Median Sternotomy Approach : The preferred approach these days is through a median sternotomy. Pericardiectoiny proceeds in the same way as done through left thoracotomy, by freeing left ventricle first. Then right ventricle is freed. The excision is from one phrenic nerve to the other. Pulmonary outflow, and right atrium and the cavae also can be cleared through median sternotomy approach. On the left side the ventricle is freed upto the atrioventricular groove superiorly and up to the diaphragm inferiorly. Very rarely pericardiectomy will have to be done on cardiopulmonary bypass. In that case femoral cannulation and median sternotomy will be the best approach.