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 surgical 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.

Intraoperative management

Monitoring and access

• Standard ASA monitors
• Arterial line (preferably pre-induction, can be optional in stable, non-tamponade effusions)
• Large bore IV access
• Central line (do not delay drainage if urgent tamponade physiology)
• TEE (may be used if diagnosis unclear or persistent hemodynamic instability after drainage

Induction and airway management

Physiologic goals:

• Maintain preload (avoid hypotension)
• Maintain heart rate (avoid bradycardia)
• Maintain contractility (avoid myocardial depression)
• Maintain SVR (avoid vasodilation)
• Avoid positive pressure ventilation before decompression (if severe)

Severe tamponade:

• Surgeon prepped and ready before induction
• Maintain spontaneous ventilation until pericardium opened (if feasible)
• Slow, titrated induction:
  • Ketamine (maintains sympathetic tone)
  • Etomidate (minimal myocardial depression)
  • Titrate narcotics carefully (large bolus can cause bradycardia)
  • Avoid large propofol bolus
• Apneic time should be minimized

• Avoid high PEEP and large tidal volumes

If patient arrests:

• Immediate surgical decompression is definitive therapy
• Epinephrine
• CPR (may be ineffective until decompression)

Stable patients:

• Standard IV induction acceptable
• Controlled ventilation tolerated

Maintenance and surgical considerations

Preserve physiologic goals above until pericardial decompression is achieved. Low-dose volatile anesthesia often used with readily available vasopressors.

Hemodynamic changes may occur immediately upon opening pericardium and evacuation of fluid:

• Increased venous return
• Improved cardiac output
• Reflex hypertension (abrupt BP changes)
• Arrhythmias

Once tamponade physiology resolves:

• Standard anesthetic maintenance
• Normal ventilation
• Persistent hypotension should prompt for evaluation for potential complications below or other etiology

Emergence

Consider OR extubation if patient is hemodynamically stable with no significant respiratory compromise. Patients with persistent hemodynamic instability, high vasopressor requirements, pulmonary dysfunction, or major comorbidities should remain intubated.

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

	Subxiphoid	Thoracotomy	VATS	Post-cardiac surgery	Pericardioperitoneal
Unique considerations	Tamponade Maintain spontaneous ventilation	OLV	OLV	Adhesions Graft injury risk	Drain into abdomen
Timing	Emergent/Urgent	Urgent/Elective	Elective	Urgent	Elective
EBL	Low	Moderate	Low	High	Low
Potential complications	Incomplete drainage	Pain, PTX	Conversion to open	Bleeding	Abdominal complications