Subxiphoid Pericardial Window: Steps and Helpful Tips

2019-02-05T19:13:04Z (GMT) by Daniel Gwan-Nulla
<p>A subxiphoid pericardial window is generally indicated for management of symptomatic pericardial effusion.<br></p><p><strong>Imaging</strong></p><ul><li>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.</li><li>In the subxiphoid approach, the surgeon will be accessing the pericardium anteriorly, over the right ventricle.</li></ul><p><strong>Anesthesia</strong></p><ul><li>The procedure can be performed under general anesthesia or under local anesthesia with sedation, depending on the hemodynamic stability of the patient.</li><li>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.</li></ul><p><strong>Procedure</strong></p><ul><li>A small upper midline incision is made over the xiphoid process.</li><li>The linea alba is incised, exposing the preperitoneal fat, but the peritoneal cavity is not entered.</li><li>The xiphoid process is excised with Mayo scissors, a rongeur, or electrocautery.</li><li>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.</li><li>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.</li><li>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.</li><li>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.</li><li>Use a Yankauer suction tube to probe the pericardial sac and suction out any loculated areas.</li><li>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.</li><li>Finally, close the incision.</li></ul>




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