Pericardial Disease

The pericardium surrounds the heart and is composed of an inner visceral layer adherent to the myocardium (also termed the epicardium) and an outer fibrous parietal layer between which there is normally a small volume of serous pericardial fluid (Fig. 25.1). In addition to metastatic cancer deposits that can lead to malignant pericardial effusions, primary diseases of the pericardium include acute pericarditis and chronic pericardial constriction. Acute pericarditis, causing severe chest discomfort, is most often transient but can be recurring and relapsing requiring pericardiectomy for relief, but most often can be managed pharmacologically. On occasion, a benign or malignant pericardial effusion will cause tamponade physiology requiring a pericardial window for drainage. In a small percentage of cases, acute pericarditis may lead to chronic constriction leading to impaired filling of the cardiac chambers and symptoms of heart failure. Constriction is an important entity to understand and include in one’s differential as is it curable by surgery. In the setting of prior mediastinal radiation therapy, it is critical to differentiate constriction from restrictive cardiomyopathy as they have similar clinical presentations and may coexist, however, the latter will not benefit from cardiac surgery short of a ventricular assist device or transplantation (see Chap. 29 —Durable Mechanical Support and Chap. 30 —Heart Transplantation). The relief obtained from surgery depends upon the completeness of pericardiectomy, so surgical technique matters.