**3.3 Timing of surgery and long-term outcomes**

The timing of creating a surgical pericardial window also varies widely. For the first presentations of pericardial effusions, surgery may not be always necessary after initial pericardiocentesis and resolution of pericardial effusions. As patients could be treated with chemotherapy or immunotherapy for their primary disease or the causative factors modified to reduce the risk of recurrent effusions, I do not recommend surgical drainage for all first presentations. However, once the effusion recurs, this increases the subsequent times that it continues to be recurrent; hence, I do advocate creating a pericardial window for this group of patients. As all other disease, discussion with the patients' primary physician or oncologist is advised to better optimize care.

Another issue which must be discussed with the patient is the likelihood of recurrent pericardial effusion despite surgical drainage. The risk of this recurring can be up to 16% in reported cases [6]. Of course there are technical pitfalls in this. For example, my preference is for an anterior thoracotomy rather than a subxiphoid approach. The latter could be under local anesthesia which sometimes is the only option in patients who are not candidates for general anesthesia. However, it has been reported to have higher failure rates [6]. This could be due to repositioning of the diaphragm closing off the window, leading to recurrent effusions. Other authors have found no significant differences between both techniques [7]. Most authors have described a 2–3 cm size of pericardium tissue to be excised [6–11]. Despite all efforts, recurrent pericardial effusions do occur, and patients should be counseled for this. It is not uncommon to see a loculated right pericardial effusion occurring after a left pericardial-pleural window (**Figures 1** and **2**). This can be contributed by intra-pericardial adhesions or disease which progress despite medical treatment. A redo pericardial window can be done in such patients and probably in my opinion, safer and more effective via a different side than the initial approach.

**59**

**Figure 3.**

*Suggested flowchart for surgical approach.*

*Pericardial Diseases: Surgery for Pericardial Effusion DOI: http://dx.doi.org/10.5772/intechopen.81927*

**4. Surgical technique**

**Figure 2.**

**4.1 Anterior thoracotomy approach**

*Axial view of the loculated right pericardial effusion (arrow).*

done in my surgical practice and it is outlined below.

I believe for surgical approach to pericardial effusion that simple is better and the best is the enemy of the good. Like many other surgical techniques, different approaches have been described to get to the same end point. My suggested surgical approach is summarized in **Figure 3**. Left anterior thoracotomy is most commonly

As mentioned earlier, whenever possible I advocate percutaneous drainage of the pericardial effusion before bringing the patient to the operating theater. This will reduce the risk of cardiovascular collapse upon initiation of general anesthesia. Often, nonsurgical colleagues or even the patient will ask the need for surgery if the

**Figure 1.** *Loculated right pericardial effusion (arrow). Patient had prior left pericardial-pleural window.*

*Pericardial Diseases: Surgery for Pericardial Effusion DOI: http://dx.doi.org/10.5772/intechopen.81927*

*Inflammatory Heart Diseases*

due to mediastinal disease.

better optimize care.

initial approach.

**3.3 Timing of surgery and long-term outcomes**

could lead to his or her symptoms. It is an unwise clinical decision to operate and drain a pericardial effusion promising full relief of symptoms, where, for example, the symptoms are actually manifested from compression of the airway

The timing of creating a surgical pericardial window also varies widely. For the first presentations of pericardial effusions, surgery may not be always necessary after initial pericardiocentesis and resolution of pericardial effusions. As patients could be treated with chemotherapy or immunotherapy for their primary disease or the causative factors modified to reduce the risk of recurrent effusions, I do not recommend surgical drainage for all first presentations. However, once the effusion recurs, this increases the subsequent times that it continues to be recurrent; hence, I do advocate creating a pericardial window for this group of patients. As all other disease, discussion with the patients' primary physician or oncologist is advised to

Another issue which must be discussed with the patient is the likelihood of recurrent pericardial effusion despite surgical drainage. The risk of this recurring can be up to 16% in reported cases [6]. Of course there are technical pitfalls in this. For example, my preference is for an anterior thoracotomy rather than a subxiphoid approach. The latter could be under local anesthesia which sometimes is the only option in patients who are not candidates for general anesthesia. However, it has been reported to have higher failure rates [6]. This could be due to repositioning of the diaphragm closing off the window, leading to recurrent effusions. Other authors have found no significant differences between both techniques [7]. Most authors have described a 2–3 cm size of pericardium tissue to be excised [6–11]. Despite all efforts, recurrent pericardial effusions do occur, and patients should be counseled for this. It is not uncommon to see a loculated right pericardial effusion occurring after a left pericardial-pleural window (**Figures 1** and **2**). This can be contributed by intra-pericardial adhesions or disease which progress despite medical treatment. A redo pericardial window can be done in such patients and probably in my opinion, safer and more effective via a different side than the

**58**

**Figure 1.**

*Loculated right pericardial effusion (arrow). Patient had prior left pericardial-pleural window.*

**Figure 2.** *Axial view of the loculated right pericardial effusion (arrow).*
