Pericardiectomy (Surgery on the Heart Membrane)
- What is a pericardiectomy?
- When is a pericardiectomy performed?
- Preparing for a pericardiectomy
- What to expect during pericardiectomy surgery
- After pericardiectomy: postoperative care and recovery
- Risks & Complications
- Postpericardiotomy syndrome
What is a pericardiectomy?
A pericardiectomy is a surgical procedure in which all or part of the pericardium is removed. The pericardium is the membrane around the heart; a sac comprised of two thin layers of tissue with lubricating fluid in between. If the pericardium experiences repeated inflammation, it may become stiff and thick, compromising the heart’s function. This is a serious condition called constrictive pericarditis.[^3]
The heart can function without the pericardium, and in many cases this membrane around the heart can be safely removed to provide relief from constrictive pericarditis and certain other cardiac conditions.
The prognosis or outlook after pericardiectomy depends on the cause of the constrictive pericarditis or other heart condition, as well as the age and overall health of the person. Many people are able to enjoy a full life after pericardiectomy.
However, since pericardiectomy is a major surgical procedure that is performed under general anesthesia, it does carry risks, and complications are possible. As a result, it is typically only performed when other treatment options have been unsuccessful.
When is a pericardiectomy performed?
Chronic constrictive pericarditis
A pericardiectomy is typically performed to treat cases of chronic constrictive pericarditis that have proven unresponsive to other types of treatment. Pericardium removal is not usually recommended for patients experiencing a first bout of pericarditis.
Constrictive pericarditis may be caused by, among other agents:[^3]
- Viral or bacterial infections, including tuberculosis (TB)
- Inflammation of the pericardial sac due to a heart attack
- Complications related to surgery
- Radiation therapy
- Adverse reactions to certain medicines
- Autoimmune conditions
- Systemic diseases like hypothyroidism
In many cases, the cause of constrictive pericarditis is unknown.
Other types of pericarditis
Pericardium removal surgery is not only used in cases of chronic constrictive pericarditis. A pericardiectomy may also be performed to treat other types of recurrent pericarditis – including those that cause a significant accumulation of pericardial fluid (effusion) – to provide relief from symptoms (such as chest pain) and improve the functioning of the heart.
Preparing for a pericardiectomy
A doctor will advise on how to prepare for the cardiac surgery. The person may be asked to refrain from eating or drinking for a period of time before the procedure, as well as to stop taking certain medications. Some tests may be done prior to the pericardiectomy, including:[^3]
- Blood tests: To check the general health of the person.
- Chest X-ray: To check for abnormalities in the heart and lungs.
- Electrocardiogram (ECG): Measurement of the heart’s electrical activity, to detect abnormal heart rhythms, known as arrhythmias, and other irregularities.
- Echocardiogram: An ultrasound scan, used to check the size and shape of the heart, its blood flow and whether any effusions are present.
- CT scan: A computed tomography (CT) scan, uses X-rays to provide a detailed image of the heart and any effusions.
- MRI: A magnetic resonance imaging (MRI) test, uses magnets and radio waves to provide a detailed image of the heart and effusions.
These tests are used to help the medical team understand the person’s condition, to confirm that the person is able to undergo surgery safely and to identify any issues that could complicate the pericardiectomy procedure.
What to expect during pericardiectomy surgery
The doctor will explain the details of the pericardiectomy procedure before starting, and a general anesthetic will be administered so that that the person undergoing surgery will be in a state of controlled unconsciousness. The surgery may take several hours to complete. The surgeon will typically make an incision through the breastbone and carefully remove part or all of the pericardium. If all or almost all of the membrane is removed, it may be called a total, complete or radical pericardiectomy. The incision will then be closed up and dressed, and the anesthesia will be reversed, so that the person wakes up.[^3]
After pericardiectomy: postoperative care and recovery
After the surgery, it is normal to feel groggy and a little disoriented. A doctor will monitor blood pressure, heart rate and other vital signs, and a drainage tube will be inserted into the chest to remove excess fluid. Side-effects may include some pain, but it is unlikely to be severe. The doctor will provide painkillers and other medication as required, and advise on when liquids and food can be reintroduced.[^3]
A pericardiectomy is a major surgical procedure that will typically require a hospital stay of five to seven days. The person will generally be advised to avoid heavy lifting in the recovery stage, which may take up to two months. Feelings of tiredness may be experienced during the recovery period and exercise may have to be limited, though it should be possible to resume many daily activities quite quickly after the surgery.[^3]
The doctor may schedule follow-up appointments to remove any stitches and check the functioning of the heart. Additionally, a person’s heart medication may need to be adjusted after the surgery. If there is a fever, increased chest pain, unusual draining from the wound or any other symptoms during the recovery period, it is advisable to consult a doctor immediately.[^3]
Pericardiectomy risks and complications
- Abnormal heart rhythm
- Low cardiac output syndrome, where the heart is unable to supply the body with sufficient oxygen
- A blocked blood vessel, in which case an additional technique called cardiopulmonary bypass may be required to maintain blood flow
- Postpericardiotomy syndrome (see below)
- Mortality (death)
Postpericardiotomy syndrome is a possible complication of cardiac surgery, including a pericardiotomy or pericardiectomy procedure.
