Definition & Overview
Pericardiotomy refers to the surgical opening or puncture of the pericardium, a double-walled sac containing the heart. It is a primary procedure that surgeons use to carry out various surgeries in the pericardium. These include pericardiocentesis (which removes fluid from the sac around the heart) and the removal of blood clots and foreign bodies in the pericardium.
For the procedure, the surgeon will make an incision, the size of which depends on the type of the procedure to be performed, which could be either open or minimally invasive surgery. Blood clots and small foreign objects in the area can be removed using a minimally invasive approach. However, in cases where the foreign object is quite big, such as surgical instruments that were left during a previous surgical procedure, open surgery is performed.
If the presence of blood clots and foreign bodies in this area has led to the development of pericardial effusions (the abnormal accumulation of fluid in the pericardial cavity), the excess fluid will also be drained during the same procedure. This removes the pressure building up in that layer and ultimately restores the heart’s normal function.
Who Should Undergo and Expected Results?
Pericardiotomy is a primary procedure that can be used to perform a range of surgical procedures that involve the pericardium. These include the surgical removal of blood clots and foreign objects in the pericardium and pericardial cavity.
The development of blood clot in this region can be due to underlying disease, blunt trauma to the chest, and postoperative complications. Such condition places the patient at risk of serious complications including stroke, paralysis, heart attack, and intense pain. This is because blood clots prevent the much-needed oxygen from reaching the vital organs.
Meanwhile, foreign bodies in the pericardium are rare and can be removed percutaneously (done via needle-puncture of the skin), surgically, or managed conservatively. The most common foreign bodies stuck in this area are devices implanted for relieving hydrocephalus and inferior cava filters. The less common, on the other hand, are surgical instruments that were inadvertently left behind during a previous surgery.
After confirming the presence of blood clot or foreign body in the region, patients are immediately scheduled for surgery and are required to stay in an intensive care unit (ICU) where they are closely monitored. Surgeons do this because such conditions can be life-threatening.
How is the Procedure Performed?
An IV is attached to the patient’s arm before the procedure starts. A drug to make the patient feel sleepy is applied and the vital signs are monitored. To monitor the heart and the pericardium, surgeons will initially perform an echocardiogram.
If minimally invasive procedure is to be performed, local anaesthesia is applied just below the breastbone. A needle is then inserted as soon as the area feels numb. The needle pierces through the skin and is guided through the pericardial sac with the help of imaging technology such as fluoroscopy or echocardiogram. The needle is replaced with a catheter as soon as it reaches the target area to remove blood clots or small foreign objects.
Another minimally invasive procedure that can be performed is percutaneous balloon pericardiotomy. For this procedure, a special catheter with a balloon at the tip is used. Once the catheter has reached the target area, the balloon is inflated until a “window” or wound is created. In some cases, several pericardial windows are created to effectively remove blood clots and small foreign objects from the pericardial sac. The balloon is deflated and the surgeon removes the catheter upon the successful creation of windows. Another catheter is put in place to remove foreign bodies or blood clots.
However, if the foreign object is rather large, the surgeon will perform the procedure via an open surgery. This involves creating an incision in the chest wall that is big enough to pull out the foreign object. This procedure is highly invasive and is performed under general anaesthesia. It involves cutting through the breastbone to expose the target area. After the foreign object is removed, the breastbone is closed using wires and the incision is stitched up.
Possible Risks and Complications
Pericardiotomy, just like any medical procedure that requires an incision, is associated with a number of risks and complications. The severity of complications varies from patient to patient and often depends on the patient’s overall health and existing medical conditions. Some risks and complications include the following:
- Puncturing of the heart - Injury caused by the catheters in the heart can cause bleeding and can make the heart stop beating.
- Pneumothorax – This refers to the presence of air in the chest cavity
- Infection of the heart and surrounding tissues
- Pleural effusion
Saint Luke’s System; “Percutaneous Balloon Pericardiotomy”; http://www.saintlukeshealthsystem.org/health-library/percutaneous-balloon-pericardiotomy
US National Library of Medicine National Institutes of Health; “Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases”; http://www.ncbi.nlm.nih.gov/pubmed/8417048