**2.4 Iatrogenic**

Iatrogenic pericardial effusion can be caused by injury to any cardiac chamber or intra-pericardial injury to the superior vena cava. Especially if the patient is anticoagulated and symptomatic, urgent intervention is required. This may be in the form of an urgent pericardiocentesis to prevent impending cardiac tamponade [3]. If there is persistent drainage after pericardiocentesis or if it is unable to adequately decompress the pericardial cavity, emergency surgical drainage is indicated. The approach would be similar to that mentioned above, although I would recommend a sternotomy approach for better exposure and safety.

**57**

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

**3. Presurgical considerations**

might be in extremis prior to surgery.

forms of drainage for short-term belief.

adverse outcomes which they might not accept.

**3.2 Preoperative assessment**

**3.1 Indications**

Another common cause of pericardial effusion encountered by both thoracic and cardiac surgeons includes the broad group underreactive causes. This also covers the postcardiotomy pericarditis and Dressler's syndrome [4, 5]. It often occurs after cardiac surgery when the pericardium gets inflamed and produces pericardial fluid which cannot be reabsorbed fast enough. Drainage can be in the form of pericardiocentesis or open subxiphoid approach which avoids re-sternotomy. But for persistent pericardial effusions, creating a surgical window between the pericardial

I would classify unknown and idiopathic causes as underreactive. This is because despite clinical suspicion, some cases of pericardial effusion may not have a definitive diagnosis. Specimens of pericardium tissue and pericardial fluid obtained during surgery may only be labeled as inflammatory or even normal in appearance under the microscope. Hence, apart from knowing there is an inflammatory reason, the patient should be treated with other clinical inputs to achieve diagnosis. These causes which are also not exhaustive include uremic, auto-immune, drug-related and postradiation. However, despite not knowing the diagnosis, most of the time, surgical drainage is therapeutic and achieves the desired outcome of symptom relief.

This is the portion that the art of medicine is needed more than the science. Being a surgeon, it would appear rather strange that I would advocate surgical drainage only if all other alternatives have been considered first. But my approach to surgical drainage of pericardial effusion is always to weigh the risks against the benefits. This is always the case in medicine and even more so in these patients who

An ideal patient for surgical drainage would be one with good life expectancy despite advanced disease or cancer. I do not recommend surgical drainage for patients with less than 6 months of life expectancy. Surgical drainage is to improve long-term outcome and relief of symptoms in patients, so I would consider other

A great deal of effort is usually required to counsel the patient prior to any surgery for pericardial effusion. In fact, I take the most time to talk to this group of patients, even more than patients with other pathologies. This is because patients in this group tend to have multiple medical conditions and pro-morbidities which complicate surgery. Speaking to them and understanding their wishes and concerns is paramount. For example, if they are not affected functionally by the pericardial effusion, they may not want surgery especially if surgery is high risk and can lead to

The patient should not have any other contra-indications to general anesthesia. A good bedside assessment, which has been handed down from seniors, would be to check if the patient is able to lie completely flat with the head not elevated. This tells two things about the patient: firstly, the pericardial collection is not causing too much hemodynamic compromise that it is affecting venous return to the heart, and, secondly, it is to ensure there is no other pathology that

cavity and the pleural cavity is better suited for longer-term drainage.

**2.5 Others**

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

### **2.5 Others**

*Inflammatory Heart Diseases*

**2.2 Infective**

with infection.

**2.3 Traumatic**

spread, whereby primary tumors of the pericardium are rare [1]. Occasionally, pericardium effusions can result from local spread of thymic malignancy and even myocardial tumor-like lymphoma. We will discuss the rationale for proceeding with therapeutic surgical drainage for this group of patients later, as this involves a

Another etiology of pericardial effusions will include infectious causes. Even though rare in this day and age due to the use of antibiotics, infection of the pericardial space is a consideration in immunocompromised patients. These groups of patients can be rather septic from this deep-lying infection, especially if the source is bacterial in origin. In areas where tuberculosis is still prevalent, infection involving the pericardial cavity has been reported [2]. Treatment with the appropriate antibiotics can then be optimized when drainage has been achieved and the correct causative organism identified. The role of the surgeon here is to assist in surgical drainage for both therapeutic and diagnostic reasons. Occasionally, smaller bore drains inserted percutaneously are unable to reduce septic foci, and surgery is required for source control. However, unlike creating a permanent window for drainage into the pleural space in cases of malignant effusions, I would be less inclined to do so for infective causes. This is to avoid contaminating the pleural space

For trauma-induced pericardial effusion, most surgeons would suggest surgical exploration rather than conservative approach. This is because in the acute setting, most patients are unstable with multiple injuries, and they would require urgent surgery to exclude ongoing bleeding into the pericardial cavity. The resultant tamponade is rapidly fatal unless drainage and hemostasis are quickly established. Any blunt or penetrating injury in the cardiac box (bounded by both nipple lines laterally, the clavicles superiorly and the costal margin inferiorly) must be viewed with a high index of suspicion that there is myocardial injury. Opinion is divided between the left anterior thoracotomy incision and the sternotomy incision. The sternotomy approach is safer as it allows rapid access to the ascending aorta and vena cava if cardiopulmonary bypass is urgently required for repair of a heart chamber perforation. Left anterior thoracotomy avoids a bigger incision and the risk of sternal wound infection; however, if cardiopulmonary bypass is required, it may still require conversion to a sternotomy for better control. Another reason why traumatic pericardial effusion cannot be usually treated conservatively is the fact that most commonly the right ventricle is involved and this usually requires surgical

Iatrogenic pericardial effusion can be caused by injury to any cardiac chamber or intra-pericardial injury to the superior vena cava. Especially if the patient is anticoagulated and symptomatic, urgent intervention is required. This may be in the form of an urgent pericardiocentesis to prevent impending cardiac tamponade [3]. If there is persistent drainage after pericardiocentesis or if it is unable to adequately decompress the pericardial cavity, emergency surgical drainage is indicated. The approach would be similar to that mentioned above, although I would recommend a

sternotomy approach for better exposure and safety.

careful consideration of their long-term prognosis.

**56**

repair.

**2.4 Iatrogenic**

Another common cause of pericardial effusion encountered by both thoracic and cardiac surgeons includes the broad group underreactive causes. This also covers the postcardiotomy pericarditis and Dressler's syndrome [4, 5]. It often occurs after cardiac surgery when the pericardium gets inflamed and produces pericardial fluid which cannot be reabsorbed fast enough. Drainage can be in the form of pericardiocentesis or open subxiphoid approach which avoids re-sternotomy. But for persistent pericardial effusions, creating a surgical window between the pericardial cavity and the pleural cavity is better suited for longer-term drainage.

I would classify unknown and idiopathic causes as underreactive. This is because despite clinical suspicion, some cases of pericardial effusion may not have a definitive diagnosis. Specimens of pericardium tissue and pericardial fluid obtained during surgery may only be labeled as inflammatory or even normal in appearance under the microscope. Hence, apart from knowing there is an inflammatory reason, the patient should be treated with other clinical inputs to achieve diagnosis. These causes which are also not exhaustive include uremic, auto-immune, drug-related and postradiation. However, despite not knowing the diagnosis, most of the time, surgical drainage is therapeutic and achieves the desired outcome of symptom relief.
