17352 Pericardiectomy

Overview

The pericardium (say: peh-ree-KAR-dee-um) is a thin, two-layered sac that wraps around your heart like a protective bag. It keeps the heart steady and lubricated. A pericardiectomy (say: peh-ree-kar-dee-EK-toh-mee) is an operation to remove part or all of this sac. It is most often done when the pericardium has become thick, stiff and scarred. A stiff sac squeezes the heart, so the heart cannot fill with blood properly between beats. Doctors call this constrictive pericarditis (say: kon-STRICK-tiv peh-ree-kar-DYE-tiss). Removing the stiff shell lets the heart fill and pump more freely again. The operation is also sometimes used when fluid keeps building up around the heart, or when an infection in the sac will not clear.

Pericardiectomy is uncommon. It is a specialised operation carried out in heart surgery centres by experienced cardiac teams. The underlying problem, constrictive pericarditis, is also rare. Because it is uncommon, you may be referred to a larger centre for assessment and surgery.

It can affect adults of any age, but it is seen most often in middle-aged and older adults. In some countries tuberculosis (TB, a bacterial chest infection) is the leading cause, so it can affect younger adults too. Children are rarely affected; when it happens, it is usually after heart surgery or in areas where TB is common. Anyone with a history of heart surgery, chest radiotherapy, repeated pericarditis or certain inflammatory conditions has a higher chance of developing the problem.

Symptoms

Common symptoms

• Shortness of breath, especially when you are active or lying flat
• Swelling in the legs, ankles and feet
• A swollen or bloated tummy, sometimes with a feeling of fullness and poor appetite
• Feeling very tired or easily worn out
• Unexplained weight gain from extra fluid
• A fast heartbeat or a fluttering feeling in the chest
• Dizziness or light-headedness when standing up
• In more serious cases, swelling of the neck veins and puffiness of the face

Symptoms in children

• Poor feeding and slow weight gain
• Breathing faster than usual, or getting tired quickly during play
• Swelling of the tummy or legs
• Being unusually sleepy or irritable
• Frequent chest infections or breathlessness that does not settle

Symptoms in older adults

• Breathlessness that is put down to age or a chest problem
• Leg swelling that is mistaken for a vein or kidney problem
• Increasing tiredness, reduced mobility or falls
• Confusion or low energy caused by poor blood flow
• Symptoms that build slowly over months, making them easy to miss

Causes

Main causes

• Scarring after inflammation of the pericardium (pericarditis), sometimes with no clear cause found
• Previous heart surgery or procedures inside the chest
• Radiotherapy (cancer treatment using radiation) to the chest
• Tuberculosis, especially in parts of the world where TB is common
• Bacterial or fungal infection of the pericardium
• Inflammatory conditions that affect the whole body, such as autoimmune diseases
• Advanced kidney disease, where waste products build up in the blood
• Cancer that has spread to or near the pericardium
• Chest injury, or long-term exposure to asbestos fibres
• Certain medicines used for cancer or immune conditions, in some people

Risk factors

• Having had heart surgery or a procedure in the chest before
• Previous radiotherapy to the chest area
• Repeated or poorly controlled pericarditis
• Living in or coming from an area where tuberculosis is common, or having had TB
• An autoimmune or inflammatory condition
• Kidney failure, particularly if you need dialysis
• Increasing age
• Being male, which is slightly more common in reported cases

When to see a doctor

See a doctor urgently if:

• You are becoming breathless more quickly than usual, or breathless at rest
• Your legs, ankles or tummy are swelling, or you gain weight quickly over a few days
• You feel your heart racing, fluttering or beating irregularly
• You develop a fever or feel shivery and unwell
• After surgery: redness, discharge or opening of the wound, a fever, or chest pain that gets worse

Book a routine appointment if:

• You have ongoing tiredness or breathlessness that is limiting your daily life
• You have had pericarditis before and want to understand your follow-up plan
• You have questions about recovery, work, driving or exercise after surgery
• You notice your symptoms changing slowly over weeks or months

Diagnosis

Doctors start by listening to your story and examining you. They will check your breathing, listen to your heart, and look for swelling in the legs, neck veins and tummy. If they suspect the pericardium is causing trouble, they will arrange heart imaging and blood tests. Often the diagnosis is made by a cardiologist (heart specialist) working with a cardiac surgeon, and it can take more than one visit to be sure.

Tests that may be done

• Echocardiogram: an ultrasound scan of the heart that shows how well it fills and whether the pericardium is thick or fluid-filled
• CT scan or MRI scan of the chest: detailed pictures that show thickening, scarring or calcium in the pericardium
• Electrocardiogram (ECG): a recording of the heart's electrical rhythm
• Chest X-ray: a simple picture of the heart and lungs
• Blood tests: to check for inflammation, kidney function, and signs of infection such as tuberculosis
• Cardiac catheterisation: a thin tube passed into the heart to measure the pressures inside it
• Sometimes a small sample of the pericardium is taken to look at under a microscope

What to expect at your appointment

You may have several tests over days or weeks. Some are quick and painless, like an ECG or ultrasound. Others, like an MRI, need you to lie still for a while. You may be referred to a specialist heart centre if surgery is being considered. Bring a list of your medicines and your questions, and ask a family member or friend to come with you if that helps you remember the answers.

