival rate than those who developed such disease due to previous surgery or those who received [radiation therapy].
As always, healthy and younger patients have a higher rate of survival compared to older patients and those suffering from other medical conditions. Also, the chance of successful management of the disease depends on how soon the condition was diagnosed and how early the intervention treatment started. In general, the less calcification found around the pericardium, the greater are the chances that patients will not develop any complications.
How is the Procedure Performed?
Pericardiectomy is invasive and requires a surgical procedure called median sternotomy. In median sternotomy, an incision is made along the sternum or the breastbone. The surgeon will then crack or divide the sternum to gain access to the heart and the pericardium. Once exposed, the surgeon will partially or entirely remove it. The breastbone is then put back in place with wires before the incision is closed with stitches.
Some doctors use the thoracotomy approach in removing the pericardium, which is somehow similar in technique and methodology to pericardiectomy.
Pericardiectomy can be performed with or without cardiopulmonary bypass, which takes over the function of the lungs and heart during open surgical procedures to maintain the circulation of oxygen content and blood of the body.
The performance of pericardiectomy requires a multidisciplinary approach. It involves doctors from different disciplines including cardiologists and radiologists. These doctors work together to carefully diagnose the condition and plan the most appropriate treatment for each patient while taking into consideration their unique circumstances.
Possible Risks and Complications
Pericardiectomy is considered a highly invasive and major cardiac surgery. As such, it is important that it is carried out by an experienced cardiothoracic surgeon with advanced surgical skills. Like most invasive procedures, mild to serious complications can occur. These could range from severe bleeding to death.
The risk of complications from occurring can increase depending on the patient’s age, gender (women are more susceptible), overall health condition, and whether or not the patient has other medical conditions.
Six weeks after the surgery, patients are required to visit their surgeons for a follow-up echocardiogram checkup. The echocardiogram allows the physician to see exactly how the heart is pumping after the procedure and during the recovery period and see if there are any irregularities.
Patients are required to take diuretic drugs (drugs that cause increased passing of urine) before the procedure and during recovery but at lower doses. It is important for patients to adhere to the advice of their surgeon and keep up with their follow-up schedule to fully monitor their recovery and check for any complications.
Despite all the complications, pericardiectomy is effective in alleviating the symptoms caused by constrictive pericarditis and is considered the best and most appropriate treatment for such a disease.
Cleveland Clinic; “Pericardiectomy”; http://my.clevelandclinic.org/services/heart/services/pericardiectomy
US National Library of Medicine National Institutes of Health; “Current indications, risks, and outcome after pericardiectomy”; http://www.ncbi.nlm.nih.gov/pubmed/1863142