**1. Introduction**

Management of pericardial effusion is a common topic for cardiothoracic surgeons. In this chapter, we will discuss the common etiologies referred for surgical management. From a surgeon's perspective, we would review how to evaluate patients for surgical drainage, as well as the frequent indications for performing pericardial window creation. Technically, surgery is rather straightforward compared to other procedures done by cardiothoracic surgeons; however, it requires lots of decision-making experience during the perioperative management of these patients who might be critically ill. For example, regardless of whether surgery is for diagnostic or therapeutic reasons, the risks of surgery must be weighed against the benefits including the odds of quality of life across a reasonable life expectancy.

Other discussion points will include anterior thoracotomy technique vs. videoassisted thoracoscopic surgery (VATS) approach. Other technical points include identifying the phrenic nerve and removing adequate pericardial tissue anterior to the nerve to avoid risk of recurrent pericardial effusions.
