What are the steps for a pericardial (pericardium) window procedure?

From the Guidelines

The pericardial window procedure involves creating a communication between the pericardial space and the pleural cavity to drain pericardial effusions, typically performed by a cardiac surgeon, and can be achieved through various methods including video-assisted thoracoscopy or balloon pericardiotomy 1. The procedure is generally indicated for recurrent large effusions or cardiac tamponade, particularly in patients with neoplastic pericardial disease or those with reduced life expectancy, where a more complex operation like pericardiectomy is high-risk 1. Key steps in the procedure include:

• Patient preparation with general anesthesia, positioning, and sterile draping
• Making an incision, typically subxiphoid or through a left anterolateral thoracotomy approach
• Dissecting through tissue layers to identify and carefully open the pericardium
• Creating a "window" by excising a portion of the pericardium to allow continuous drainage into the pleural or peritoneal space
• Draining accumulated fluid and collecting it for diagnostic testing
• Placing a temporary drain tube to remove residual fluid, which is typically removed after 1-3 days when drainage becomes minimal
• Closing the incision in layers and monitoring the patient postoperatively for complications such as bleeding, infection, or cardiac injury 1. It's worth noting that while a pericardial window can provide palliative relief, the results may be less definitive compared to pericardiectomy, as the communication may close and recurrent effusions can occur 1.

From the Research

Pericardial Window Procedure Steps

The pericardial window procedure involves several steps to create a window in the pericardium, allowing for drainage of pericardial effusion. The steps may vary depending on the approach used, which can be percutaneous, video-assisted thoracoscopic, or surgical.

• Percutaneous Approach:
  • Puncture of the pericardial space is performed under ultrasound and fluoroscopic guidance 2.
  • A guidewire is advanced into the pericardial cavity, and the pericardial wall is identified.
  • The pericardial keyhole is dilated with a balloon catheter (e.g., 18 mm or 20 mm diameter) 2, 3.
  • A temporary pigtail catheter is inserted to stabilize the tract and aspirate the fluid 2.
• Video-Assisted Thoracoscopic Approach:
  • The procedure is performed under general anesthesia and single-lung ventilation using 2 to 3 trocars 4.
  • A pericardial window is created, allowing for excellent view of both the pleural cavity and pericardium.
  • Biopsy sites can be precisely selected for histologic examination 4.
• Surgical Approach:
  • A subxiphoid incision or thoracotomy can be used to access the pericardium 5, 6.
  • A pericardial window is created, and the effusion is drained.
  • The approach may vary depending on the patient's condition and the surgeon's preference.

Considerations and Outcomes

The choice of approach depends on various factors, including the patient's condition, the etiology of the pericardial effusion, and the surgeon's experience.

• Efficacy: Pericardial window creation can provide effective mid-term relief of pericardial effusion, with similar outcomes for subxiphoid and transpleural approaches 6.
• Complications: The procedures are generally safe, with minimal complications reported 2, 4, 3.
• Recurrence: The risk of pericardial effusion recurrence varies, with some studies reporting lower recurrence rates with video-assisted thoracoscopic approach 5.