Treatment

Treatment depends on what is causing the problem and how much it is affecting you. The aims are to ease the strain on the heart, remove extra fluid, treat any underlying cause, and decide whether surgery is likely to help. Not everyone needs an operation. Your team will weigh up your symptoms, your test results and your general health.

Self-care at home

• Weigh yourself at the same time each day and write it down, so you can spot fluid building up early
• Limit salty foods, as salt makes the body hold on to fluid
• Take your medicines exactly as prescribed and ask your pharmacist if you are unsure
• Build activity up gradually; short, regular walks are often better than occasional bursts
• Stop smoking, and keep alcohol within the limits your doctor advises
• Keep all follow-up appointments, even if you feel well
• Ask for help with lifting, housework and childcare while you recover

Medical treatments

Doctors may use medicines that help the body pass extra fluid as urine, which reduces swelling and breathlessness. Anti-inflammatory medicines are used when active inflammation of the pericardium is present. If an infection such as tuberculosis is found, it is treated with a full course of antibiotics over several months. Extra fluid around the heart can be drained with a fine needle in hospital. All of these are used alongside rest, monitoring and regular check-ups. Your doctor will explain which options suit you and why, and will not recommend anything without discussing the benefits and risks.

When is surgery considered?

Surgery is usually considered when the pericardium is clearly thickened or scarred and is causing symptoms that medicines are not controlling. It may also be offered when fluid keeps coming back despite drainage, when an infection in the sac will not clear, or when the heart's filling is seriously restricted. The decision is made together with you, usually by a cardiologist and a cardiac surgeon. They will explain the expected benefits, the risks of major heart surgery, and what recovery involves, so you can decide what feels right for you.

Living with this condition

In the first weeks after surgery you will tire easily, and your chest and shoulder muscles may ache. This is normal. Recovery is gradual: many people feel a real change in breathing and energy over one to three months, and some take longer. Plan rest into your day, accept offers of help, and follow your team's advice about lifting, driving and returning to work. Keep your wound clean and dry as instructed, and check it daily.

Lifestyle tips

• Pace yourself and rest between activities rather than pushing through tiredness
• Avoid heavy lifting and strenuous activity until your surgical team says it is safe
• Keep your home smoke-free
• Take short walks and gently increase the distance as you feel able
• Ask your doctor before flying or travelling long distances after surgery
• Keep a simple symptom diary of weight, swelling and breathlessness to share at check-ups

Diet and exercise

Eat regular, balanced meals with plenty of vegetables, fruit, beans, wholegrains and lean protein. Cut back on salt, processed foods and takeaways, as these make fluid build-up worse. Ask whether you should see a dietitian. For exercise, gentle and steady is the rule at first. Walking is ideal. Your cardiac team can advise on a rehabilitation programme, which gives you a safe, supervised way to rebuild strength and confidence.

Mental health and emotional wellbeing

It is very common to feel anxious before heart surgery and low or frustrated afterwards. You may worry about your heart, your recovery or your family. Sleep can be disturbed, and some people feel tearful for no clear reason. These feelings usually ease as you recover, but they deserve attention. Tell your doctor, nurse or a trusted person how you are feeling. Talking therapies and support groups can help a great deal. If you ever have thoughts of harming yourself, contact your local emergency number or a crisis support service straight away.

Prevention

Not every case can be prevented, especially when the cause is unknown. But some important causes can be reduced. Getting pericarditis treated promptly, completing treatment for infections such as tuberculosis, keeping kidney disease well managed, and controlling inflammatory conditions all lower the risk of scarring. If you have had heart surgery or radiotherapy to the chest, tell your doctor about any new breathlessness or swelling so it can be checked early.

Vaccines

Vaccination against tuberculosis is part of routine childhood programmes in many countries, and it helps prevent the form of TB that can affect the heart. If you have heart disease, your doctor or pharmacist can advise whether routine vaccinations such as flu and pneumonia vaccines are recommended for you.

Screening programmes

There is no general screening programme for pericardial disease. If you have had pericarditis, chest radiotherapy or heart surgery, your team may arrange follow-up visits and repeat echocardiograms to check the pericardium over time. This is decided case by case.

Complications

If left untreated

• Worsening heart failure, with increasing breathlessness and swelling
• Build-up of fluid in the tummy that can damage the liver over time
• Kidney problems caused by poor blood flow and raised pressure in the veins
• Irregular heart rhythms
• A serious build-up of fluid that suddenly squeezes the heart, which is a medical emergency
• In severe, long-standing cases, the condition can become life-threatening

Long-term outlook

Most people who have a pericardiectomy notice less breathlessness and swelling, and a better quality of life. Improvement usually comes steadily over weeks to months, and some people still need medicines for a while. It is major heart surgery, so the team will talk you through the risks honestly. Many centres report good long-term results, particularly when the operation is done before the heart has been under strain for too long. Your own outlook depends on your age, general health and the underlying cause, and your specialist can discuss this with you personally.

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