Pericardiectomy (removal of Pericardium)

Pericardiectomy is the surgical removal of a portion or all of the pericardium. It is also called pericardial stripping. The pericardium is a double-walled, membrane sac that surrounds the heart. It contains a small amount of fluid that lubricates the heart during its regular pumping movements within the pericardium.

The heart can function without the pericardium, and in many cases, this membrane around the heart can be safely removed to provide relief from constrictive pericarditis and certain other cardiac conditions.

The prognosis or outlook after pericardiectomy depends on the cause of the constrictive pericarditis or other heart condition, as well as the age and overall health of the person. Many people can enjoy a full life after pericardiectomy.
However, since pericardiectomy is a major surgical procedure that is performed under general anesthesia, it does carry risks, and complications are possible. As a result, it is typically only performed when other treatment options have been unsuccessful.

When is a pericardiectomy performed?

Chronic constrictive pericarditisA pericardiectomy is typically performed to treat cases of chronic constrictive pericarditis that have proven unresponsive to other types of treatment. Pericardium removal is not usually recommended for patients experiencing a first bout of pericarditis.

Constrictive pericarditis may be caused by, among other agents:

  • Viral or bacterial infections, including tuberculosis (TB)
  • Cancer
  • Inflammation of the pericardial sac due to a heart attack
  • Complications related to surgery
  • Radiation therapy
  • Adverse reactions to certain medicines
  • Autoimmune conditions
  • Systemic diseases like hypothyroidism

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

Other types of pericarditis

Pericardium removal surgery is not only used in cases of chronic constrictive pericarditis. A pericardiectomy may also be performed to treat different kinds of recurrent pericarditis – including those that cause a significant accumulation of pericardial fluid (effusion) – to provide relief from symptoms (such as chest pain) and improve the functioning of the heart.

Preparing for a pericardiectomy

A doctor will advise on how to prepare for cardiac surgery. The person may be asked to refrain from eating or drinking for a period of time before the procedure, as well as to stop taking certain medications. Some tests may be done before the pericardiectomy, including:

  • Blood tests: To check the general health of the person.
  • Chest X-ray: To check for abnormalities in the heart and lungs.
  • Electrocardiogram (ECG): Measurement of the heart’s electrical activity, to detect abnormal heart rhythms, known as arrhythmias, and other irregularities.
  • Echocardiogram: An ultrasound scan, used to check the size and shape of the heart, its blood flow, and whether any effusions are present.
  • CT scan: A computed tomography (CT) scan, uses X-rays to provide a detailed image of the heart and any effusions.
  • MRI: A magnetic resonance imaging (MRI) test, uses magnets and radio waves to provide a comprehensive picture of the heart and effusions.

These tests are used to help the medical team understand the person’s condition, to confirm that the person can undergo surgery safely and to identify any issues that could complicate the pericardiectomy procedure.

What to expect during pericardiectomy surgery

The doctor will explain the details of the pericardiectomy procedure before starting, and a general anesthetic will be administered so that that the person undergoing surgery will be in a state of controlled unconsciousness. The surgery may take several hours to complete. The surgeon will typically make an incision through the breastbone and carefully remove part or all of the pericardium. If all or almost all of the membrane is removed, it may be called a total, complete or radical pericardiectomy. The incision will then be closed up and dressed, and the anesthesia will be reversed so that the person wakes up.

After pericardiectomy: postoperative care and recovery

After the surgery, it is reasonable to feel groggy and a little disoriented. A doctor will monitor blood pressure, heart rate, and other vital signs, and a drainage tube will be inserted into the chest to remove excess fluid. Side-effects may include some pain, but it is unlikely to be severe. The doctor will provide painkillers and other medication as required, and advise on when liquids and food can be reintroduced.

A pericardiectomy is a major surgical procedure that will typically require a hospital stay of five to seven days. The person will generally be advised to avoid heavy lifting in the recovery stage, which may take up to two months. Feelings of tiredness may be experienced during the recovery period, and exercise may have to be limited, though it should be possible to resume many daily activities quite quickly after the surgery.

The doctor may schedule follow-up appointments to remove any stitches and check the functioning of the heart. Additionally, a person’s heart medication may need to be adjusted after the surgery. If there is a fever, increased chest pain, unusual draining from the wound, or any other symptoms during the recovery period, it is advisable to consult a doctor immediately.

Pericardiectomy risks and complications

Like all types of surgery, pericardiectomy carries certain risks and may result in complications. These include:

  • Bleeding
  • Abnormal heart rhythm
  • Infection
  • Pneumonia
  • Low cardiac output syndrome, where the heart is unable to supply the body with sufficient oxygen
  • A blocked blood vessel, in which case an additional technique called cardiopulmonary bypass may be required to maintain blood flow
  • Postpericardiotomy syndrome (see below)
  • Mortality (death)

Postpericardiotomy syndrome

Postpericardiotomy syndrome is a possible complication of cardiac surgery, including a pericardiotomy or pericardiectomy procedure.

