What is a pericardial window?

Pericardial Window: A Surgical Procedure for Managing Pericardial Effusions

A pericardial window is a cardiac surgical procedure that creates a communication between the pericardial space and the pleural cavity to allow drainage of pericardial effusions, primarily to prevent cardiac tamponade. 1

Definition and Purpose

• A pericardial window creates an opening from the pericardial space to the pleural cavity, allowing continuous drainage of pericardial fluid into the chest cavity 1
• The primary purpose is to prevent accumulation of large pericardial effusions and subsequent cardiac tamponade 1
• It serves as both a diagnostic and therapeutic intervention, especially in cases of recurrent effusions 1

Procedural Approaches

There are several techniques to create a pericardial window:

• Surgical approach: Traditionally performed by a cardiac surgeon through a subxiphoid or transthoracic approach 1, 2
• Video-assisted thoracoscopy (VATS): Minimally invasive approach with comparable efficacy to open surgical techniques 1, 3
• Percutaneous balloon pericardiotomy: Creates a window using balloon dilation under fluoroscopic guidance 4
• Laparoscopic pericardio-peritoneal window: Creates drainage from pericardium to peritoneum rather than pleural space 5

Primary Indications

• Recurrent large pericardial effusions that have failed conservative management 1
• Cardiac tamponade, especially in patients with malignant effusions 1, 6
• Palliative management in patients with reduced life expectancy (e.g., neoplastic pericardial disease) 1
• High-risk patients who cannot tolerate more complex operations like pericardiectomy 1

Efficacy and Outcomes

• Success rates for preventing recurrent effusions range from 69-90%, depending on etiology and technique 2
• Pericardial windows provide effective mid-term relief of pericardial effusion 2
• Both subxiphoid and transpleural approaches show equivalent mid-term efficacy 2
• Laparoscopic approaches have shown good outcomes with mean operative times of approximately 40 minutes 5

Limitations and Considerations

• The communication created may close over time, especially with loculated effusions 1
• Recurrent effusions may still occur and require additional interventions 1
• Less definitive than pericardiectomy, which is a more complex but complete operation 1
• Should be avoided in purulent effusions due to risk of spreading infection 1
• For neoplastic effusions, consider combining with intrapericardial chemotherapy (cisplatin or thiotepa) 1

Comparison with Pericardiectomy

• Pericardiectomy involves removal of the pericardium rather than creating a window 1
• Pericardiectomy is the treatment of choice for constrictive pericarditis 1
• Pericardial window is less invasive and preferred for high-risk patients or those with limited life expectancy 1
• Pericardiectomy provides more definitive treatment but carries higher surgical risk 1

Special Considerations

• In malignant effusions, patients have acceptable operative mortality with low incidence of recurrent effusion, supporting palliative indications 2
• For uremic pericardial effusions, consider intensified hemodialysis alongside pericardial drainage 1
• Balloon pericardiotomy should be avoided in neoplastic or purulent effusions 1