Pericardial Window

Pericardial Window

Anesthesia type	General
Airway	ETT
Lines and access	PIV x2 Arterial line (if tamponade physiology or instability) Central line only if necessary (do not delay drainage)
Monitors	Standard ASA Invasive arterial BP +/- CVP TEE
Primary anesthetic considerations
Preoperative	-Determine presence and severity of tamponade physiology -Identify etiology (malignancy, uremia, infection, post-cardiac surgery, trauma) -Assess degree of sympathetic compensation -Evaluate anticoagulation
Intraoperative	-Avoid loss of sympathetic tone -Avoid reductions in preload -Avoid sudden increases in intrathoracic pressure -Surgeon scrubbed and ready before induction if unstable
Postoperative	-Hemodynamic instability after decompression -Acute RV failure -Re-expansion pulmonary edema -Reaccumulation of effusion
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A pericardial window creates a surgical communication between the pericardial space and pleural or peritoneal cavity to allow continuous drainage of pericardial fluid. It is indicated for symptomatic effusions, cardiac tamponade, purulent pericarditis, recurrent malignant effusions, and failed percutaneous drainage.

From an anesthesia standpoint, the central issue is tamponade physiology, not the incision itself.

Overview

Indications

• Cardiac tamponade
• Symptomatic moderate-to-large effusion
• Recurrent effusion after percutaneous drainage
• Malignant effusion
• Purulent pericarditis

Unlike percutaneous pericardiocentesis, a pericardial window provides:

• Ongoing drainage
• Lower recurrence rates
• Ability to obtain pericardial biopsy
• Direct visualization of bleeding or loculations

Surgical procedure

Most common approach for urgent tamponade is via subxiphoid. A small infraxiphoid incision is made and the retrosternal space is entered bluntly. The anterior pericardium is identified, opened sharply, and a segment of pericardium is excised to create a window. Fluid is evacuated, often sent for cytology, culture, or pathology, and a drain is left in the pericardial space.

In a left anterior thoracotomy or VATS approach, the chest is entered through the left pleural space. The pericardium is opened anterior to the phrenic nerve, and a segment is resected so that fluid drains directly into the pleural cavity. A chest tube is placed.

Preoperative management

Patient evaluation

System	Considerations
Airway	-Prior mediastinal radiation or malignancy (difficult airway, limited neck mobility) -Orthopnea (tamponade may not tolerate supine positioning)
Neurologic	-Altered mental status from low cardiac output -Syncope or presyncope (suggests severe tamponade physiology)
Cardiovascular	-Assess tamponade physiology (Beck's triad, tachycardia, narrow pulse pressure, pulsus paradoxus, electrical alternans) -Echo findings (RA systolic collapse, RV diastolic collapse, dilated IVC with minimal variation, large effusion with swinging heart) -Assess underlying cardiomyopathy or recent cardiac surgery
Pulmonary	-Dyspnea at rest, orthopnea -Pleural effusion
Gastrointestinal	-NPO status uncertain in urgent cases -Hepatic congestion or ascites
Hematologic	-Anticoagulation usage -Thrombocytopenia (malignancy, chemotherapy) -Coagulopathy
Renal	-Uremia? -AKI from low cardiac output
Endocrine	-hypothyroidism can cause pericardial effusion
Other	-etiologies include TB, autoimmune diseases

Labs and studies

• CBC/CMP
• Coags
• T&S (consider crossmatch if unstable)
• EKG (low voltage, electrical alternans)
• CXR (enlarged cardiac silhouette if chronic effusion)
• TTE/TEE

Operating room setup

For tamponade physiology:

• Arterial line before induction
• Large-bore IV access
• Vasopressors ready and spiked
  • Epinephrine
  • Norepinephrine
  • Phenylephrine
• Atropine and glycopyrrolate available
• Emergency pericardiocentesis tray accessible
• Defibrillator immediately available
• TEE

If stable, non-tamponade effusion:

• Arterial line may be optional

Avoid delay to drainage in unstable patients

Patient preparation and premedication

In tamponade:

• Avoid sedative premedication
• Even small doses of benzodiazepines or opioids may cause collapse
• Maintain spontaneous ventilation until surgical access if severe physiology

Goal:

• Maintain preload
• Maintain heart rate
• Maintain SVR
• Avoid myocardial depression

If unstable:

• Transport to OR with monitoring
• Consider awake arterial line
• Surgeon prepped and ready before induction

Standard premedication acceptable in stable, non-tamponade effusions

Regional and neuraxial techniques

Neuraxial anesthesia is contraindicated in tamponade physiology as sympathectomy leads to drop in preload and SVR, causing potential CV collapse

• Even in stable effusions, neuraxial techniques are generally avoided.
• Subxiphoid approach typically does not require regional analgesia.
• Paravertebral or erector spinae blocks may be considered for thoracotomy approach post-drainage once hemodynamics stabilize.

• Avoid blocks before decompression in unstable patients.

Postoperative management

Disposition

ICU admission recommended for:

• Tamponade physiology
• Hemodynamic instability
• Malignant effusion
• Post-cardiac surgery effusion
• Significant cardiopulmonary comorbidities

Step-down/telemetry for stable elective effusion

Pain management

Subxiphoid approach - mild to moderate pain comparable to laparoscopic upper abdominal incision

• acetaminophen, low dose opioid, consider NSAIDs

Thoracotomy/VATS approach - moderate to severe pain, especially with chest tube placement

• Multimodal including acetaminophen, opioids, regional anesthesia.

Potential complications

• Recurrent effusion
• Bleeding
• Pneumothorax
• Myocardial injury
• Arrhythmias
• Re-expansion pulmonary edema
• Persistent hypotension
• Infection

Procedure variants

	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications