**3. Presurgical considerations**

#### **3.1 Indications**

This is the portion that the art of medicine is needed more than the science. Being a surgeon, it would appear rather strange that I would advocate surgical drainage only if all other alternatives have been considered first. But my approach to surgical drainage of pericardial effusion is always to weigh the risks against the benefits. This is always the case in medicine and even more so in these patients who might be in extremis prior to surgery.

An ideal patient for surgical drainage would be one with good life expectancy despite advanced disease or cancer. I do not recommend surgical drainage for patients with less than 6 months of life expectancy. Surgical drainage is to improve long-term outcome and relief of symptoms in patients, so I would consider other forms of drainage for short-term belief.

#### **3.2 Preoperative assessment**

A great deal of effort is usually required to counsel the patient prior to any surgery for pericardial effusion. In fact, I take the most time to talk to this group of patients, even more than patients with other pathologies. This is because patients in this group tend to have multiple medical conditions and pro-morbidities which complicate surgery. Speaking to them and understanding their wishes and concerns is paramount. For example, if they are not affected functionally by the pericardial effusion, they may not want surgery especially if surgery is high risk and can lead to adverse outcomes which they might not accept.

The patient should not have any other contra-indications to general anesthesia. A good bedside assessment, which has been handed down from seniors, would be to check if the patient is able to lie completely flat with the head not elevated. This tells two things about the patient: firstly, the pericardial collection is not causing too much hemodynamic compromise that it is affecting venous return to the heart, and, secondly, it is to ensure there is no other pathology that

#### *Inflammatory Heart Diseases*

could lead to his or her symptoms. It is an unwise clinical decision to operate and drain a pericardial effusion promising full relief of symptoms, where, for example, the symptoms are actually manifested from compression of the airway due to mediastinal disease.