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Pericardiotomy
Last reviewed: 06.07.2025
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Surgical dissection, that is, opening the fibrous membrane surrounding the heart - the pericardium, is defined as pericardiotomy, which provides access to the heart during surgical interventions.
Indications for the procedure
In cardiac surgery, access to the heart by opening the pericardium and the hermetic pericardial cavity (a slit-like space between the epicardium and pericardium) is necessary:
- in cases of damage to the myocardium and cardiac conduction system of any etiology;
- if it is necessary to correct anatomical abnormalities of the heart, for example, a defect in the interventricular septum (its hypertrophy or non-closure), aortic defects, abnormalities of the atrioventricular valves, etc.;
- during resuscitation thoracotomy (opening of the chest) - when there is compression of the lung behind the heart;
- in the presence of myocardial bulging - cardiac aneurysm;
- for performing coronary artery bypass grafting;
- if removal of benign cardiac tumors is necessary;
- in case of severe prolapse and severe stenosis of the mitral or tricuspid valve, requiring their reconstruction or replacement;
- due to inflammation of the pericardium – pericarditis, primarily purulent, constrictive and adhesive (with the formation of adhesions between the pericardium and epicardium).
In acute cardiac injuries, in particular, combined thoracoabdominal injuries, urgent pericardiotomy can be performed for diagnostic purposes: in the form of a pericardial window - transdiaphragmatic or subxiphoid - under the xiphoid process (processus xiphoideus) of the sternum. [ 1 ]
In addition, the indication for this surgical manipulation may be an excess amount of fluid in the pericardium of the heart (hydropericardium) or accumulation of blood in it - hemopericardium of the heart. But to decompress the pericardium and remove pericardial effusion by aspiration, in most cases a puncture is performed, that is, a puncture of the pericardium, pericardiocentesis.
Preparation
In essence, the preparation is not for pericardiotomy, but for a specific operation (depending on the diagnosis), which requires access to the heart, and patients are prepared for it in advance (excluding acute and emergency cases).
Hospitalized patients undergo blood tests (clinical, biochemical, coagulogram) and urine (general), and also undergo a heart examination, which includes: electrocardiography (ECG); ultrasound of the heart - echocardiography; MRI of the mediastinal organs; X-ray or ultrasound of the blood vessels of the heart. [ 2 ]
10-12 hours before the operation, food intake is stopped, only water is allowed. The procedure requires general anesthesia, so the patient must meet with an anesthesiologist to determine the most suitable painkiller and how to use it, as well as a means for preliminary sedation. On the morning of the operation, the patient's intestines are cleaned with an enema, after which a shower is taken. [ 3 ]
If the patient has a history of thrombophlebitis or varicose veins, the shins are bandaged with an elastic bandage.
Technique pericardiotomies
Several techniques are used to dissect the pericardial sac. Thus, during anterior pericardiotomy during cardiac surgery, a vertical dissection of the sternum is first performed (median sternotomy), and then the anterior surface of the pericardium is dissected in the area where the parietal pleura adjoins the mediastinum.
In a substernal pericardiotomy, the cardiac surgeon cuts the skin and subcutaneous tissue vertically above the xiphoid process, and the incision is made under the floor of the chest cavity - above the upper part of the dome of the diaphragmatic septum between the thoracic and abdominal cavities. Depending on the purpose of the operation, the xiphoid process may be excised. [ 4 ]
A right vertical pericardiotomy is performed downward on the right side, parallel to the point where the pericardium overlaps the diaphragm, toward the inferior vena cava.
The technique of subxiphoid pericardiotomy involves a vertical incision (5-8 cm) from the distal end of the sternum. The xiphoid process is then lifted, grasped with a clamp, and the attachment of the diaphragm to the sternum and the anterior part of the diaphragm itself are dissected and retracted. The pericardium is thus visualized, and the surgeon makes a vertical incision in it. [ 5 ]
The opening of the pericardial sac during transdiaphragmatic pericardiotomy is preceded by such manipulations as a vertical incision along the midline of the tendinous part of the diaphragm and its downward displacement, as well as separation of the pericardium from the pleura. [ 6 ]
Extrapleural pericardiotomy (according to Mintz) is performed on the anterior surface of the pericardium - with the imposition of fixing sutures and an incision between the sutures. And access to the pericardium is performed by longitudinal dissection from the xiphoid process along the upper edge of the oblique abdominal muscle - along the lower edge of the cartilage of the 7th rib (with resection of part of it), dissection of the perichondrium and separation of the costal part of the diaphragm at the site of its attachment.
Consequences after the procedure
Possible consequences after pericardiotomy may manifest as the formation of pleural effusion and effusion into the pericardial cavity; pericardial tamponade; the appearance of intrapericardial adhesions, which negatively affect the functioning of the heart and coronary circulation. [ 7 ]
Surgeons also note the development of postpericardiotomy syndrome, caused by an immune-mediated reaction to damage to the pericardium or myocardium, which manifests itself as fever, chest pain, vomiting, liver enlargement, hypotension, and tachycardia. Sometimes this condition progresses to cardiac tamponade.
Complications after the procedure
Complications of pericardiotomy depend on the purpose and outcome of the operation during which access to the heart was performed. In most cases, they are associated with chest pain; infection; bleeding; impaired lung function due to the development of atelectasis; accumulation of blood (hemothorax) or air (pneumothorax) in the pleural cavity. The development of postoperative pericarditis is also possible.
In addition, some patients experience poor healing of the severed sternum.[ 8 ]
Care after the procedure
Care and rehabilitation after surgery, part of which is pericardiotomy, consists of antiseptic treatment of the postoperative wound on the chest to prevent its infection, which causes hyperemia, swelling, increased pain, and bloody discharge. If such symptoms appear, antibiotic treatment is prescribed.
Daily measurement of body temperature is mandatory. In case of pain, the doctor prescribes painkillers. [ 9 ]
You can take a shower no earlier than ten days after the operation. And physical activity after heart and coronary vessel operations should be dosed and correspond to the condition; patients receive individual recommendations from a physiotherapist.
It is recommended to follow a diet after surgery.
After sternotomy, the sternum heals differently in each patient – from two to four months, and during this time, you should avoid putting stress on the chest, including lifting heavy objects (maximum 2-3 kg), driving, or swimming.