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The pericardium is a thin, protective sac that surrounds your heart. It helps protect the heart, reduces friction as it beats, and allows it to move and function efficiently. In some cases, problems can develop when this sac becomes inflamed or when fluid builds up around the heart. Pericardial diseases include Pericarditis, Pericardial effusion, Cardiac tamponade, and Constrictive pericarditis. Pericarditis is usually treated with medication, but some of the other conditions may require surgical treatment depending on their severity.
Surgical treatment is considered when there is a significant collection of fluid within the pericardial cavity, which is the space between the heart and the surrounding sac. This fluid can place pressure on the heart and affect how well it pumps blood. In more severe cases, such as cardiac tamponade, this pressure can become dangerous and requires urgent treatment to relieve it.
Surgery may also be needed when the pericardium itself becomes thickened and stiff, a condition known as constrictive pericarditis. In this situation, the heart is unable to fill properly with blood, which reduces its ability to pump effectively and can lead to symptoms such as breathlessness and fatigue. In these cases, surgical procedures can help by draining excess fluid or removing part or all of the pericardium. These treatments are designed to relieve pressure on the heart, improve symptoms, and restore normal heart function, helping patients return to a better quality of life.
When there is a large or recurring build-up of fluid around the heart, it may need to be removed to help the heart work properly. Too much fluid in this space can put pressure on the heart and affect its ability to pump blood efficiently, which can lead to symptoms such as breathlessness, fatigue, or chest discomfort. The first step in treatment is usually a procedure called Pericardiocentesis, where the fluid is carefully drained using a thin needle. This is typically done under local anaesthetic, meaning you are awake but the area is numbed to keep you comfortable. In some cases, a small drain (tube) may be left in place to allow any remaining fluid to continue draining safely over time. This procedure is carried out by specially trained doctors in a hospital with specialist heart services, ensuring the highest level of safety. Keeping the drain in place for a short period is important, as it allows the space around the heart to heal and reduces the chance of fluid building up again. Overall, this approach is effective in relieving pressure on the heart, improving symptoms, and helping your heart return to normal function.
In some cases, a more involved procedure is needed to treat fluid around the heart. One of the most effective options is creating a pericardial “window”, which allows fluid to drain continuously and prevents it from building up again. This is often performed using Video-assisted thoracoscopic surgery (VATS). This is a minimally invasive procedure carried out in an operating theatre under general anaesthetic, so you will be asleep throughout. Small incisions are made in the chest, and a camera is used to guide the surgeon. Other approaches may include a small incision below the breastbone (sub-xiphoid approach) or creating a connection between the heart sac and the abdominal cavity, depending on what is most suitable for you. During a VATS pericardial window procedure, the surgeon removes a small section of the pericardium. This creates an opening (“window”) that allows fluid to drain safely into the chest cavity (pleural space). The body can absorb fluid more easily in this area because it has a much larger surface, reducing the risk of fluid building up again around the heart. A small drain is often left in place after the procedure. This helps remove any remaining fluid from areas not directly connected to the window. If a drain is used, it usually stays in place until the amount of fluid coming out is very low for at least 24 hours. This allows time for natural healing and for the space around the heart to close down, which further reduces the chance of fluid returning. For many patients, this procedure can be performed as a day case, meaning you may go home the same day or shortly afterwards, depending on your recovery. When carried out by an experienced cardiothoracic team, it is a safe and highly effective treatment. Compared with needle drainage alone, it provides longer-lasting results and a lower chance of the fluid coming back.
Constrictive pericarditis can develop after a range of conditions affecting the pericardium (the sac around the heart). In many parts of the world, Tuberculosis (TB) is a common cause. In the UK and other Western countries, the most frequent causes include previous heart surgery, bacterial infections, or cases where no clear cause is identified (known as idiopathic). Some patients experience ongoing or repeated episodes of pericardial inflammation that do not improve with medication. In these cases, surgery called Pericardiectomy can be a safe and effective way to relieve symptoms and improve heart function. Careful and thorough assessment is essential before deciding on surgery. Interestingly, some patients who are found to have constrictive pericarditis during surgery may have scans that appear normal beforehand. On the other hand, some people may have a thickened pericardium visible on imaging but do not develop symptoms or signs of constriction, particularly if they have previously had radiotherapy or heart surgery. This is why clinical evaluation by an experienced specialist team is so important.
A pericardiectomy involves removing most of the outer layer of the pericardium to allow the heart to move and fill normally again. The procedure is performed under general anaesthetic, meaning you will be asleep throughout. It is usually carried out through an incision in the centre of the chest (sternotomy), although in some cases a smaller incision on the side of the chest (thoracotomy) may be used. Wherever possible, the surgery is performed while the heart is still beating. This operation can significantly improve symptoms such as breathlessness, swelling, and fatigue, helping patients return to a more active and comfortable life.
In recent years, outcomes for patients undergoing Pericardiectomy have improved significantly. This progress is due to a better understanding of constrictive pericardial disease, careful patient selection, and treatment by experienced specialist teams in dedicated heart centres. Advances in intensive care also mean that patients can be supported more effectively before and after surgery, improving overall safety. When performed in experienced centres, pericardiectomy (particularly when most of the diseased pericardium can be removed) remains the most effective treatment for Constrictive pericarditis. For many patients, it provides long-lasting relief from symptoms such as breathlessness and fatigue, often reducing or eliminating the need for ongoing medication. The procedure is widely recommended when symptoms persist and significantly affect quality of life.
Medical therapy still plays an important role alongside surgery. It is used to treat the underlying cause, such as infection or autoimmune disease, and to help stabilise patients before surgery. In some cases—particularly when surgery is not suitable or has not fully relieved symptoms—medication can also be used to manage symptoms and improve comfort.
In developed countries, patient can develop pericarditis after heart surgery, a condition that is called post-cardiotomy constrictive pericarditis. This happens when the lining around the heart (pericardium) becomes inflamed, thickened, and stiff over time, affecting how well the heart fills and pumps. Because of this risk, preventing pericardial inflammation after surgery is very important. Careful surgical technique, close follow-up, and early management of inflammation all play a role in reducing the chances of this complication developing.
Current medical guidelines recommend the use of low-dose Colchicine for around one month after cardiac surgery in suitable patients. Colchicine is an anti-inflammatory medication that helps reduce irritation and swelling of the pericardium, lowering the risk of longer-term complications such as constrictive pericarditis. Your medical team will assess whether this treatment is appropriate for you, taking into account your overall health and any other medications you may be taking. When used as part of a comprehensive care plan, this approach has been shown to be one of the most effective ways to prevent post-surgical pericardial problems.
Early recognition of symptoms (such as increasing breathlessness, swelling, or fatigue after heart surgery—is also important. Prompt review by your healthcare team ensures that any concerns can be investigated and treated early, helping to protect your long-term heart health.
