What Is a Pericardial Window?

Pericardial effusion is a more common clinical manifestation and is one of the important signs of pericardial disease. Pericardial effusion can be seen in exudative pericarditis and other non-inflammatory pericardial lesions, which can usually be determined by physical examination and X-ray examination. When the pericardial effusion lasts for more than several months, it forms a chronic pericardial effusion.

Basic Information

English name: pericardial effusion
English alias: hydropericardium
Visiting department: cardiology

Multiple groups: Menopause women
Common causes: Tuberculosis, virus, bacteria, tumor, rheumatism, etc.
Common symptoms: Shortness of breath, chest pain, etc.
Contagious: no

Causes of pericardial effusion

The common causes of pericardial effusion are divided into two categories, infectious and non-infectious.

Infective pericardial effusion

Including tuberculosis, viruses (coxsackie, influenza and other viruses), bacteria (staphylococcus aureus, pneumococcus, gram-negative bacteria, mold, etc.), protozoa (amoeba), etc.

2. Non-infective pericardial effusion

Including tumors (especially lung cancer, breast cancer, lymphoma, mediastinal tumors, etc.), rheumatism (rheumatoid arthritis, systemic lupus erythematosus, scleroderma, etc.), heart injury or rupture of large blood vessels, endocrine and metabolic diseases (such as Hypothyroidism, uremia, gout, etc.), radiation damage, fluid accumulation after myocardial infarction, etc.

Pericardial effusion clinical manifestations

Patients with this disease are more common in women, and the age of onset is more common in menopause. Patients often can participate in daily work without conscious discomfort. Shortness of breath and chest pain usually appear when symptoms appear. In some patients, the symptoms of pericardial obstruction appeared early in the course of the disease, and gradually reduced or even disappeared as the course of the disease progressed. Since there is almost no history of acute pericarditis, the time of onset cannot be determined. When the pericardial effusion increases suddenly and abruptly, the adaptive expansion of the pericardium decreases and the effusion increases, manifesting as a restricted pericardial effusion, which may cause pericardial obstruction.

Pericardial effusion

1. X-ray inspection

Heart shadows generally expand to both sides (more than 300 ml of effusion); when a large amount of effusion (greater than 1000 ml), the heart shadow is flask-shaped, the superior vena cava shadow widens, and the heart beats weakly under perspective. Clear lung field can be distinguished from heart failure.

2. ECG

Often with low voltage, tachycardia, and a large amount of fluid, it can be seen that the voltage is alternating.

3. Echocardiography

M-mode ultrasound showed fluid dark areas between the anterior wall and the posterior wall of the heart, that is, when the maximum diastolic dark area between the pericardium and epicardium (10 mm, the effusion is small; as in Between 10 and 19 mm is a medium amount; if it is greater than 20 mm, it is a large amount).

4. Pericardial puncture

It can confirm the presence of pericardial effusion and relieve the symptoms of pericardial stuffing. Save part of the effusion for laboratory examination of the relevant cause.

Pericardial effusion diagnosis

The disease lacks a precise and uniform definition. Generally, the disease is classified as having the following characteristics: there is a large amount of pericardial effusion and it has been confirmed by echocardiography; the pericardial effusion volume remains basically stable during the observation period; the pericardial effusion persists for at least 3 months The patient has been ruled out of any systemic disease, regardless of whether the disease may be related to pericardial effusion; systematic etiological examination is negative.

Clinically, the heart shadow is often increased by routine X-ray chest examination, and then diagnosed by echocardiography and systemic examination, as well as etiological examination, to exclude specific lesions such as tuberculous pericarditis and rheumatic pericarditis. .

Pericardial effusion treatment

Medical treatment

Medical treatment includes the use of hormones, anti-inflammatory drugs, anti-tuberculosis drugs and other etiological treatments. It can also be observed without medication when there are no symptoms.

Pericardial puncture can reduce symptoms, and the pericardial fluid can be extracted for analysis to help diagnosis and treatment, but its own therapeutic effect is not exact and it is not the main treatment.

2. Surgical treatment

The purpose of surgical treatment is to relieve existing or possible pericardial obstruction, clear pericardial effusion, reduce the possibility of pericardial effusion recurrence, and prevent late pericardial constriction.

Pericardial drainage and pericardial resection are feasible in the case of clear diagnosis and ineffective medication.

(1) Pericardial drainage through the xiphoid process The operation is simple and rapid, the injury is small, the recent effect is clear, the pulmonary complications are fewer, and it is suitable for critically ill and elderly patients; In order to reduce the recurrence rate, the scope of pericardial resection can be increased.

It was called the pericardial window in the 1970s. However, the treatment mechanism of pericardial fenestration has only become clear in recent years. Studies have shown that on the basis of continuous and adequate drainage, fibrosis occurs between the epicardium and the pericardium, and the pericardial cavity disappears, which is why the pericardial window has long-term efficacy.

Technique of pericardial drainage through the xiphoid process: the incision starts from the lower end of the sternum and extends downwards, with a total length of 6-8cm. Cut the midline of the ventral white line midline to expose and remove the xiphoid process. The blunt separation of the loose tissue between the posterior wall of the sternum and the anterior wall of the pericardium. The external retractor exposes the upper abdominal incision and pulls the lower end of the sternum with a straight-angled hook. Cut the front wall of the pericardium and aspirate the pericardial fluid. The pericardium was excised about 3cm × 3cm, and the pericardium was opened. Make another small incision next to the incision to place the pericardial drainage tube. Suture the incision. The pericardial drainage tube was left in place for 4 to 5 days.

(2) Partial or complete resection of the thoracic pericardium and drainage of the thoracic cavity. This method has complete drainage and a low recurrence rate. Because more pericardium is removed, the root cause of pericardial effusion and pericardial constriction is reduced, so the surgical effect is reliable. However, the surgical injury is large, and complications of lung and incision may occur.

(3) Pericardial resection and thoracic drainage using thoracoscopy (VATS) The pericardium can be resected over a large area with minimal damage and satisfactory drainage. Postoperative complications were fewer. But anesthesia is more complicated.

Key points of pericardial resection using thoracoscopy: general anesthesia, double endotracheal intubation of the trachea, right lateral position, right lung ventilation, left pleural cavity open, and left lung collapse. Firstly, a 10mm trocar was inserted through the seventh intercostal space to expand the intercostal path and placed into the thoracoscopy camera. Intrathoracic exploration. Then insert the jaw along the anterior axillary line through the sixth intercostal space and the shear through the fifth intercostal space. During the operation, a continuous positive pressure of about 8 cm of water can be used to inject carbon dioxide to collapse the lungs and keep them in order to expose the pericardium. Identify the phrenic nerve, make an incision on its front and back, and remove a total of 8-10 cm ^{2 of the} pericardium. Be careful not to hurt the left atrial appendage. Clamp out the resected pericardium. A drainage tube was placed at the pericardial resection and led out through the intercostal space. It was retained for 2 to 3 days after surgery.