**5. Surgical treatment for pericardial disease**

#### **5.1 Pericardial window**

A pericardial window is the procedure to create a communication from the pericardial space to the pleural space. The purpose of this procedure is to allow a pericardial effusion (usually malignant) to drain from the pericardial space into the chest cavity to prevent a large accumulation of pericardial fluid and cardiac tamponade.

Subxiphoid pericardial window is done by either local or general anesthesia. A vertical incision about 4 cm is made over the xiphoid process and upper abdomen. The diaphragm is dissected away from the undersurface of the sternum and xiphoid, fat is removed from over the pericardium, and the pericardium is opened under direct vision. All fluid is aspirated, and loculations may be broken up gently with the sucker. As large a pericardial window as possible is made by excision of the pericardium. Pericardial tissue and fluid are sent for bacteriologic and histologic study.

Another way to do a pericardial window is via a left anterolateral approach. A small left anterolateral incision is made, and a simple pericardial window is created, usually of necessity anterior to the phrenic nerve. After evacuation of fluid, chest tubes are placed in the pleural space.

#### **5.2 Pericardiectomy**

Pericardiectomy is indicated in patients with symptomatic constrictive pericarditis, especially those patients requiring increasing doses of diuretics. It is also indicated in patients with effusive-constrictive pericarditis who do not respond to anti-inflammatory medications.

Pericardiectomy is typically done through median sternotomy, whereas it can be done via left anterolateral or bilateral thoracotomy. Complete pericardiectomy is defined as removal of the whole pericardium overlying the heart and proximal great vessels except for the pericardium posterior to the left atrium in the oblique sinus and variable amounts of pericardium adjacent to the phrenic nerves. Thus, the anterior pericardium (phrenic nerve to phrenic nerve), the diaphragmatic pericardium, and a portion of the pericardium posterior to the left phrenic nerve should be removed. Failure to remove the pericardium from the diaphragmatic surface may lead to late recurrence of constrictive physiology.

Although cardiopulmonary bypass and systemic heparinization may increase the risk of bleeding, decompression of the heart with extracorporeal circulation is useful and necessary in many patients because circulatory support facilitates dissection of the pericardium and allows wide manipulation of the ventricles. Further, with cardiopulmonary bypass, any injury to the myocardium is more easily repaired. Another advantage is that during cardiopulmonary bypass, the patient's total blood volume is drained into the cardiotomy reservoir, and after pericardiectomy, intravascular volume is adjusted to maintain adequate cardiac output and perfusion.

One of the largest number of pericardiectomy was reported from the Mayo Clinic [6]. They reviewed 1071 pericardiectomy operations for about 80 years. The etiology of constrictive pericarditis was idiopathic in 62%, post-cardiac surgery in 27%, and postradiation in 10% in the contemporary era. The 30-day mortality was 5.2% in the contemporary era and 13.5% in the historical era. The risk factors of overall mortality in the contemporary era were the New York Heart Association class III or IV, etiology of radiation or post-cardiac surgery, and the need for cardiopulmonary bypass.

### **6. Conclusions**

Despite the recent advancement in diagnostic images and treatment options, there have been a limited number of randomized controlled studies in the field of pericardial disease. Therefore, contemporary management of pericardial disease is mainly performed empirically. Nowadays new diagnostic techniques have been available in the study of pericardial diseases.

#### **Author details**

Takashi Murashita University of Missouri, Columbia, Missouri, USA

\*Address all correspondence to: tmurashita@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**9**

*Prologue: Introduction to Advanced Concepts in Pericardial Disease*

Experience with pericardiectomy for constrictive pericarditis over eight decades. The Annals of Thoracic Surgery. 2017;**104**(3):742-750. DOI: 10.1016/j.athoracsur.2017.05.063

*DOI: http://dx.doi.org/10.5772/intechopen.86164*

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