Pericardiectomy

Pericardiectomy is a surgical procedure doctors perform to treat diseases of the pericardium like pericardial mesothelioma. The surgery removes the pericardium, the outer covering of the heart sac. It may be used to extend life span or to relieve symptoms.

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A pericardiectomy can help with difficulty breathing, chest pain, heart palpitations and fatigue. The surgery can also relieve pericarditis (inflammation of the pericardium) as well as pericardial effusion (buildup of fluid in the pericardium). It's important to treat these conditions early, before they cause deadly complications. If pleural effusion goes untreated, for example, it can put a significant amount of pressure on the heart. This can cause the heart to compress, called cardiac tamponade.

A partial pericardiectomy removes the affected portion of the heart lining, while a total pericardiectomy removes as much of the heart lining as possible. In some cases of primary malignant pericardial mesothelioma (PMPM) the procedure may lengthen life span.

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What to Expect

During the Surgery

Before surgery, a patient receives general anesthesia and will remain asleep for the duration of the procedure, which lasts several hours. A surgeon makes an incision between the ribs and spreads the ribs apart with a mechanical spreader, giving access to the heart. The pericardium then is carefully stripped off and removed. Along with it, the surgeon removes fluid in the area as well as tumor growth. Once this is completed, the surgeon stitches shut the initial incision.

After the Surgery

This procedure usually requires a hospital stay of one or two weeks, but the length of time varies by patient. While in the hospital, the patient receives pain medication as needed, and recovery is monitored by a doctor or nurse. In the first few weeks after surgery, some patients experience complications such as fever, redness, severe pain, swelling or drainage from the incision site. Such complications may result in a longer hospital stay.

Effects on Life Span

Depending on the progression of a patient's mesothelioma, pericardiectomy may improve prognosis or just alleviate symptoms. As a palliative measure, the procedure may have little effect on life span. One patient in advanced stages of pericardial mesothelioma received a pericardiectomy to relieve symptoms. Because the cancer had already spread beyond the initial site, the procedure had little effect on life span and the patient lived for eight months after the operation.

Depending on the progression of a patient's mesothelioma, pericardiectomy may improve prognosis or just alleviate symptoms.

In other patients with less progressed forms of the cancer, this surgery could have better results. In one mesothelioma patient, a pericardiectomy was followed by a chemotherapy regimen. This combination put the cancer into remission and the patient remained free of cancer at a three-year follow-up.

Finding A Doctor

Though specialists in pleural and peritoneal mesothelioma are found throughout the United States, the extremely rare incidence of pericardial mesothelioma complicates a doctor's ability to specialize in the disease. Only 350 cases of pericardial mesothelioma are reported in medical history, and the annual incidence is approximately 1 in 40 million (0.0022 percent).

Heart surgeons, known as cardiac surgeons, are the physicians who perform pericardiectomies. Patients should ask how many of these procedures a surgeon has performed to gauge the experience level of the physician. Certain hospitals perform more of these surgeries than others, such as the Cleveland Clinic in Ohio and the Mayo Clinic in Rochester, Minn.

Dr. Allan Klein is director of the Center for the Diagnosis and Treatment of Pericardial Diseases at Cleveland Clinic. Dr. Klein has also published several articles on pericardial disease and works with cardiac surgeons, such as Dr. A. Marc Gillinov and Dr. Douglas Johnston, who perform pericardiectomies at Cleveland Clinic.

Dr. Jae K. Oh is director of cardiac imaging and the pericardial disease clinic at Mayo Clinic in Rochester. Dr. Oh has published several articles on pericardial disease and often serves as the overseeing cardiologist for patients who undergo pericardiectomies with cardiovascular surgeon Dr. Hartzell V. Schaff.