Postpericardiotomy syndrome is understood to be an immune reaction that can occur a few days to a few months after heart surgery, injury to the heart, or a heart attack. It is characterized by chest pain and fever. In rare cases, postpericardiotomy syndrome can lead to severe complications.

If the postpericardiotomy syndrome is suspected, medical advice should be sought without delay. Treatment is possible and may include anti-inflammatory medicines such as NSAIDs and colchicine, or a course of steroid medication.

Pleurodesis

Pleurodesis is a procedure that uses medicine to adhere to your lung to your chest wall. It seals up the space between the outer lining of your lung and chest wall (pleural cavity) to prevent fluid or air from continually building up around your lungs.

What’s the purpose of pleurodesis?

You may need pleurodesis if you’ve had a recurring collapsed lung (pneumothorax) or an ongoing buildup of fluid around your lungs (pleural effusion). Usually, you have a little bit of fluid in the pleural cavity — the space between your chest wall and lungs. When there’s too much fluid in that space, your lungs can’t properly expand.

A variety of conditions can cause extra fluid to collect in the pleural cavity, including:

  • heart failure
  • pneumonia
  • tuberculosis
  • cancer
  • liver and kidney disease
  • inflammation of the pancreas
  • rheumatoid arthritis

The buildup of fluid can cause symptoms like pain, coughing, and shortness of breath.

In pleurodesis, your doctor injects a medicine (such as a talc mixture) into space between your lung and chest wall. There are a variety of substances that can be used. The medicine irritates and inflames the tissue, producing scar tissue that makes the lung stick to the chest wall.

By adhering the lung to the chest wall, pleurodesis eliminates the space where fluid or air could collect. It also helps to keep the lung inflated.

Procedure details

Pleurodesis may be done on its own, or together with a procedure to drain air or fluid from around your lungs (thoracostomy or thoracoscopy).

If you only have pleurodesis, it may be done in your hospital room.

During a pleurodesis procedure:

  • You’ll get medicine to control your pain and relax you.
  • The chosen medication for pleurodesis will be injected into your chest via a tube.
  • You may need to change position about once every 10 minutes or so to ensure the medicine reaches every part of your chest cavity.
    If you have pleurodesis with thoracostomy or thoracoscopy, it will be done in an operating room under anesthesia.
    During the procedure:
  • You’ll get medicine to prevent pain and relax you.
  • The doctor will use a local anesthetic to numb the area of your chest where the incision will be made. That area of skin will also be sterilized.
  • The doctor will make a small incision and insert a camera for surgery or a narrow tube called a chest tube. Then the fluid will be drained into a collection bag.
  • Once the fluid has been drained, talc powder, doxycycline, or another medicine will be injected into the pleural space through the chest tube. The medicine will coat the outside of your lung and create a sticky surface that makes it adhere to the chest wall.
  • Your doctor might do an X-ray to confirm that the procedure was successful.

A possible alternative to this procedure is a catheter placement. It allows you to go home with a tube much smaller than a chest tube, and also continually drains. Your doctor can discuss the pros and cons of a catheter versus the above procedure.

Recovering from pleurodesis

The chest tube will stay in place for 24 to 48 hours, or until your lung has stuck to your chest cavity. If you had a surgical procedure, you might have to stay in the hospital for a few days. You’ll get regular X-rays to check your progress.

After the chest tube is removed, you’ll need to keep the wound clean. Wash it every day with mild soap and pat it dry.

You may notice some drainage from the wound for a day or two. Keep a bandage over it until it stops draining. Change the dressing at least every day.

Follow all wound care and follow up instructions given to you. Here’s what you shouldn’t do after your procedure:

  • Don’t rub the wound. This can slow your healing.
  • Don’t put any ointment, lotion, or powder on the incision.
  • Don’t take a bath, swim, or sit in a hot tub until the incision has fully healed.
  • Don’t take nonsteroidal anti-inflammatory drugs (NSAIDs) for at least seven days after pleurodesis. These drugs can prevent lung surfaces from sticking together. Ask your doctor what medicines you can take instead to control your pain.
  • Don’t lift objects that weigh more than 10 pounds until you get approval from your doctor.
  • Avoid straining or holding your breath.
    Potential complications of pleurodesis
    Risks of the procedure include:
  • infection
  • a collection of pus in the pleural space (empyema)
  • fever
  • pain
    If you also have a thoracostomy, possible complications can include:
  • collapsed lung
  • injury to the chest wall, arteries, or lungs
  • blood clots
  • a tube that moves out of place

Pleurodesis is generally an effective procedure. However, there’s a small chance that the procedure won’t work, and you’ll need to undergo another surgery.