Improved management of pericardial disease has resulted from a better understanding of the pathological physiology and refined surgical technique. In acute cardiac tamponade from trauma, our experience has shown that simple pericardial aspiration, because it relieves the tamponade, renders open operation unnecessary unless the hemorrhage is unusually severe. However, in chronic tamponade, from prolonged pericardial bleeding or effusion, the "pericardio-pleural window" operation described in this article will safely decompress the pericardium without secondary infection and the necessity of reoperation. With chronic constrictive pericarditis, on the other hand, catheterization studies reveal that left heart constriction is more important than that of the right heart or vena cavae. So it is important to pay more attention to decortication of the left heart than was formerly believed. Excision of pericardial tumors, most often cystic, is indicated because they are indistinguishable from malignant growths, although they in themselves are not of serious import. Fatty and fibrous pericardium have proved to be suitable viable material for various plastic operations on the heart, lung and esophagus. Finally, experience with poudrage to revascularize the myocardium is proving that this is a very satisfactory technique which can be performed with minimal risk.