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Case Reports

A 61-year-old woman went to the hospital seeking treatment for chest pain and shortness of breath. An echocardiography indicated pericardial effusion, for which a pericardiocentesis was performed. The patient's symptoms subsided after the procedure. Three months later the effusion returned and another pericardiocentesis successfully removed the fluid, which tested negative for malignant cells. The patient soon developed constrictive pericarditis and a partial pericardiectomy was performed. A biopsy collected during the surgery indicated pericardial mesothelioma and prompted surgeons to operate again, this time performing a total pericardiectomy to remove more of the heart lining. Four cycles of chemotherapy with cisplatin and pemetrexed were administered over four months, and the cancer went into remission. At three-year follow-up, the patient had no symptoms and remained cancer-free.

A 72-year-old man was experiencing head pressure (when lying down) for three months and chest pain for three weeks before he went to a hospital in December 2010. Echocardiography revealed pericardial effusion and thickening of the pericardium. A pericardiocentesis was performed to remove the pericardial effusion, and the fluid tested negative for malignancy. The fluid recurred and the patient underwent a pericardiectomy to treat the persistent pericardial effusion. The surgery was effective at relieving the patient's symptoms. A biopsy taken during the surgery confirmed the patient had PMPM. One cycle of chemotherapy with cisplatin and pemetrexed was administered and the patient developed acute kidney injury from the cisplatin; chemotherapy was discontinued as a result. The patient passed away in February 2011, six months after symptoms arose (the average life expectancy for pericardial mesothelioma).

A diagnosis of pericardial mesothelioma can feel devastating to a person and their loved ones. If you or a loved one is diagnosed with this cancer, consider joining the monthly mesothelioma online support group to connect with other people facing mesothelioma cancer.

Additional Resources

  1. Butz, T., Faber, L., Langer, C., Korfer, J., Lindner, O., Tannapfel, A., … & Piper, C. (2009). Primary malignant pericardial mesothelioma – a rare cause of pericardial effusion and consecutive constrictive pericarditis: a case report. Journal of Medical Case Reports, 3(9256). doi:10.1186/1752-1947-0003-0000009256
  2. Chahinian, A.P. (2005). Clinical presentation and natural history of mesothelioma: Pleural and pericardial. In Pass, H.I., Vogelzang, N.J. & Carbone, M. (Eds.), Malignant Mesothelioma (380-390). New York: Springer.
  3. Cleveland Clinic. (2014). Search for a specialist. Retrieved from: http://my.clevelandclinic.org/p2/specialty_search.aspx
  4. Kainuma, S., Masai, T., Yamauchi, T., Takeda, K., Ito, H., & Sawa, Y. (2008). Primary Malignant Pericardial Mesothelioma Presenting as Pericardial Constriction.Annals of Thoracic & Cardiovascular Surgery, 14(6). Retrieved from http://www.atcs.jp/pdf/2008_14_6/396.pdf
  5. Klein, A. (2010). Pericarditis and Pericardial Disease. Retrieved from: http://my.clevelandclinic.org/heart/webchat/pericarditis-and-pericardial-disease-dr-klein.aspx
  6. Lee, M.J., Kim, D.H., Kwan, J., Park, K.S., Shin, S.H., Woo, S., … & Lee, W.S. (2011). A Case of Malignant Pericardial Mesothelioma with Constrictive Pericarditis Physiology Misdiagnosed as Pericardial Metastatic Cancer. Korean Circulation Journal, 41(6), 338-341. doi: 10.4070/kcj.2011.41.6.338
  7. Mayo Clinic. (2014). Hartzell V. Schaff, M.D. Retrieved from http://www.mayoclinic.org/biographies/schaff-hartzell-v-m-d/bio-20053174
  8. National Institutes of Health. (2011).Cardiac tamponade. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000194.htm
  9. Southwestern Medical Center. (2010).Pericardiectomy. Retrieved from http://www.utsouthwestern.edu/utsw/cda/dept27737/files/345006.html
  10. Southwestern Medical Center. (2010).Pericarditis. Retrieved from http://www.utsouthwestern.edu/utsw/cda/dept27737/files/173318.html
  11. Feng, X., Zhao, L., Han, G., Khalil, M., Green, F., Ogilvie, T., & Krause, V. (2012). A case report of an extremely rare and aggressive tumor: Primary malignant pericardial mesothelioma. Rare Tumors, 4(2): e21. doi: 10.4081/rt.2012.e21

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