Subxiphoid Pericardial Window: Steps and Helpful Tips

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.