What is the procedure for a pericardial window in an adult patient with recurrent or large pericardial effusions and significant symptoms?

Pericardial Window Procedure

Surgical Technique and Approach

The pericardial window procedure creates an opening from the pericardial space to either the pleural cavity or peritoneal cavity, allowing continuous drainage of pericardial fluid and preventing reaccumulation. 1

Primary Surgical Approaches

• Subxiphoid approach: The most commonly performed technique, creating a 3-cm window in the fused portion of the pericardium and diaphragm, typically performed under local anesthesia with sedation 2, 3
• Transpleural approach via left anterior thoracotomy or VATS: Creates a pleuropericardial communication, requires general anesthesia but provides excellent visualization 1, 4
• Both approaches demonstrate equivalent mid-term efficacy with no significant difference in freedom from recurrent effusion (69% at 5 years for both techniques) 4

Step-by-Step Procedural Details

For subxiphoid pericardial window:

• Access is obtained through a small incision below the xiphoid process 3
• The pericardium is identified and a 3-cm window is created in the diaphragmatic portion overlying the left lobe of the liver 2
• A drainage catheter (typically 8 Fr pigtail) is placed and left in position for an average of 5.6 days 3
• Initial drainage volume ranges from 200-2,000 mL, with continued drainage postoperatively 3
• The drain should remain in place for 3-5 days and until drainage falls below 25 mL per 24-hour period 5

For transpleural approach:

• Access via left minithoracotomy or VATS creates a window between pericardial and pleural spaces 1, 4
• Drain duration averages 4 days (shorter than subxiphoid approach) 4
• Allows for direct visualization and biopsy of pericardial tissue 1

Primary Indications

Pericardial window should be considered when:

• Recurrent large pericardial effusions have failed conservative management 6, 1
• Pericardiocentesis alone has been unsuccessful or effusion reaccumulates 6
• Malignant effusions require definitive palliative management 1, 2
• Drainage output remains >25 mL/day at 6-7 days post-pericardiocentesis 5
• Symptomatic moderate-to-large effusions are unresponsive to medical therapy 6

Outcomes and Efficacy

• Immediate symptom relief occurs in 96.7% of patients following drainage 3
• Recurrence rate is approximately 27-31%, which is significantly lower than pericardiocentesis alone (40-70% recurrence) 1, 7
• 30-day mortality ranges from 6.7-9%, though deaths are typically related to underlying disease rather than the procedure itself 2, 3
• Mid-term freedom from moderate or greater effusion recurrence is 69% at 5 years 4

Critical Contraindications and Caveats

Absolute contraindications:

• Purulent pericardial effusions (risk of spreading infection to pleural or peritoneal cavity) 1
• Aortic dissection with hemopericardium (except controlled minimal drainage as bridge to surgery) 5

Relative contraindications:

• Uncorrected coagulopathy or anticoagulant therapy 5
• Thrombocytopenia <50,000/mm³ 5
• Small posterior or loculated effusions 5

Important limitations:

• The created communication may close over time, especially with loculated effusions 1
• Less definitive than pericardiectomy but carries significantly lower surgical risk 1
• Surgical pericardiotomy does not improve clinical outcomes over pericardiocentesis and is associated with higher complication rates including myocardial laceration and pneumothorax 1

Etiology-Specific Considerations

For malignant effusions:

• Consider combining pericardial window with intrapericardial chemotherapy 1, 5
• Cisplatin is most effective for lung cancer involvement (93% free of recurrence at 3 months) 5
• Thiotepa is preferred for breast cancer metastases 5
• Patients with breast cancer have the longest survival after pericardial window 2
• Operative mortality in malignant effusions is 36.4%, but freedom from recurrence remains acceptable at 69% 4

For uremic effusions:

• Intensify hemodialysis alongside pericardial drainage 1

Comparison with Alternative Procedures

Percutaneous balloon pericardiotomy:

• Creates a non-surgical pericardial window using balloon dilating catheter (typically 18 mm) 7, 8
• Effective in 90-97% of cases for malignant effusions 5
• Should be avoided in neoplastic or purulent effusions due to risk of seeding 1
• Recurrence rate of 27% with mean follow-up of 147 days 7

Pericardiectomy:

• More definitive but carries higher surgical risk 1
• Reserved for constrictive pericarditis, frequent symptomatic recurrences resistant to medical treatment, or complications of previous procedures 5
• Rarely indicated as first-line treatment 1

Postoperative Management

• Monitor drain output every 4-6 hours 5
• Drain fluid in increments less than 1 liter to avoid acute right ventricular dilatation 5
• Continue drainage until output falls below 25 mL per 24-hour period 5
• If drainage remains >25 mL/day at 6-7 days, consider surgical pericardial window if not already performed 5
• Echocardiographic follow-up at 6-month intervals for moderate effusions, 3-6 months for large chronic effusions 5