Definition & Overview

The heart has a membrane sac surrounding it called the pericardium. This double-walled sac plays a role in the circulatory system by providing protection and containing fluid to lubricate the heart. It also provides support when the organ has to handle increased blood volume during pregnancy or kidney failure. However, when the pericardium starts to malfunction, it can lead to a variety of medical conditions.

Pericardiectomy is the surgical procedure used to remove a part or the entire pericardium to treat pericarditis or inflammation of the pericardium and to relieve pericardial effusion or the building up of fluid in the pericardium. A patient can undergo either partial or total pericardiectomy, depending on the severity and extent of the damage.

The removal of the pericardium is not considered a grave medical condition because the heart can still function normally as long as the nearby organs like the lungs and diaphragm are still intact.

Who Should Undergo & Expected Results

Pericardiectomy is recommended for those who are suffering from chronic constrictive pericarditis. This condition is characterized by the scarring and thickening of the pericardium, likely caused by viral infections like tuberculosis, surgical complications, or even cancer. Normal heart functions are compromised and the patient experiences chest pains, difficulty in breathing, heart palpitations, and fatigue.

Pericardium opening is also advised for those who are diagnosed with pericardial effusion, a condition wherein the heart cannot pump blood properly due to fluid buildup in the membrane sac. Pericardiectomy is performed to remove the accumulated fluid but only if less invasive procedures are unable to accomplish such.

However, those with pre-existing major heart conditions like myocardial atrophy or fibrosis are advised against the procedure to avoid further complications and increased morbidity.

Pericardiectomy generally has favourable outcomes, with patients reporting long-term improvement of their condition following the procedure. Depending on the severity of underlying conditions, recovery could take several weeks, even months. Among cancer patients, pericardium opening helps alleviate symptoms associated with pericarditis but might not have a significant impact on their life spans and survival rate.

Pain medication is typically required following surgery to help manage chest pains. Patients should avoid lifting heavy objects and strenuous activities. Breathing exercises are also performed to maintain good lung function.

Despite favourable results, there are a small number of patients who report persistent symptoms after a significant period of time.

How Does the Procedure Work?

The patient is administered with anaesthesia and would remain heavily sedated throughout the procedure. Pericardiectomy starts with the surgeon making an incision either in front or on the side of the chest. A mechanical spreader is used to spread the ribs and breastbone. The heart is then exposed and, depending on the condition, a part or the entire pericardium is carefully stripped off. If present, the surgeon also removes the thick scar tissue as well as any tumour growth surrounding the heart. To treat pericardial effusion, fluid is drained from the membrane sac. The surgeon then closes and rewires the breastbone and ribs. Incision is closed with sutures or surgical staples.

Possible Complications and Risks

Pericardiectomy has its own associated risks and complications including bleeding. This is one procedure where a heart-lung machine is on standby in case significant bleeding occurs. As with any major surgical procedure, there is also the possibility that the patient will not respond well to anaesthesia.

This procedure could also tear the heart muscle, especially if the pericardium is tightly attached to it. The surgeon might have difficulty detaching the thickened tissues in the pericardium from the underlying myocardium and nearby coronary arteries. A possible tearing or injury to the heart muscle or blood vessels would require emergency care.

Postoperatively, the patient could experience bacterial infection at the surgery site or the infection could travel to the blood causing a serious medical condition called sepsis. Fluid could also build up around the nearby lungs and would need to be drained.

A number of heart-related conditions could also develop following pericardiectomy. The patient could experience low cardiac output syndrome, which requires long-time mechanical support of blood circulation. Abnormal heart rhythms and even heart attack are also possible with this procedure.

References

  • Jouriles NJ. Pericardial and Myocardial Disease. In Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Mosby Elsevier; 2013:chap 82.

  • LeWinter MM, Tischler MD. Pericardial diseases. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap75.

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