PERICARDIAL EFFUSION AND

CARDIAC TAMPONADE

Sunitha Daniel

OUTLINE Brief Overview Causes Clinical Presentation Investigations Management Update

OVERVIEW Abnormal amount

of and/or an abnormal character to fluid in the pericardial space.

Normal fluid 15-50ml

Among malignancies lung-highest prevalance(37%)

CAUSESPrimary Acute

inflammatory pericarditis (infectious-viral(HIV),bacterial,fungal autoimmune)

Previously unknown neoplasia

Idiopathic

Secondary Acute MI Cardiac surgery Trauma Metastasis Chest irradiation End-stage renal failure Hypothyroidism Autoimmune diseases Pulm HTN Chylopericardium Drugs : procainamide,

hydralazine, INH, minoxidil, phenytoin, anticoagulants

Corey et al Colombo et al Sagristà-Sauleda et al

Corey et al

Effusion > 5 mm > 10 mm > 10 mm Not reported

n 57 25 322 106

Tamponade (%) Not reported 44 37 Not reported

Idiopathic (%) 7 32 20 25

Chronic idiopathic effusion (%)

? ? 9 ?

Neoplastic (%) 23 36 13 37

Uremia (%) 12 20 6 4

Iatrogenic (%) 0 0 16 0

Post-acute myocardial infarction (%)

0 8 8 0

Viral (%) 14 0 0 7

Collagen vascular disease (%)

12 0 5 5

Tuberculosis (%) 0 0 2 2

Other (%) 9 4 21 20

CLINICAL FEATURESSymptoms Chest pain. Syncope Palpitations Cough Dyspneoa Hoarseness

Signs Beck triad Pulsus paradoxus Pericardial friction rub Tachycardia Hepatojugular reflux Tachypnea Decreased breath

sounds Ewart sign Weakened peripheral

pulses, edema, and cyanosis.

ECGStage I - Diffuse ST-

segment elevation and PR-segment depression

Stage II - Normalization of the ST and PR segments

Stage III - Widespread T-wave inversions:

Stage IV - Normalization of the T waves

CXR Enlarged cardiac

silhouette (water-bottle heart)

Pericardial fat stripe.

Pleural effusion(1/3)

ECHOCARDIOGRAPHY Echo-free space

between the visceral and parietal pericardium

Small effusions < 10 mm and are generally seen posteriorly

Moderate 10-20 mm and are circumferential.

Large :>20 mm

CT &MRI loculated

pericardial effusions.

CT detects 50ml fluid

MRI 30ml fluid. MRI for

hemorrhagic and non hemaorrhagic

TREATMENT Based on etiology Medical Surgical

MEDICAL Aspirin/NSAIDs – viral/idiopathic Colchicine –relapsing pericarditis Steroids- systemic

inflammation/pregnancy/autoimmune Antibiotics Chemotherapy

MANAGEMENT STRATEGY

INDICATIONS FOR PERICARDIAL DRAINAGE PROCEDURES Diagnostic or therapeutic purposes Not routinely for diagnosis-poor yield. Strong suspicion of purulent or

tuberculous pericarditis. Malignancy Asymptomatic patients with massive

idiopathic chronic pericardial effusion

PROCEDURES OF PERICARDIAL DRAINAGE

Pericardiocentesis: idiopathic/viral Indwelling pericardial catheter:

neoplastic Percutaneous ballon pericardiotomy Subxiphoid pericardiotomy: purulent Pleuropericardial window Partial pericardiectomy Wide anterior pericardiectomy

NEOPLASTIC PERICARDIAL INVOLVEMENT relapses in as many as 40%-50% of

patients terminal patients-pericardiocentesis

alone patients with a longer expected survival-

Indwelling pericardial catheters( 75% success rate)

Balloon pericardiotomy

MANAGEMENT STRATEGY

REFERENCES Diagnosis and management of

pericardial effusion World J Cardiol. 2011 May 26; 3(5): 135–143.

Management of pericardial effusion Eur Heart J first published online November 2, 2012 doi:10.1093/eurheartj/ehs372

http://emedicine.medscape.com/article/157325-overview