Thoracotomy with Pleuropericardial Window

Thoracotomy with pleuropericardial window

Manikandan¹, Yashoda²

¹Staff Nurse, Nursing, Kauvery Hospital, Salem, Tamil Nadu

²Deputy Nursing Superintendent, Kauvery Hospital, Salem, Tamil Nadu

Background

Thoracotomy with creation of a Pleuropericardial window is a surgical procedure that involves making an incision in the chest wall to access the thoracic cavity and create a window in the pericardium and Pleura performed to provide continuous drainage and relieve pericardial effusion. It serves both diagnostic and Therapeutic purposes.

Case Presentation

A 47-year-old lady presented with complaints of breathing difficulty/Neck pain/ Back pain since 2 weeks. She had undergone Closure of Sinus Venous Atrial septal defect (Pericardial patch) + Mitral valve repair (Teflon ring annuloplasty) + Tricuspid valve replacement (31mm Epic Plus Bioprosthetic valve) + Rerouting of pulmonary veins done on 06.06.2025 at outside hospital Chennai followed by patient developed large pericardial effusion & underwent Pericardiocentesis done on 20.06.25 at outside Hospital, Salem.

In view of recurrent collection of pericardial fluid, she was advised to have Pleuropericardial window surgery. She was referred here for Pleuropericardial window surgery.

Vitals

PR: 42/min, AF
BP: 90/60mmHg
RR : 22 / min
SPO2: 92% in 3L O₂

Past History

S/P Closure of Sinus Venous Atrial septal defect (Pericardial patch) + Mitral valve repair (Teflon ring annuloplasty) + Tricuspid valve replacement (31mm Epic Plus Bioprosthetic valve) + Rerouting of pulmonary veins done on 06.06.2025 at Sri Ramachandra Medial Centre, Chennai
S/P Pericardiocentesis done on 20.06.25 at SKS Hospital, Salem
No history of DM/ HTN/ TB/ CVA/ Covid

On examination

Thinly built, Mild respiratory distress, not able to lie down flat, No pallor, No jaundice, No cyanosis, No edema,

Weight – 52 Kg,
Pulse: 50/min Irregular (Complete heart block),
BP: 100/60 mmHg,
SPO2: 96% in room air,
CVS: S1 S2 varying.,
RS: B/L AE +,
Abdomen: Soft, non-tender,
CNS: normal,
Pigtail catheter insitu.

ECHO

S/P TVR + SV ASD Closure + MV Repair + Rerouting of PV.
S/P Pericardiocentesis (20.06.25).
Normally functioning bioprosthetic valve in tricuspid position.
No paravalvular leak.
ASD Patch intact/ No residual shunt across the patch.
Dilated LA, RV, MPA, LPA & RPA.
Moderate MR & pulmonary regurgitation.
Aortic valve sclerosis: Mild AR/ No AS.
Low probability for pulmonary hypertension.
No RWMA.
Normal LV systolic function (EF-68%).
RV systolic dysfunction present.
A large pericardial effusion present.
No evidence of tamponade.
No clot/ Vegetation.

ECG

Complete heart block with rate – 50/ min

Final Diagnosis

Post Closure of Sinus Venous Atrial septal defect + Mitral valve repair + Rerouting of pulmonary veins + Tricuspid valve replacement (06.06.25) with large pericardial effusion/ Normal left ventricular function (EF-68%)/ Right ventricular dysfunction/ Complete heart block

Surgery

Left anterior thoracotomy + Pleuropericardial window

Surgical Management

She had mild breathlessness at 6.30pm on 30.06.25. Initially to relieve her breathlessness. Pericardial fluid aspiration was done through pigtail catheter under aseptic precaution, draining about 250ml of serous fluid.

Left anterior thoracotomy + Pleuropericardial window was successfully done on 01.07.2025 under high pressure drained about 1250 ml of serous fluid. Patients were shifted to CTICU. In view of complete heart block, Cardiologist opinion was obtained and advised Permanent pacemaker implantation.

She was transferred to ward on the first post-operative day. Left Intercostal drainage tube was removed on second post-operative day. Cardiology review was obtained and orders were followed.

Local Examination: Operated site – wound healthy.

Nursing management

Post-Operative Care

Pain management: Ensure adequate pain control using multimodal analgesia, including opioids, NSAIDs, and regional anesthesia
Respiratory care: Encourage deep breathing exercises, coughing and incentive spirometry to prevent respiratory complications.
Cardiac Monitoring: Monitor ECG, blood pressure and oxygen saturation closely.
Chest drainage management: Maintain patency of chest tubes, monitor drainage color/amount. Prevent kinking or blockage.
Wound care: Ensure proper wound dressing and monitor for signs of infection.
Fluid management: Manage fluid balance carefully to prevent overload and cardiac complications.
Infection prevention: Strict aseptic dressing changes. Monitor temperature, WBC count, and incision site.
Mobility and rehabilitation: Early ambulation
Fall risk assessment
Hourly Spirometry exercise training
Physiotherapy
Providing back care
Providing care three times per day
ICD bag monitoring
MEWS monitoring second hourly.
Monitoring: Vital signs, hemodynamic stability and cardiac function
Pain management: Administer analgesics and titrate as needed
Respiratory care: Encourage deep breathing, coughing and incentive spirometry.
Wound care: Monitor incision sites for signs of infection.
Mobility: Encourage early ambulation and range-of-motion exercises
Medication Management: Administer medications as prescribed.
Complication prevention: Monitor for signs of bleeding, cardiac complications, or respiratory issues.

Advice on Discharge

Activity and Mobility

Sitting up and walking short distances as advised
Gradually increase activity level daily
Stop if there is sharp pain or shortness of breath.
Support incision site with a small pillow or binder during cough and deep breathing exercise.
Avoid heavy lifting, pushing, or pulling for at least 6 – 8 weeks.
Gently squeeze shoulder blade together, hold for 3 sec releases
Follow physiotherapist instructions for arm and shoulder exercises on the operated side.

Diet and Hydration

Eat a balanced, high-protein diet for healing.
Drink adequate fluids unless restricted by the doctor
Small, frequent meals may be easier if appetite is low.
Total fluids: 1.0 Lit/ Day

S. No	Medicine	Dose	Morning	Afternoon	Night	Instruction	Duration
1	Tab. Acitrom	2mg	0	0	1 (6pm)	Before food	7 Days
2	Tab. Alupent	10mg	1	1	1	After food	7 Days
3	Tab. Dytor	10mg	1 (9AM)	0	1 (4PM)	After food	7 Days
4	Tab. Aldactone	25mg	1 (10AM)	0	1 (6PM)	After food	7 Days
5	Tab. Asthalin	4mg	1	1	1	After food	7 Days
6	Tab. Sildenafil	25mg	1	1	1	After food	7 Days
7	Cap. Becosules	1 tab	0	1	0	After food	7 Days
8	Tab. Famocid	40mg	1	0	1	Before food	7 Days
9	Tab. Xykaa	1gm	1	0	1	After food	7 Days
10	Tab. Tramadol	50mg	1	1	1	After food	7 Days
11	Tab. Anxit	0.25mg	0	0	1	After food	7 Days
12	Syp. Cremaffin Plus	15 mL	0	0	1	After food	7 Days

Nursing Goals

Promote cardiac stability.
Manage pain and discomfort.
Prevent complications.
Enhance patient education and self-care.
Support recovery and rehabilitation.

Thoracotomy with pleuropericardial window

Thoracotomy with pleuropericardial window

Manikandan1, Yashoda2

Nightingale Journals

Manikandan¹, Yashoda²