Pericardiectomy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Hafiz M. Ahmed, M.D.[2]

Synonyms and keywords: Pericardial stripping; pericardial excision

Overview

Pericardiectomy is the surgical removal of part or most of the pericardium. This operation is most commonly performed to relieve constrictive pericarditis or to remove a pericardium that is calcified and fibrous. It may also be considered as a last-resort option for recurrent or incessant pericarditis that is refractory to all medical therapies. Constrictive pericarditis is a progressive disease without spontaneous reversal of pericardial thickening. Some patients can be medically managed for several years. Edema can be controlled with diuretics and slowing the heart rate can maximize the diastolic filling time. Many patients eventually develop significant debility from impaired cardiac output and elevated right and left sided filling pressures. The definitive treatment for chronic permanent constrictive pericarditis is pericardiectomy, also known as pericardial stripping. The 2025 ACC Expert Consensus Statement specifies that radical pericardiectomy on cardiopulmonary bypass is the recommended surgical approach, and that partial pericardiectomy is not recommended due to the risk of incomplete relief and recurrent constriction. This procedure should be performed at a high-volume experienced pericardial surgical center. Due to the significant risks involved, many patients are initially treated medically, with judicious use of diuretics, and surgery is reserved for those with persistent symptoms despite optimal medical therapy.

Indications

The indications for pericardiectomy include:

• Chronic permanent constrictive pericarditis causing hemodynamically significant symptoms despite medical therapy.
• Recurrent or incessant pericarditis that is refractory to all pharmacologic therapies (including NSAIDs, colchicine, anti-IL-1 agents, and corticosteroids), or in patients who have contraindications to continued medical therapy, or who desire pregnancy and need to discontinue anti-inflammatory medications.
• Effusive-constrictive pericarditis with persistent constriction after pericardiocentesis.

Before proceeding with pericardiectomy for constrictive pericarditis, it is important to distinguish chronic permanent constriction from transient constrictive pericarditis, which may resolve with anti-inflammatory therapy alone. Transient constriction should be suspected when there is concomitant evidence of pericardial inflammation (elevated CRP, pericardial enhancement on CT or CMR). A trial of anti-inflammatory therapy (typically 2 to 3 months) is reasonable before committing to surgery in such cases. Anti-inflammatory medications may be continued until surgery and for 3 to 6 months postoperatively if active inflammation persists .

Procedure

The procedure begins when the surgeon makes an incision in the skin over the sternum and divides it to expose the pericardium. During the surgery, the surgeon will grasp the pericardium surrounding the heart, and will remove the fibrous, calcified or infected tissue covering of the heart. Once the pericardium is removed, the surgeon will wire the sternum back together, the incision is closed, and the procedure is completed. The 2025 ACC Expert Consensus Statement recommends radical pericardiectomy on cardiopulmonary bypass rather than partial pericardiectomy, as incomplete pericardial removal is associated with persistent or recurrent constriction .

Complications

The procedure has significant risks involved, with mortality rates of 6%-12% in major referral centers. The procedure can be complicated by perforation or tearing of the heart muscle if the heart muscle is tightly adherent to the pericardium. Stated simply, removal of the pericardium can remove the densely adherent heart muscle itself which is a catastrophic complication.

The high risk of the procedure is attributed to adherence of the thickened pericardium to the myocardium and coronary arteries. In patients who have undergone coronary artery bypass surgery with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium. Given the thin wall of the right ventricle, this can be a dangerous procedure and should only be undertaken if the patient's symptoms are incapacitating.

Prognosis and Long Term Outcomes Following Pericardiectomy

If any pericardium is not removed, it is possible for bands of pericardium to cause localized constriction which may cause symptoms and signs consistent with constriction. Some patients do not have complete relief of symptoms and up to 60% will have at least echocardiographic evidence of a restrictive filling pattern at approximately 2 years. Radiation induced disease seems to have a worse prognosis for improvement in functional class. The 5 and 10-year survival after pericardiectomy is 78% and 57% respectively, but is obviously highly correlated with the underlying illness.

Outcomes are generally worse in patients with radiation-induced constrictive pericarditis compared with idiopathic or post-surgical etiologies, largely due to co-existing radiation-induced myocardial fibrosis. The 2025 ACC Expert Consensus Statement emphasizes that pericardiectomy should be performed at high-volume experienced centers, as surgical volume and institutional expertise are associated with improved outcomes.

Special Patient Groups

Pericardiectomy in Patients with Tuberculous Pericarditis

Pericardiectomy may be used in treatment of recurrent pericardial efussion due to TB, in tuberculous constrictive pericarditis, or if there is no hemodynamic and general improvement after 4-8 weeks following antituberculosis chemotherapy. If it is performed in the early stages of TB pericardial constriction, pericardiectomy has a low mortality rate when compared to advanced stages of the disease where pericardiectomy is poorly tolerated. Mortality rate secondary to this procedure is 3-16%. This surgery should be undertaken under the coverage of antitubercular drugs.

Treatment of effusive constrictive pericarditis is challenging because pericardiocentesis does not relieve the impaired filling of the heart, and surgical removal of the fibrinous exudate coating the visceral pericardium may not be possible. Patients should be started on antitubercular drugs and serial echocardiography should be performed to monitor the changes of pericardium and to make a decision regarding its surgical stripping.

Pericardiectomy for Recurrent Pericarditis

Radical pericardiectomy may be considered as a last-resort option for patients with recurrent or incessant pericarditis who have failed all available medical therapies, including NSAIDs, colchicine, anti-IL-1 agents (anakinra, rilonacept, goflikicept), corticosteroids, and other immunosuppressive agents such as azathioprine or IVIG. It may also be considered in patients who have contraindications to continued medical therapy or who desire pregnancy. Partial pericardiectomy is not recommended. Anti-inflammatory medications may be continued until surgery and for 3 to 6 months postoperatively if active inflammation persists. Most patients will respond to aggressive medical therapy before surgery is needed .

Related Chapters

• Hemopericardium
• Pneumopericardium
• Chylopericardium
• Pericardial effusion
• Congenital absence of the pericardium
• Pericardial window
• Pericardial sac
• Pericardial friction rub
• Pericardiocentesis
• Pericardium

Sources

• National Guideline Clearinghouse

Acknowledgements

The content on this page was first contributed by C. Michael Gibson, M.S., M.D.

Additional Resources

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References

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