Pericardiectomy

Pericardiectomy refers to the surgical removal of the whole or part of the pericardium.

Pericardium is a two-walled sac present around the heart. It contains fluid that provides lubrication to the heart during its pumping movement. Additionally, pericardium protects the heart from diseases and infections. The pericardium also prevents the over-enlargement of the heart due to increased blood volume caused by conditions such as pregnancy, kidney failure, and so on.

In certain conditions like tuberculosis and bacterial/viral infections, the pericardial layer stiffens. This condition is called constrictive pericarditis - inflammation of the pericardial layer. Due to the condition, the heart is unable to expand as it normally does (while beating), thereby causing the blood to accumulate behind the heart, resulting in swelling and, ultimately, heart failure. 

Removal of the pericardium does not affect normal heart function.

A surgeon will recommend pericardiectomy to you if you have chronic constrictive pericarditis, which cannot be resolved/managed by medical treatment. The condition causes a sharp and stabbing chest pain that worsens when you try to swallow, cough, lie down in a flat position or take deep breaths. However, it goes away when you sit in an upright position or lean in the forward direction. Other symptoms of pericarditis are as follows:

• Dry cough
• Pain in the neck, back or left shoulder
• Difficulty in breathing while lying flat. You may be able to breathe better when you bend forward or hold your chest
• Fatigue
• Anxiety
• Swelling in the legs, feet and ankles
• Swelling in abdomen and lungs

This surgery may not be performed if you have any of the following conditions:

• Myocardial atrophy (loss or shrinkage of heart muscles)
• Perimyocardial fibrosis (thickening of pericardium)

The surgeon will enquire about the following things before the surgery:

• Details/status of your pregnancy
• All prescription and non-prescription medicines, supplements or herbs you are taking.

The following preparations will need to be done before the surgery:

• The surgeon may ask you not to take certain medicines such as aspirin or blood-thinning medicines, which can interfere with blood clotting.
• You will be provided with a list of medicines that you should take on the day of surgery.
• If you are a smoker, you will be asked to stop smoking as it can cause complications during and after surgery.

The hospital staff may perform some of the following medical tests and procedures as a part of the pre-operative assessment:

• Blood tests (to examine your general health)
• Chest x-ray (to check the internal structures of your chest)
• Electrocardiogram (to examine and detect your heart rhythm)
• Heart catheterisation (to examine the working of your heart)
• Echocardiogram (to look at the structure of your heart and blood flow within it)
• Other imaging tests such as computed tomography or magnetic resonance imaging to obtain more information about your heart.

You may be admitted a day before the surgery. After admission to the hospital:

• The medical team looking after your surgery will discuss the procedure with you.
• Your hair on the area of surgery will be removed and an antiseptic solution will be used to clean the surgical site to prevent the risk of infection.
• The medical staff will conduct some medical tests, if necessary.
• You will not be allowed to eat or drink anything after midnight prior to the day of surgery.

On the day of the surgery:

• A doctor will visit you about an hour before the surgery and provide you medicines to help you relax.
• You will be asked to remove any jewellery, dentures, watch, glasses, contact lenses and other personal items.
• The hospital staff will then shift you to the operating room.

The procedure for the surgery usually involves the following steps:

• An anesthesiologist will administer you with general anaesthesia/medicines that will put you into a deep sleep.
• Thereafter, the surgeon will make a cut in the vertical position, a few inches long, over the flat bone at the centre of your chest (breastbone or sternum). 
• He/she will separate your sternum to access your heart.
• Then, the surgeon will remove the affected part or your entire pericardium as required. If needed, other repairs will be performed as well.
• After this, the surgeon will join and put back your sternum to its original place.
• He/she will also place a tube in your chest to drain out fluids, stitch together your muscles and skin and cover the operated area with a bandage.

You might need hospitalisation for five to seven days after the surgery. During your stay at the hospital:

• You will feel dizzy and confused for a while after waking up from the surgery. 
• The medical team will closely observe your vital signs such as oxygen levels, breathing, blood pressure and heart rate during after the surgery.
• The fluid drained from your chest will be sent to the laboratory for examination.
• You may feel sore at the site of the surgery. The surgeon will prescribe pain medicines for the same.
• You will have a liquid diet for a day after the surgery. You can start eating solid foods as soon as you start feeling comfortable.

About six to eight weeks are required for a complete recovery after a pericardiectomy. However, the recovery period depends on your condition before the surgery. Some individuals may need more than eight weeks to recover.

The following self-care may be recommended after this surgery:

• Cleaning your wound: You should gently clean/wash the site of surgery with mild soap and water. Avoid scrubbing or rubbing your wound.
• Discomfort: You may experience stiffness around the operated area in the morning or due to weather changes. The surgeon may prescribe some pain medications for the same. You can also apply gentle heat on the operating site for some relief.
• Physical therapist: You may be referred to a physical therapist who will teach you some exercises to perform during the recovery period. These exercises will help you in returning to your normal activity levels.
• Lifting heavy objects: Avoid lifting objects that weigh over 4.5 kg for six weeks post-surgery as it can delay the healing process of your chest bone and cause discomfort.
• Smoking: Avoid smoking for as long as your doctor asks you to as it can slow down your recovery.
• Climbing stairs: During the first week after surgery, climb stairs only if it is essential. Inform your physical therapist if you have to climb stairs at home.
• Sexual activity: Resume sexual activity only if you can effortlessly climb about two flights of stairs without getting tired. 
• Driving: Avoid driving for at least four to six weeks after surgery. Resume driving only after a proper discussion with the surgeon.
• Work: The surgeon may advise you to rest for at least three months after surgery before resuming work. However, the period varies with the nature of your work.

The benefits of pericardiectomy are:

• Relief from symptoms
• Prevents worsening of the disease
• Increases the chances of survival

When to see the doctor?

You should inform/contact the hospital immediately if you have any of the following symptoms after surgery:

• Increased pain in the chest
• Increase in drainage from the wound
• Fever
• Increased heart rate
• Difficulty breathing

This surgery is associated with the following risks:

• Blood clot that can cause other problems like stroke
• Irregular heart rhythm
• Accumulation of fluids around the lungs
• Infection
• Heart attack
• Pneumonia
• Decreased quantity of blood pumped by the heart
• Complications of general anaesthesia such as drug allergy, confusion and damage to the vocal cords
• Death

You may be asked to visit the surgeon a week or 10 days later to get the stitched removed. You may also need to visit the hospital six weeks after surgery for an electrocardiogram to check the working of your heart.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.