Pericardium: operations and procedures

Pericardium operations are a type of heart surgery. They are necessary if the pericardium, or heart sac, becomes thickened or filled with fluid. In general, there are two operations available: the opening of the pericardium, which is known as pericardial fenestration, and the removal of the pericardium, which is referred to as a pericardectomy.

The pericardium consists of connective tissue (tissue that surrounds organs or is found between organs) and forms a thin pouch around the heart. If fluid builds up in the pericardium due to inflammation in this area (pericarditis), cancer or an injury/haemorrhage, this is called pericardial effusion. If the fluid presses too hard against the heart, it causes the heart to become constricted. In the medical world, this phenomenon is known as pericardial tamponade. Pericardial effusion or pericardial tamponade are treated surgically with either a pericardial fenestration or a pericardectomy.

Thoracoscopic pericardial fenestration

In the case of thoracoscopic pericardial fenestration, an endoscope is used to help make a hole in the pericardium, so that the fluid can be drained or removed.

What preparations are carried out before the operation?

Before pericardial fenestration, an attempt will firstly be made to drain the fluid by puncturing the pericardium and inserting a thin tube. If this is insufficient, or the fluid keeps accumulating, pericardial window surgery is required. This operation is performed under general anaesthetic and involves all the usual preparations required for a general anaesthetic. 

How is the operation performed?

A thoracoscope is inserted into the chest cavity through an incision below the fifth rib on the patient’s left-hand side. The incision is around 10 cm long. Guided by camera imaging, a hole (window) is cut into the pericardium so that the fluid can drain into the chest cavity. There it is absorbed by the membrane around the lungs (pleura). After pericardial fenestration, a drainage tube is usually inserted to aid the removal of fluid. The operation takes around one hour. The drainage tube is removed after two or three days and the patient is usually hospitalised for four or five days.

What is the success rate of this procedure?

The results are generally very good. Pericardial fenestration removes the fluid and the ‘hole’ in the pericardium does not negatively impact on the heart. However, the underlying illness that caused the build-up of fluid may require further treatment.

What are the possible complications and risks of this operation?

This is a low-risk operation and generally does not result in complications. As with all surgery, the operation may lead to infections, post-operative haemorrhaging or blood clots in rare cases.

What happens after the operation?

In the initial period after pericardial fenestration, ultrasound examinations are necessary to investigate how the pericardium is progressing and to ensure there is no new fluid build-up.

 

Removal of the pericardium, pericardectomy

Chronic inflammation or irritation of the pericardial sac can cause it to become thicker over time and scar tissue to form, which constricts the heart. This phenomenon is also known as constrictive pericarditis. The surgical treatment of this condition involves either the partial or entire removal of the pericardium (pericardectomy).

What preparations are carried out before the operation?

Pericardectomies are performed under general anaesthetic. As such, all the assessments that usually take place before an operation are required – such as a blood test, blood pressure measurement and an ECG. The patient is admitted to hospital on the day before the operation.

How is the operation performed?

The chest cavity is opened using a small incision between the ribs, known as a thoracotomy. Then the surgeon removes part or all of the pericardium, depending on how thick and calloused it has become. The pericardium does not need to be replaced. The heart can move freely in the chest cavity without it. The operation can usually be performed without the use of a life-support machine.

What is the success rate of this procedure?

This operation delivers excellent results. After a short period of time adjusting to the lack of pericardium, the heart regains its full functionality.

What are the possible complications and risks of this operation?

This is a low-risk operation and generally does not result in complications. As with all surgery, the operation may lead to infections, post-operative haemorrhaging or blood clots in rare cases.

What happens after the operation?

The heart needs to adjust to its new surroundings, so intensive monitoring is necessary for a few days after surgery. The patient’s circulation also needs to be supported with the use of medication. People who have undergone this operation should avoid lifting heavy objects and major physical exertion until their wounds have fully healed. After the operation, the patient’s heart function is checked regularly over an extended period of time.

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