Pericardiectomy

Overview

Pericardiectomy, or pericardial stripping, is the surgical removal of part or all of the pericardium, a double-walled membrane sac surrounding the heart, holding fluid that lubricates the heart as it pumps. It protects the heart from infection, holds it in place, prevents it from expanding too much and keeps it functioning normally when blood volume increases due to conditions such as kidney failure or pregnancy. However, a heart can function normally without it.

A pericardiectomy usually is performed to treat constrictive pericarditis, a condition in which the pericardium becomes stiff and calcified, preventing the heart from expanding normally. The heart chambers then fill incompletely with blood, which backs up behind the heart, causing it to swell. Heart failure symptoms may develop. Pericardiectomy also can treat patients who have recurrent symptoms and complications from anti-inflammatory medications including steroids.

If the pericardium already is unable to lubricate, removing it does not cause problems if the patient’s lungs and diaphragm are intact and functioning normally.

More than two decades ago, most constrictive pericarditis cases were idiopathic; i.e., its cause was unknown. Now we know that previous heart surgery and radiation to the chest are leading causes of constrictive pericarditis. Others include:

  • Diseases such as tuberculosis and mesothelioma
  • Viral or bacterial infection
  • Surgical complications

Our approach

Patients with less severe pericardium constriction may be treated with anti-inflammatory medications. Transient constriction, a syndrome that appears fairly quickly (sooner than six months), may be a result of inflammation of the pericardium, and may be treated with medication. Minimally invasive surgery is not recommended, as it is not safe.

Surgery is the best option for advanced cases. A pericardiectomy is performed by a cardiothoracic surgeon, who works with heart specialists, including cardiologists and radiologists, to diagnose the problem and devise individual treatment.

Pericardiectomy is performed via a median sternotomy, which is an incision through the breastbone (sternum) that allows the surgeon to reach the heart. The surgeon removes the pericardium, wires the breastbone and ribs back together and stiches the incision closed. A thoracotomy, in which a surgeon cuts into the pleural area of the chest, is another approach.

Risks

Pericardiectomy is a major cardiac surgery procedure. Risks include the need for cardiopulmonary bypass or blood transfusion during surgery, bleeding complications or death. Older patients, women and patients with other medical problems are at greater risk for complications.

Results

A hospital stay of five to seven days is normal. When they get home, patients can pursue their usual activities, except for lifting. Recovery can take six to eight weeks, depending on how serious the patient’s condition was. For some, recovery can take longer. Patients with severe pericardial constriction but no other heart or lung disease may feel improvement soon after surgery. Patients should see their cardiologist for an echocardiogram six weeks after surgery, and then at specific intervals. Scar tissue will form around the heart and possibly between the heart and lungs or diaphragm; because of this, future heart surgeries may be difficult, but not impossible.

The highest long-term survival rate is for patients with idiopathic constrictive pericarditis. Younger patients and healthier patients have better survival rates than patients with other medical conditions.

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