Pericardial Window

The pericardium is the sac which surrounds the heart. 

In a normal state, the pericardium is not very thick, but it is strong and fairly inelastic - a lot like a burlap sack. 

To access the heart for heart operations, the pericardium is cut. This does not seem to cause any untoward effects. 

However, the pericardium can become inflamed. The nerves in the pericardium can become inflamed, causing pain. 

The body usually makes a small of fluid within the pericardial space. The fluid cushions the heart and provides a protective film. 

Certain disease states can cause a build-up of fluid within the pericardial space. This fluid is called a pericardial effusion. Because the pericardium is relatively inelastic, a build-up of fluid can lead to impaired heart function. You would think the heart is strong enough to overcome some fluid around it, but the heart can have difficulty filling when the pressure goes up in the pericardial space. 

Fluid can build up in the pericardial space for a number of reasons. Causes of pericardial effusion include:

     - Infection: bacterial or viral or tuberculous

     - Inflammation aka pericarditis = could be after a     

              heart attack or placement of a stent or heart                      surgery

     - Cancer

     - Autoimmune condition, such as lupus

     - Kidney failure

     - Blood thinners

If a pericardial effusion impairs the function of the heart, the condition is termed tamponade. Tamponade can be life-threatening. The heart struggles to fill and struggles to pump and struggles to produce enough blood pressure. 

A patient with tamponade may feel short of breath, lightheaded, or dizzy. 

If tamponade occurs, prompt drainage of the fluid is needed. Sometimes the fluid can be drained with a needle, usually guided by ultrasound. This is called pericardiocentesis. This is usually performed by a cardiologist. 

Sometimes the fluid is thick and won't come out thru a needle or sometimes the fluid is located in a position where a needle cannot access, in which case a surgical procedure called a pericardial window may be needed.

 

A pericardial window may also be used if fluid comes back after it has been drained with a needle. A pericardial window may also be needed if all of the fluid could not be adequately drained with pericardiocentesis.   

A pericardial window involves cutting a hole out of the pericardium. This will allow the fluid to be removed. Also, if fluid tries to build up again, the window allows for the fluid to move out of the pericardial space into the body space nearby. 

If a pericardial window needs to be done, there are a couple of options on how it can be done:

SUBXIPHOID

ROBOTIC

A subxiphoid approach is the most direct method to perform a pericardial window. 

The patient is put to sleep with a general anesthetic. 

A small incision is made at the bottom of the breast-bone and at the top of the abdomen. 

Patients are usually in the hospital 2-3 days after a subxiphoid approach, disharged home after the drain is removed. 

If fluid tries to accumulate after a subxiphoid window, it will pass into the abdomen - where it can be more easily resorbed. 

The incision is carried deeper and the pericardium is cut. 

The fluid is removed. A drain, like a flexible straw, is placed in the pericardial space. 

Often, only a small piece of pericardium can be removed thru a subxiphoid approach, due to limitations in seeing the pericardium. 

A subxiphoid approach usually takes 30-45 minutes to perform. 

For patients not in tamponade, Dr. Pool prefers a robotic approach, since the visualization of the pericardium is better and a larger piece of pericardium can be removed. This may help insure that the window does not get plugged. 

A minimally-invasive method can often be used for pericardial window. 

Dr. Pool has performed many pericardial window operations using the daVinci robot. 

The patient is put to sleep with a general anesthetic. 

Several small incisions - usually 4 - are made on the side of the chest. Each incision is less than in inch in size. 

A video camera and the robotic instruments are inserted thru the small incisions. 

The pericardium is cut. The fluid is removed. A drain, like a flexible straw, is placed in the pericardial space. 

A robotic approach usually takes 30-45 minutes to perform. 

Patients are usually in the hospital 2-3 days after a robotic approach and are discharged home after the drain is removed. 

If fluid tries to accumulate after a robotic pericardial window, it will pass into the lung space - where it can be more easily resorbed. 

A robotic pericardial window can be done from either side - usually the right side is a bit easier, since the heart takes up some space slightly off to the left side. 

 

God bless & heal you! 

J. Mark Pool, MD

ABTS Board-certified

214-692-6135

Member of Society of Thoracic Surgeons