Pericardiectomy

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What is pericardiectomy?

A pericardiectomy is a procedure done on the sac around the heart. A surgeon cuts away this sac or a large part of this sac. This allows the heart to move freely.

A fibrous sac called the pericardium surrounds the heart. This sac has 2 thin layers with fluid between them. This fluid reduces friction as the 2 layers rub against each other when the heart beats. Normally, this sac is thin and flexible, but repeated inflammation can cause it to become stiff and thick. When this happens, the heart can’t stretch properly as it beats. This can prevent the heart from filling up with as much blood as it needs. The lack of blood can cause increased pressure in the heart, a condition called constrictive pericarditis. Cutting this sac away allows the heart to fill normally again. But pericardiectomy doesn’t fix the problem that was causing the inflammation.

Pericardiectomy is a surgery done under general anesthesia. The surgeon makes an incision over the breastbone to access the heart. Then the surgeon removes either a large part or the entire pericardium. Or, the surgeon makes an incision between the ribs to reach the pericardium. Doctors also may use several small incisions on the side of the chest. This is called video-assisted thoracoscopy (VATS). Tiny cameras and tools are used to do the surgery through these small holes.

Why might I need a pericardiectomy?

Pericardiectomy is most often needed in people with chronic constrictive pericarditis. It’s not usually an option for people who have had just 1 instance of pericarditis. With chronic constrictive pericarditis, the pericardium has become stiff and thick. This is due to repeated scarring. This scarring constricts the heart’s movement. This can cause symptoms like fatigue and swelling. Conditions that can cause constrictive pericarditis include:

Autoimmune disease
Cancer (that has spread from elsewhere in the body or cancer in the heart tissue itself)
Infection of the heart or pericardium
Inflammation of the pericardium due to a heart attack
Radiation therapy to the chest
Reactions to certain medicines
Metabolic causes, like an underactive thyroid
Viruses, specifically COVID-19

In some cases, the cause of constrictive pericarditis is unknown.

If you have severe symptoms, you may need a pericardiectomy. Medicines may help your symptoms if you have chronic constrictive pericarditis. Surgery may be advised when medical therapies can't resolve the condition.

In some cases, inflammation can cause a pericardial effusion. This is a buildup of fluid in the pericardium. This can make it hard for the heart to beat normally. You may need a pericardiectomy to drain this fluid and prevent it from coming back. In most cases, a pericardiectomy is only done if problems with fluid buildup occur again. A less invasive method is often used to drain the fluid the first time fluid builds up around the heart.

What are the risks of pericardiectomy?

All procedures have some risks. The risks of pericardiectomy include:

Abnormal heart rhythms, which can cause death in rare instances
Blood clot, which can lead to stroke or other problems
Complications from anesthesia
Death
Excess bleeding
Fluid buildup around the lungs
Heart attack
Infection
Low cardiac output syndrome
Pneumonia

Your own risks may vary according to your age, general health, and the reason for your procedure. They may also vary depending on the anatomy of the heart, fluid, and pericardium. Talk with your healthcare provider to find out what risks may apply to you.

How do I get ready for a pericardiectomy?

Ask your doctor how to get ready for pericardiectomy. Follow any directions you're given for not eating or drinking before the surgery. Ask the doctor if you need to stop taking any medicines before the surgery.

The doctor may want some extra tests before the surgery. These might include:

Chest X-ray
Electrocardiogram (ECG) to check the heart rhythm
Blood tests to assess general health
Echocardiogram, to view heart anatomy and blood flow through the heart
Imaging such as a CT scan or MRI if the doctor needs more information about the heart
Heart catheterization to measure the pressures inside the heart

Hair on and around the area of the operation may be removed ahead of time. About an hour before the surgery, you may be given medicines to help you relax.

What happens during a pericardiectomy?

Talk with the doctor about what to expect during the surgery. The details of your surgery will vary according to the exact kind of repair the doctor is doing. Usually, doctors do the repair without the use of a heart-lung machine (cardiopulmonary bypass). During the repair, the team will carefully monitor your vital signs. In general:

An anesthesiologist will give you general anesthesia before the surgery starts. You will sleep deeply and painlessly during the operation. You won’t remember it afterward.
The surgery will take several hours.
There are different types of procedures that may be done.
In some cases, the surgeon will make a vertical incision along the breastbone. This incision will be several inches long. To access the heart, the surgeon will separate the breastbone.
The doctor will surgically remove a large portion of the pericardium or the entire pericardium.
The doctor will do other repairs to the heart if needed.
The muscle and the skin incisions will be closed and a bandage will be applied.

What happens after a pericardiectomy?

Ask your doctor about what to expect after the procedure. In general, after your pericardiectomy:

You may be groggy and disoriented upon waking.
Your vital signs, such as your heart rate, blood pressure, breathing, and oxygen levels, will be closely monitored.
You may have a tube draining the fluid from your chest.
The drained fluid may be sent to a lab for analysis.
You may feel some soreness, but you shouldn’t feel severe pain. Pain medicines are available if needed.
Your heart symptoms will likely get better very soon after surgery.
You will probably be able to have liquids the day after surgery. You can have regular foods as soon as you can handle them.
You'll likely need to stay in the hospital at least a few days. This will partly depend on the reason you needed a pericardiectomy.

After you leave the hospital:

You'll likely have your stitches or staples removed at a follow-up appointment in 7 to 10 days. Be sure to keep all follow-up appointments.
You should be able to resume normal activities relatively soon, but you may be a little more tired for a while after the surgery. Ask your doctor when you can go back to all of your activities.
Ask the doctor if you have any exercise limitations. Avoid heavy lifting.
Call the doctor if you have fever, increased draining from the wound, increased chest pain, or any severe symptoms.
Follow all the instructions your healthcare provider gives you for medicines, exercise, diet, and wound care.