SURGERY ON PERICARDIUM

1. Surgery on
Pericardium
Submitted to- Dr. Jamal Moiz
Submitted by- Hamda Furqan
BPT 4th year
Subject: Physiotherapy in
cardiopulmonary conditions (BPT 402)
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2. Pericardium
• The pericardium is a thin sac that surrounds the
heart. It protects and lubricates the heart and
keeps it in place within the chest.
• Pericardium layers
• The pericardium has two layers:
• Fibrous pericardium is the outer layer. It’s
made from thick connective tissue and is attached
to the diaphragm. It holds the heart in place in the
chest cavity and protects from infections.
• Serous pericardium is the inner layer. It’s
further divided into two more layers: the visceral
and parietal layers. The serous pericardium helps
to lubricate the heart.
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3. Surgeries on Pericardium
• Pericardium operations are a type of heart surgery. They are necessary if the
pericardium, or heart sac, becomes thickened or filled with fluid.
• In general, there are two operations available:
 Pericardial fenestration-the opening of the pericardium and
 Pericardiectomy: the removal of the pericardium
Indications:
• Constrictive pericarditis: pericardium becomes stiff and calcified
• Pericardial effusion: If fluid builds up in the pericardium due to inflammation
in this area (pericarditis), cancer or an injury/haemorrhage, this is called
pericardial effusion.
• Pericardial tamponade: Accumulation of fluid in the pericardial space causing
increase in pressure with subsequent cardiac compression
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4. Thoracoscopic pericardial fenestration
• In the case of thoracoscopic pericardial fenestration, an endoscope is used to help make
a hole in the pericardium, so that the fluid can be drained or removed.
• Before pericardial fenestration, an attempt will firstly be made to drain the fluid by
puncturing the pericardium and inserting a thin tube.
• If this is insufficient, or the fluid keeps accumulating, pericardial window surgery is
required.
• This operation is performed under general anaesthetic and involves all the usual
preparations required for a general anaesthetic.
Procedure:
• A thoracoscope is inserted into the chest cavity through an incision below the fifth rib
on the patient’s left-hand side.
• The incision is around 10 cm long. Guided by camera imaging, a hole (window) is cut
into the pericardium so that the fluid can drain into the chest cavity.
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5. • There it is absorbed by the membrane around the lungs (pleura). After pericardial
fenestration, a drainage tube is usually inserted to aid the removal of fluid. The
operation takes around one hour.
• The drainage tube is removed after two or three days and the patient is usually
hospitalised for four or five days.
• The results are generally very good. Pericardial fenestration removes the fluid and the
‘hole’ in the pericardium does not negatively impact on the heart. However, the
underlying illness that caused the build-up of fluid may require further treatment.
Complications
• This is a low-risk operation and generally does not result in complications.
• As with all surgery, the operation may lead to infections, post-operative
haemorrhaging or blood clots in rare cases.
Follow-up:
• In the initial period after pericardial fenestration, ultrasound examinations are
necessary to investigate how the pericardium is progressing and to ensure there is no
new fluid build-up. 5

6. Pericardiectomy
• Pericardiectomy is the surgical removal of a portion or all of the pericardium. It is
also called pericardial stripping.
• The most common reason for performing a pericardiectomy is constrictive
pericarditis, a condition in which the pericardium has become stiff and calcified.
The stiff pericardium prevents the heart from stretching as it normally does when
it beats. This causes the heart chambers to fill incompletely with blood, and blood
backs up behind the heart. The heart swells, and symptoms of heart failure
develop.
• Pericardiectomy also can be used to treat recurrent pericarditis, in patients with
intractable recurrent symptoms and complications of the anti-inflammatory
medications including steroids.
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7. Preparation:
• The patient should not eat or drink anything after midnight before the day of the
surgery.
• The doctor may want some extra tests before the surgery. These might include:
 Chest X-ray
 ECG or EKG to check the heart rhythm
 Blood tests to assess general health
 Echocardiogram, to view heart anatomy and blood flow through the heart
 CT scan or MRI if the doctor needs more information about the heart
• Heart catheterization to measure the pressures inside the heart
• Hair on and around the area of the operation may be removed ahead of time.
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8. Procedure:
• The procedure is performed under general anesthesia
• There are different types of procedures that may be done.
• The chest cavity is opened using a small incision between the ribs, known as a
thoracotomy. Then the surgeon removes part or all of the pericardium, depending on how
thick and calloused it has become. The pericardium does not need to be replaced. The
heart can move freely in the chest cavity without it. The operation can usually be
performed without the use of a life-support machine.
• In some cases, the surgeon will make a vertical incision along the sternum. This incision
will be several inches long. To access the heart, the surgeon will separate the sternum.
• The doctor will surgically remove a large portion of the pericardium or the entire
pericardium.
• The doctor will do other repairs to the heart if needed.
• The muscle and the skin incisions will be closed and a bandage will be applied.
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9. Risks/complications:
• Abnormal heart rhythms, which can cause death in rare instances
• Blood clot, which can lead to stroke or other problems
• Complications from anesthesia
• Death
• Excess bleeding
• Fluid buildup around the lungs
• Heart attack
• Infection
• Low cardiac output syndrome
• Pneumonia
• Risks may vary according to the age, general health, and the cause. They may also
vary depending on the anatomy of the heart, fluid, and pericardium.
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10. In general, after the pericardiectomy:
• The patient may be groggy and disoriented upon waking.
• The patient’s vital signs, such as heart rate, blood pressure, breathing, and oxygen
levels, will be closely monitored.
• The patient may have a tube draining the fluid from the chest.
• The drained fluid may be sent to a lab for analysis.