Postpericardiotomy syndrome is understood to be an immune reaction that can occur a few days to a few months after heart surgery, injury to the heart or a heart attack. It is characterized by chest pain and fever. In rare cases, postpericardiotomy syndrome can lead to serious complications.
If postpericardiotomy syndrome is suspected, medical advice should be sought without delay. Treatment is possible and may include anti-inflammatory medicines such as NSAIDs and colchicine, or a course of steroid medication.
In the past, pericardiectomy was associated with relatively high rates of postoperative disease and mortality. However, thanks to advances in medicine, the surgical procedure to remove the membrane around the heart is considered to be much safer today and can be an effective way of treating constrictive pericarditis and certain other cardiac conditions.
Q: Pericardiectomy vs. pericardial window – what is the difference?
A: A pericardiectomy is a major surgical procedure that is performed to remove a section or all of the pericardium – the membrane around the heart. It is typically used to provide relief from chronic constrictive pericarditis, where the pericardium has become thick and stiff.[^3]
A pericardial window is a less-invasive technique that can be performed under local anesthesia, where a small part of the pericardium is removed to drain excess fluid from the membrane. It is also known as subxiphoid pericardiostomy and is generally used to provide relief from large or recurrent pericardial effusions, rather than thickened pericardial tissue.
Q: What is the difference between a pericardiectomy and pericardiotomy?
A: In a pericardiectomy, part or all of the pericardium, the membrane around the heart, is removed to provide relief from chronic constrictive pericarditis. A pericardiotomy, generally understood to be a percutaneous balloon pericardiotomy, is a less invasive procedure used to drain excess fluid from the pericardium. It typically involves the insertion of a catheter – a thin tube – with a balloon tip, which is inflated to create a small hole in the pericardium. This procedure is typically used in the treatment of recurrent pericardial effusions, and sometimes also to reduce the risk of developing atrial fibrillation, an abnormal heart rhythm, after heart surgery.
Q: What is the pericardiectomy mortality rate?
A: Compared to other more minor types of surgery, the mortality rate for pericardiectomy is somewhat higher. However, the majority of people who undergo a pericardiectomy will survive and experience long-term relief from constrictive pericarditis. The outlook is influenced by the cause and stage of the constrictive pericarditis, as well as the age and overall health of the person. A doctor will be able to provide details on the risks and benefits of pericardiectomy for a particular person.
American College of Cardiology. “Isolated Pericardiectomy: Outcomes are Well Worth the Challenge.” January 12, 2017. Accessed October 2, 2017. ↩ ↩ ↩
European Journal of Cardio-thoracic Surgery. “Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy: 24 years of experience.” June 12, 2013. Accessed July 10, 2018. ↩
The Korean Journal of Thoracic and Cardiovascular Surgery. “The Importance of Complete Pericardiectomy and the Role of the Apical Suction Device in Chronic Constrictive Pericarditis.” February, 2017. Accessed July 10, 2018. ↩
Journal of Cardiothoracic Surgery. “Long-term outcomes of pericardiectomy for constrictive pericarditis.” November 27, 2015. Accessed July 11, 2018. ↩ ↩
The Tohoku Journal of Experimental Medicine. “Posterior pericardiotomy reduces the incidence of atrial fibrillation, pericardial effusion, and length of stay in hospital after coronary artery bypasses surgery.” October, 2011. Accessed July 10, 2018. ↩