Mini-Thoracotomy Versus Subxiphoid Pericardial Window: Two Cases of Hemodynamically Significant Pericardial Effusions

Pericardial effusions can progress to cardiac tamponade, a life-threatening condition that requires immediate management. Although the first-line treatment for cardiac tamponade is pericardiocentesis, a surgical approach becomes necessary to create a pericardial window in cases of failure to drain, recurrence, or loculated effusions or in unsafe percutaneous procedures. We present two cases of hemodynamically significant pericardial effusions treated with different techniques to emphasize the determinants in choosing the most appropriate surgical approach. The first case is a 46-year-old male patient with pneumonia and a progressively increasing pericardial effusion with early signs of tamponade who underwent a left anterior mini-thoracotomy for the creation of a pericardial window. The second case is a 50-year-old male patient with a past medical history of bilateral lung transplantation who developed a loculated pericardial effusion and signs of tamponade. Because of previous thoracic surgery and an unsafe percutaneous access, a subxiphoid window with xiphoidectomy and a small wedge sternotomy was performed. The patients in both cases showed resolution of tamponade physiology and symptomatic relief after surgical drainage. Pathologic evaluation in both patients revealed fibrous pericarditis, with no evidence of malignancy or infection. These two cases showcase that the choice of surgical method for pericardial window depends on patient-specific factors, which include previous thoracic surgery, percutaneous accessibility, and the nature of pericardial effusion. Thus, careful operative planning is key to optimize outcomes and minimize procedural risks.