Definition & Overview
Pericardiostomy is a surgical procedure that creates an opening in the pericardium, which is the double-layered conical sac that encloses and protects the heart. Its outer layer is fibrous while its inner double-membrane layer has serous contents. The space between the two layers is called the pericardial cavity.
Pericardiostomy is the treatment of choice for managing pericardial effusions, a condition characterised by the presence of excess fluid around the heart. The pericardial cavity normally contains a small amount of serous fluid. If the amount of pericardial fluid in and around the area increases, it is considered a medical problem. Abnormal effusions compress and prevent the heart from filling its space with an adequate amount of blood. This leads to an inadequate supply of oxygen that impairs many biological functions of the body.
One method that can be used in performing the procedure is the subxiphoid approach. This is what most surgeons use for patients being treated for pericardial effusions or tamponade. Tamponade is the compression of the heart due to the abnormal accumulation of fluid in the pericardial sac. The subxiphoid approach avoids most of the body’s vital organs and allows doctors to operate while minimising damage or injury to surrounding tissues. This minimises the risk of postoperative infections.
The procedure is minimally invasive and is carried out below the xiphoid process, the lowest portion of the breastbone (sternum).
Who Should Undergo and Expected Results?
Tube pericardiostomy is a procedure performed in patients suffering from a range of pericardial diseases, specifically pericardial effusion and tamponade. Often, patients who experience effusions around the heart are those suffering from cancer or a terminal disease. Tube pericardiostomy is performed with the goal to improve the quality of life of patients as they near the end stage of their lives.
In this procedure, the risk of developing postoperative infection is low, and most patients recover with minimal to zero postoperative pain. Generally, patients are able to tolerate the procedure well because it leaves only little trauma at the site where tubes and catheters are inserted.
Tube pericardiostomy is more cost-effective when compared to other alternatives, such as the creation of a pericardial window where part of the pericardial sac is removed to drain effusions in the pericardial cavity. The latter is quite expensive but offers the same result. However, it is important to note that some patients are suggested to undergo pericardial window depending on the uniqueness of their case.
A cross comparison of the charges shows that patients have almost 89% cost savings with tube pericardiostomy compared to invasive procedures such as surgical draining.
The procedure has a high success rate. In most cases, it requires one day or no recovery time at all. However, in cases of failure or recurrence, an open surgery is performed or similar procedures, such as pericardial window, are considered.
How is the Procedure Performed?
The procedure is minimally invasive and only requires local anaesthesia. However, in some cases, general anaesthesia is preferred. Even though it is minimally invasive, it is important to note that tube pericardiostomy is a considerably sensitive procedure and should only be carried out by experienced and trained doctors.
There are varied approaches to this method aside from the subxiphoid process already explained above. Other techniques used are needle aspiration, small plastic tube drainage, and anterior thoracotomy, a video-assisted thoracic surgery.
The procedure uses a gauge needle, measuring about 18 inches, to access the pericardial cavity. The needle, along with a J-tip wire and French pigtail catheter, is advanced through the area to drain the fluid in the pericardial cavity. The excess fluid is manually aspirated and examined later on to check for signs of microbial agents such as fungi, bacteria, and viruses through cell culture.
One of the areas of focus these days is in the application of minimally invasive treatment that does not involve the opening of the chest to access the heart. The use of tube pericardiostomy avoids all that. On average, the procedure takes only about 10 minutes. Surgeons create a hole in the pericardium so that the excess fluid trapped in and in between the pericardium and the heart can drain out. Doctors would usually keep the window open to prevent recurrences.
In recent years, CT-guided tube pericardiostomy that uses computed tomography, a machine that makes use of x-ray to scan the body organs and tissues), has become the most used method. CT scans provide a very detailed view of the area being treated that helps surgeons to avoid accidentally injuring nearby tissues.
CT-guided tube pericardiostomy is widely used for pericardial effusion. Most patients who have undergone cardiovascular surgery almost always experience pericardial effusion and CT-guided TP is often recommended. Surgeons usually opt for this procedure because it is less expensive, less risky for the patient, and it minimises the risk of complications.
Possible Risks and Complications
The morbidity rate, or the chances of developing postoperative infections or serious complications, is very low for patients undergoing this procedure. However, recurrences were noted in past cases.
Some serious infections that can develop after the procedure are viral pericarditis (inflammation of the pericardium) and serositis (infection of the serous membrane in the pericardium). Viral pericarditis is easily treated with nonsteroidal anti-inflammatory drugs or NSAIDs, which include ibuprofen and naproxen.
A few tube pericardiostomy patients in the past had to subsequently undergo invasive open surgery due to serious cases of effusions and inadequate drainage. However, in the majority of cases, the treatment was successful and no serious damage to nearby organs or secondary infections were noted.
Patients and their caretakers are advised to be aware of any symptoms of effusions or any signs of abnormal discomfort related to the procedure. Surgeons also advise patients about the importance of their follow-up schedule, especially the follow-up imaging study, to evaluate any signs of recurrence. Follow-up examinations are also very important for the detection of early signs of tamponade.
US National Library of Medicine National Institutes of Health; “Percutaneous Tube Pericardiostomy”; http://www.ncbi.nlm.nih.gov/pubmed/14980854
US National Library of Medicine National Institutes of Health; “CT-guided tube pericardiostomy: a safe and effective technique in the management of postsurgical pericardial effusion”; http://www.ncbi.nlm.nih.gov/pubmed/19770301