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Subxiphoid Pericardial Window: Steps and Helpful Tips

Tuesday, February 5, 2019

By

Daniel Gwan-Nulla

Gwan-Nulla D. Subxiphoid Pericardial Window: Steps and Helpful Tips. February 2019. doi:10.25373/ctsnet.7663130.

A subxiphoid pericardial window is generally indicated for management of symptomatic pericardial effusion.

Imaging

  • Generally, the patient will have had some type of imaging study, most often an echocardiogram or a computed tomography scan of the chest. It is important to review these studies prior to surgery to get a sense of the size of the effusion and to determine whether the effusion is predominantly anterior or posterior.
  • In the subxiphoid approach, the surgeon will be accessing the pericardium anteriorly, over the right ventricle.

Anesthesia

  • The procedure can be performed under general anesthesia or under local anesthesia with sedation, depending on the hemodynamic stability of the patient.
  • If using general anesthesia in a relatively unstable patient, the patient should be prepped and draped prior to induction in case a sudden cardiovascular collapse requires urgent surgical intervention.

Procedure

  • A small upper midline incision is made over the xiphoid process.
  • The linea alba is incised, exposing the preperitoneal fat, but the peritoneal cavity is not entered.
  • The xiphoid process is excised with Mayo scissors, a rongeur, or electrocautery.
  • The lower sternum is retracted anteriorly with a Richardson retractor. This will expose the cardiophrenic fat pad and not necessarily the pericardium. Use a small sponge stick or Kittner blunt dissector to sweep the overlying fat pad until the glistening pericardium can be visualized.
  • If the preoperative imaging study showed a good amount of fluid collection anteriorly, one can safely use a #15 blade to incise the pericardium. The author would not recommend using a #11 blade.
  • With drainage, hemodynamic collapse can occur as a result of a diminished preload. It is important to communicate this with anesthesia ahead of time and to administer fluid boluses as necessary.
  • Next, grab an edge of the incised pericardium with a tonsil and excise about an inch and a half of tissue to create the window.
  • Use a Yankauer suction tube to probe the pericardial sac and suction out any loculated areas.
  • Introduce a drain into the pericardial sac. The author’s preference is to use a 10 Fr flat JP drain and to direct it posteriorly.
  • Finally, close the incision.

Disclaimer

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Comments

Submitted by Scot Schultz on
While this may be a "pericardial window", it does not allow for continued drainage of the pericardium once the drain is removed. I reserve this approach for post-operative effusions. I prefer a mini left anterior thoracotomy 2-3 inch incision and a generous pericardial resection above the phrenic nerve allowing ongoing drainage into the left pleural space. Once the drain is removed, the residual pericardial fluid is either absorbed by the pleura or at worst can be drained safely under local anesthesia with ultrasound guidance.
Submitted by Daniel Gwan-Nulla on
Thank you for the comments. There are several approaches for performing a pericardial window. The subxiphoid approach is expeditious and can be done under local anesthesia in the ICU, on the unstable patient. While it does not allow for drainage into the pleural space, recurrence rates with this approach remain very low.
Submitted by Francis Carroll on
well-produced clearly scripted and narrated account of standard technique may be useful reference for newcomers or as a refresher for some. I question the commentary which warns that sudden drainage may decrease preload and lead to hemodynamic instability. This I think is contra to established understanding of tamponade physiology, but also not consistent with my own experience in hundreds of cases. If there is any element of hypotension, tachycardia, need for pressor support, these are nearly universally and nearly immediately reversed upon pericardial decompression. Thank you/ FXC
Submitted by Daniel Gwan-Nulla on
Dr. Carroll, thank you for your comments and input. I do agree that we often see an improvement in hypotension, tachycardia and need for pressor support following pericardial decompression. However, an important aspect of tamponade physiology (or pathophysiology) is an underfilled heart (low preload) as a result of pericardial restriction. This can result in paradoxical hemodynamic instability at the time of pericardial decompression or shortly thereafter, in the absence of adequate perioperative volume resuscitation.
Submitted by Brian Mott on
I've traditionally used this approach with good success but now my preferred method is a left or right robotic true window with drainage into the pleural space. https://www.youtube.com/watch?v=DZ4mGt-EWV8
Submitted by Albert Olivier on
Whether in the ER, ICU, or OR setting, hemodynamic instability can often be timely offset by an emergency real-time ultrasound-guided pericardiocentesis thus avoiding endotracheal intubation and general anesthesia which may exacerbate both respiratory and hemodynamic status. As a result, local anesthesia with mild sedation in a semi-Fowler position provide a more efficacious arena for a relaxing subxyphoid incision with pericardial drainage and window. Concomittantly, an ultrasound-guided thoracentesis can be safely and easily performed via the same incision or an anterior or axillary site. Thus, simplicity with efficacy counters complexity with higher risk of complications of thoracotomy, thoracoscopy, robotic surgery.

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