• The patient may feel some soreness, but shouldn’t feel severe pain. Pain medicines
are available if needed.
• The heart symptoms will likely get better very soon after surgery.
• The patient will probably be able to have liquids the day after surgery. The patient
can have regular foods as soon as he can handle them.
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11. When discharging from the hospital following instructions are given to
the patient:
• You will probably have your stitches or staples removed in a follow-up
appointment in 7 to 10 days. Be sure to keep all follow-up
appointments.
• You should be able to resume normal activities relatively soon, but you
may be a little more tired for a while after the surgery.
• Ask the doctor if you have any exercise limitations. Avoid heavy
lifting.
• Call the doctor if you have fever, increased draining from the wound,
increased chest pain, or any severe symptoms.
• Follow all the instructions your healthcare provider gives you for
medicines, exercise, diet, and wound care.
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12. Physiotherapy Management
There are 3 main areas of physiotherapy involvement:
• 1. Chest care
• 2. General mobility
• 3. Rehabilitation
Chest Care:
Chest care Chest problems do occur after cardiac surgery even if the patient have no
history of chest problems or smoking.
Reasons for chest problems after the operation include:
• The anaesthetic gases – increase the amount of phlegm produced – make the
phlegm sticky and difficult to cough up – make the patient sleepy after operation –
make you take small rather than big breaths – make your cough less effective
• Previous chest problems or history of smoking – can lead to increased amounts of
phlegm being produced after the operation.
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13. • The incision – the discomfort from the wound may mean the patient is reluctant to take deep breaths or
cough effectively.
• Posture – if sitting or lying in a slumped position in the bed or chair, the will be unable to take a full
deep breath. So, ask the patient to always sit in an upright position, not slumped
• Decreased activity – in the early stages after the operation the patient spend more time in bed than
usual, and do not take such deep breaths as they would when walking, so phlegm can accumulate.
Therefore to speed the recovery and prevent chest infections, it is vital
that the patient practice the breathing exercises and coughing
• Ask the patient to complete 3 sets of 4 deep breaths every 30 minutes
• Cough and clear your chest as necessary
Coughing
Effective coughing is extremely important to clear any phlegm
present on the chest.
• When coughing, ensure that the patient is sitting upright and that he/she
support the wound with the cough pillow provided
• Ask the patient to take a deep breath in and Cough strongly from your tummy not your throat
• Afterwards do some relaxed breathing
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14. Cardiac Rehabilitation
Comprehensive cardiac rehabilitation program should contain specific core components.
These components should optimize cardiovascular risk reduction, reduce disability,
encourage active and healthy lifestyle changes, and help maintain those healthy habits after
rehabilitation is complete. Cardiac rehabilitation programs should focus on:
• Patient assessment nutritional counselling
• Weight management
• B.P management
• Lipid management
• Diabetes management
• Tobacco cessation
• Psychosocial management
• Physical activity counselling
• Exercise training
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15. Phase 1: Inpatient phase
• Involves immediate inpatient exercise rehabilitation that emphasizes:
a) Patient education (informal discussions with nurses and physicians) and
b) Counselling.
Exercise therapy
• Musculoskeletal ROM activities. b) ADLs (sitting, standing, and walking).
• Purpose:
a) Counter the deconditioning effects of prolonged bed rest,
b) Prepare patient for a return to normal daily activities.
• EXERCISE PRESCRIPTION FOR PHASE I
• 1. ROM EXERCISES:
• Shoulder flexion, abduction and internal & external rotation
• Elbow flexion
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16. Ambulation
• Ambulatory activities in phase 1 should be low in intensity (approx. 1.5-3 METS)
and initially include self care activities (eating, sitting), which are gradually
progressed to slow walking, ROM exercises and activities of daily living.
• Later stair climbing can also be introduced.
• EXERCISE INTENSITY: • Exercise performed in phase 1 typically do not exceed 2-
3 METS.
• The use of Borg Rating of Perceived Exertion Scale is encouraged after first few days
in the hospital.
Phase II: Outpatient cardiac rehabilitation
• Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation
may begin.
• Phase II typically lasts three to six weeks though some may last up to up to twelve
weeks. Initially, patients have an assessment with a focus on identifying limitations in
physical function, restrictions of participation secondary to comorbidities, and
limitations to activities.
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17. • A more rigorous patient-centered therapy plan is designed, comprising three
modalities: information/advice, tailored training program, and a relaxation program.
The treatment phase intends to promote independence and lifestyle changes to prepare
patients to return to their lives.
Exercises include: breathing exercises: During the first two weeks after the patient is
discharged home, it is important to continue with the breathing exercises,
Shoulder exercises: shoulder shrugs
Trunk exercises
A. Alternate side bending in standing
B. Thoracic rotation
Leg exercises:
A.Alternate knee bends
B. Half squats
C. Step ups
Perform 2 sets of 10 reps each
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18. Phase III: Post-cardiac rehab. Maintenance
• This phase involves more independence and self-monitoring. Phase III centers on increasing
flexibility, strengthening, and aerobic conditioning.
• Goal: facilitate long term maintenance of lifestyle changes, monitoring risk factor changes
and secondary prevention.
• Educational sessions
• Support groups
• Telephone follow up
• Review in clinics
• Outreach programmes
• Exercise program organised by qualified phase IV gym instructor
• Links with GP and primary health care team
• Ongoing involvement of partners/spouses/family
at home.
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19. References:
• Hirslanden: Pericardium: operations and procedures
• Cleveland clinic: Pericardiectomy
• Hopkinsmedicine: Pericardiectomy
• Physiopedia
• NHS: Physiotherapy following cardiac surgery
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