CHAPTER

10 
Subxiphoid Pericardial
Window
Juan A. Asensio, Federico N. Mazzini, Alejandro J. Pérez-Alonso, Patrizio Petrone,
Jose Ceballos, Tamer Karsidag, Takashi Fujita, Pablo Menendez Sanchez,
Juan Manuel Sánchez González, Juan Manuel Verde, Hassan Adnan Bukhari,
Gerd Daniel Pust, Rubén Gonzalo Gonzalez, Eva Iglesias Porto,
Mamoun A.Y. Nabri, A. Alejandro Gigena, Luis Manuel García-Núñez,
Anthony J. Policastro, and Corrado P. Marini

Beck’s triad represents the classic presentation of a patient arriving in an emergency department
with a full-blown pericardial tamponade. Kussmaul’s sign, described as jugular venous disten-
tion on inspiration, is another classic sign attributed to pericardial tamponade. In reality, the
presence of Beck’s triad or Kussmaul’s sign represents the exception rather than the rule. In
general, penetrating cardiac injuries can be extremely deceptive in their clinical manifestations;
patients may present with penetrating injuries located in the precordium, or their injuries may
be found in an extraprecordial location. Most wounds located in the precordium are generally
stab wounds, whereas gunshot wounds can injure the heart from both a precordial and an
extraprecordial location. Thoracoabdominal injuries can be lethal, and the heart as well as many
other organs can be affected.
The clinical manifestation of penetrating cardiac injuries ranges from complete hemodynamic
stability to acute cardiovascular collapse and cardiopulmonary arrest. Their clinical manifesta-
tions can also be related to several factors, including wounding mechanism; length of time
elapsed before arrival in a trauma center; extent of the injury, which, if it is sufficiently large,
causes exsanguinating hemorrhage into the left hemithoracic cavity; whether blood loss exceeds
40% to 50% of the intravascular blood volume, resulting in cessation of cardiac function; and
whether a pericardial tamponade is present. In any patient who sustains a penetrating injury
in an area inferior to the clavicles, superior to the costal margins, and medial to the midclavicular
lines, an injury to the heart should be suspected. A subxiphoid pericardial window evaluates
for the presence of blood in the pericardium; it is indicated for penetrating trauma in proximity
to the heart and is considered to be simple and safe. However, inexperienced surgeons often
mistake the central tendon of the diaphragm for the pericardium or spend undue amounts of
time in performing this procedure.

105
106    Section II  •  Chest

Clinical Anatomy

♦ The xiphoid process measures between 1 and 3 cm.

♦ It is attached with fibrous tissue to the anterior thoracic chest wall.
♦ It is supplied by small branches of the internal mammary arteries.
♦ There are always small veins laterally.
♦ The left xiphisternal junction is called the angle of Larrey.

Preoperative Considerations

♦ In the operating room, the patient’s entire torso from the neck to midthighs is prepared and
draped.
♦ The trauma surgeon must confirm that there are sufficient units of blood in the operating

room for immediate transfusion by rapid infusion technology.

♦ The availability of an autotransfusion apparatus and cell-saving technology is of great value.
♦ Appropriate instruments must always be available, including a sternal saw and other instru-

ments used for cardiac injury management.

♦ Institute maneuvers to prevent hypothermia, which include the following:
▲ Place a warming blanket on the operating table.
▲ Cover the patient’s lower extremities with a circulating warm air mattress and cover the

head to prevent heat loss.

▲ Increase the ventilator cascade temperature to 42° C and use warm intravenous fluids.

Operative Steps

♦ The patient is placed supine on the operating room table with the arms extended in a cross
position.
♦ Creation of a subxiphoid pericardial window should be performed in an operating room

under general anesthesia.

♦ A 10-cm incision is made in the midline over the xiphoid process.
♦ This incision is carried through skin and subcutaneous tissue, and hemostasis is achieved

by electrocautery. Electrocautery can also be used to dissect directly around the xiphoid
(Figure 10-1).
♦ Then, by a combination of blunt and sharp dissection, the xiphoid process is separated, dis-

sected, and grasped by an Allis or Kocher clamp and displaced cephalad; blunt dissection
with a Kittner dissector separates adipose tissue beneath the xiphoid.
♦ A combination of blunt and sharp dissection after digital palpation of the transmitted cardiac

impulse is used to locate the pericardium, which is grasped between two Allis clamps.
♦ At that time, if the hemodynamic status allows, the patient may be placed in a reverse Tren-

delenburg position to allow the pericardium to descend and become more accessible.
♦ A better grasp is usually obtained by replacing the Allis clamps and regrasping the pericar-

dium until full visualization can be achieved.

♦ Once the pericardium has been firmly grasped and adipose tissue has been cleared away, the

surgical area is lavaged with normal saline to remove any blood that may bias the results of
the window, and hemostasis is once again checked.
♦ A longitudinal incision measuring approximately 1 cm is made in the pericardium with

meticulous care taken not to lacerate the underlying epicardium (Figure 10-2).
 Chapter 10  •  Subxiphoid Pericardial Window    107

10-cm
incision

Figure 10-1 

1-cm incision

Figure 10-2 
108    Section II  •  Chest

♦ After this aperture is made, the field is flooded with either clear straw-colored pericardial
fluid, signifying a negative window, or with blood, which is indicative of a positive window
and thus an underlying cardiac injury.
♦ Finally, the field may remain dry if blood has clotted within the pericardium. Many inexpe-

rienced surgeons are misled into thinking that no cardiac injury exists, given this setting. We
recommend passing a suction catheter into the previously made aperture when this situation
arises. This move, more often than not, liberates a clot and allows blood to escape through
the aperture, in which case the window is positive and the surgeon should proceed to a
median sternotomy.
♦ If the window is negative, the pericardium should be closed with simple interrupted sutures

of 2-0 Vicryl or Dexon and the incision should be closed.

Postoperative Care

♦ If the pericardial window is negative, the patient may be admitted to the ward.
♦ If the pericardial window is positive and the patient has required a median sternotomy, the
patient is admitted to the surgical intensive care unit.

Pearls and Pitfalls

♦ Properly identify the pericardium.

♦ Do not transect the central tendon of the diaphragm.
♦ Be meticulous with hemostasis to prevent falsely positive windows resulting in negative

median sternotomies.
♦ If the window is negative, close the pericardium with absorbable sutures of 2-0 Vicryl or

Dexon.

Selected Readings

Andrade-Alegre R, Mon L. Subxiphoid pericardial window in the diagnosis of penetrating cardiac trauma. Ann Thorac Surg
1994;58:1139–41.
Arom KV, Richardson JD, Webb G, et al. Subxiphoid pericardial window in patients with suspected traumatic pericardial tamponade. Ann
Thorac Surg 1977;23:545–9.
Asensio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries. Surg Clin North Am 1996;76:685–724.
Brewster SA, Thirlby RC, Snyder WH. Subxiphoid pericardial window and penetrating cardiac trauma. Arch Surg 1988;123:937–9.
Duncan A, Scalea TM, Sclafani S, et al. Evaluation of occult cardiac injuries using subxiphoid pericardial window. J Trauma
1989;29:955–60.
Garrison RN, Richardson JD, Fry DE. Diagnostic transdiaphragmatic pericardiotomy in thoracoabdominal trauma. J Trauma
1982;22:147–9.
Miller FB, Bond SJ, Shumate CR, et al. Diagnostic pericardial window: a safe alternative to exploratory thoracotomy for suspected heart
injuries. Arch Surg 1987;122:605–9.