Pericardial window is used diagnostically and, more often, therapeutically for drainage of accumulated pericardial fluid (a condition that most often occurs after cardiac surgery but has many other possible causes). The pericardium envelops the heart like a cocoon; its cardiac filling can be impaired when this cavity fills with excess fluid. When the limited space between the noncompliant pericardium and heart is acutely filled with blood or fluid, cardiac compression and tamponade may result. Pericardial window in combination with systemic chemotherapy may also prevent accumulation of large fluid volumes in patients with neoplastic pericardial disease.
Pericardial window involves the excision of a portion of the pericardium, which allows the effusion to drain continuously into the peritoneum or chest.
The fluid can be drained in any of 3 ways: via a small subxiphoid incision, thoracoscopically,
or via a thoracotomy.
The following are indications for a pericardial window
Symptomatic pericardial effusions
Asymptomatic pericardial effusions that warrant a pericardial window for diagnosis
Hemodynamically stable patients with an undiagnosed pericardial effusion (a thoracoscopic approach is ideal)
Coexisting pericardial, pleural, or pulmonary pathology that requires diagnosis or therapy (a thoracoscopic approach is ideal)
Known benign effusions that reaccumulate after aspiration
Drainage of a purulent pericardial effusion
Early fungal or tuberculous pericarditis in which resection of the pericardium is required to prevent future pericardial constriction
Use as part of the mediastinal debridement, in patients with descending mediastinitis
Loculated effusions situated unilaterally or posteriorly (more easily approached thoracoscopically)
Chylopericardium (thoracoscopic window and ligation of the thoracic duct)
Delayed hemopericardium or effusions after cardiac surgery (usually treated via a subxiphoid approach, but a thoracoscopic approach is also used)
An effusion in a patient with a substernal gastric or colonic conduit in whom a subxiphoid approach is not possible (an unusual indication for a thoracoscopic pericardial window)
The following is a contraindication for a pericardial window
Concomitant cardiac surgery necessitating a sternotomy for which a full pericardiotomy would be performed
The following technical points may improve the performance of pericardial window procedures:
If the patient is unstable, employ the subxiphoid approach
Use the Allis clamp to grasp the pericardium
Resect an adequate area of pericardium
Ensure that no undrained areas of the pericardial space remain by using a sucker to explore all areas