Pediatric pericardiectomy—a narrative review

Background and Objective: Pediatric pericardiectomies are rare operations used to treat recurrent, purulent, or constrictive pericarditis. Given the lack of pediatric-specific guidelines, we conducted a review to summarize the current literature on pediatric pericardiectomies including: etiology, diagnosis, timing of operation, surgical methods, and outcomes. Methods: We conducted a PubMed literature review including articles in English from 2000-2025. To ensure completeness, we utilized a systematic search with "pediatric" and "pericardiectomy" as medical subject heading or text words. We identified 92 articles and included 58 relevant publications. Key Content and Findings: The most common etiology of pericarditis in pediatric patients requiring a pericardiectomy is idiopathic. The second most common etiology is prior cardiac surgery in the United States and bacterial infections in India. The majority of pediatric patients (i.e., >80%) treated with a pericardiectomy present with dyspnea, chest pain, or heart failure symptoms. Transthoracic echocardiogram (TTE) is the first line imaging test. Adult guidelines for the treatment of pericarditis can be utilized to inform individualized care decisions, including timing of operation, for pediatric patients potentially requiring a pericardiectomy. Specifically for constrictive pericarditis, pericardiectomy is the mainstay treatment for chronic constriction. In addition, there is concern that delaying surgery in cases of constrictive pericarditis could result in deteriorating patient status and irreversible myocardial damage. Most pediatric pericardiectomies (~90%) are performed without the use of cardiopulmonary bypass. Complete pericardiectomies are more common than partial pericardiectomies, and a median sternotomy is the most utilized approach. Among patients in the United States, the mortality rate is ~2% (1/45, range 0-4%) compared to ~11% (8/70, range 0-22%) in lower-resourced countries. The increased mortality rate in lower-resourced countries could be due to the predominance of tubercular etiology or delayed patient presentation, emphasizing the potential importance of identifying patients requiring pericardiectomy and intervening early. Conclusions: Pediatric pericardiectomies are rare and generally safe operations, especially in the United States. There is a need to further investigate and delineate outcomes in relation to timing for pediatric pericardiectomies.