In the case of a diseased pericardium, such as pericardial mesothelioma, or to prevent or manage advanced spread of another malignancy, such as malignant pleural mesothelioma, one surgical option available is a pericardiectomy. The function of the surgery is to remove the heart sac, known as the pericardium, to relieve a patient’s symptoms and increase their life expectancy. Common symptoms that a pericardiectomy can help to improve include chest pain, difficulty breathing, fatigue, and peripheral swelling.
The procedure can be used to treat excessive, recurrent, and severe fluid build-up within the pericardial cavity (pericardial effusion) that cannot be drained with less invasive treatments such as pericardiocentesis or percutaneous balloon pericardiotomy. Pericardiectomy can also be used to treat chronic inflammation and scarring of the pericardial tissue (constrictive pericarditis) that has failed medical treatment.1
When conditions such as recurrent, severe pericardial effusion or constrictive pericarditis are detected, it is imperative that they are treated as quickly as possible to prevent them from progressing to potentially fatal consequences. Untreated pericardial effusion can result in cardiac tamponade, a life-threatening compression of the heart that can deteriorate into cardiogenic shock, cardiovascular collapse, cardiac arrest, multiorgan failure, and ultimately, death.2
A pericardiectomy can either be partial, such as a pericardial window, where only a portion of the pericardium is removed through a minimally invasive surgery, or total, where as much of the heart sac is removed as possible through open chest surgery. In cases of primary malignant pericardial mesothelioma, a successful pericardiectomy can significantly improve a patient’s quality of life and life-expectancy.
Pericardiectomy: What to Expect
The patient must refrain from eating or drinking after midnight the day of the surgery. They are placed on an IV to ensure any needed medications or fluids can be administered if required during the surgery. Pericardiectomy takes several hours to complete and will require the patient to remain under general anesthesia for the entire operation. A catheter is placed in the patient’s bladder to drain urine.
The surgeon will usually begin by making an incision along the sternum, spreading the sternum apart with a saw to have direct access to the chest cavity and heart. Sometimes, the surgeon can perform the surgery much less invasively by making several small incisions in the chest and using video-assisted thorascopy (VAT) and special surgical instruments to visualize and access the heart. The pericardium is then slowly stripped from the rest of the heart and removed. During this time, the surgeon will also drain any excessive fluid found within the pericardium or surrounding area and remove any visible tumors that they can access. Once the surgeon is satisfied that all cancerous material has been removed, the sternum is bound together with wires and screws or bone cement, a chest tube is placed to drain excess fluid and blood, and the incision area is closed and sutured.
Recovery from Pericardiectomy
Once the operation has been completed, recovery begins in the surgical intensive care unit (ICU) for a day. The tube for chest drainage remains in place if needed to prevent excessive fluid buildup. Medicine and food are provided intravenously.
Within a day, the patient is usually able to leave the ICU and continue recovering in a regular hospital room. During this time, their care plan focuses on reducing and relieving pain; monitoring breathing, oxygen levels, blood pressure, and heart rate, and maintaining a high level of mobility to prevent blood clots from developing.
Patients are usually able to go home seven days after the surgery, which is also around the time their stiches or staples are removed. If complications arise, the patient may be required to remain in the hospital longer until they have been successfully treated. A patient’s surgeon will advise them to abstain from heavy lifting and avoid strenuous activity until they are satisfied with the patient’s recuperation. While taking narcotic pain medication, the patient must also abstain from driving. A full recovery from surgery usually takes six to eight weeks. Follow-up care with the surgeon who performed the procedure occurs during this time.
Risks and Possible Complications of Pericardiectomy
As with all surgical procedures, there is the possibility of complications developing from the surgery. In addition to the risks of pain, bleeding, and a possible adverse reaction to anesthesia, some of the complications that may affect patients who have had a pericardiectomy include
- Excessive bleeding
- Blood clot
- Pulmonary edema: accumulation of fluid in the lungs
- Infection in or around the surgical site
- Pneumonia: infection of the lungs
- Arrhythmia: abnormal heart rhythm
- Myocardial infarction: heart attack
- Low cardiac output syndrome: a potentially life-threatening decrease in heart function that results in inadequate oxygen delivery to the rest of the body’s organs
Benefits of Pericardiectomy
A pericardiectomy can be used to significantly improve a patient’s symptoms and their prognosis, depending on their health status. If the cancer has metastasized and spread to other locations, a pericardiectomy is performed to improve the patient’s comfort and quality of life, only, not to extend their life.
For patients with an early-stage diagnosis, a pericardiectomy may have more significant curative results. By performing the surgery within a multimodal treatment plan (e.g., combining it with other treatments such as chemotherapy and immunotherapy), there is an increased chance of achieving cancer remission.
Finding a Surgeon
The rarity of pericardial mesothelioma makes finding an appropriate surgical specialist difficult. Most pericardiectomies are performed by cardiothoracic surgeons who are specialists in heart-based procedures. When looking for an experienced surgeon, patients should find out how many of these particular surgeries the surgeon has performed and the surgeon’s comfort level with the procedure. Some medical facilities and hospitals have more experience performing pericardiectomies than others.3