Cardiac Tamponade

Cardiac TamponadeCardiac Tamponade

Dr. Mohammad AlGhamdiDr. Mohammad AlGhamdiConsultant cardiologistConsultant cardiologist

King AbdulAziz Cardiac CenterKing AbdulAziz Cardiac Center

National Guard- RiyadhNational Guard- Riyadh

Cardiac TamponadeCardiac Tamponade

Life threateningLife threatening

Cardiac compression Cardiac compression syndromesyndrome

Due to pericardial Due to pericardial fluid accumulationfluid accumulation

Predisposing conditionsPredisposing conditions

60% of cases have known underlying conditions

Neoplasm-related conditions

Pericarditis (viral, uremic, TB, SLE,…)

Trauma (medical & non-medical)

Unrelated to effusion size,

but to the rate of accumulation

one-third of asymptomatic large chronic effusions

develop unexpected cardiac tamponade

Tamponade pathophysiologyTamponade pathophysiology

Low cardiac output state due to reduced cardiac filling.

Echo/Doppler findings attributed to hemodynamic abnormalities.

Pericardial pressure equal to or exceeds intracardiac pressure.

Pathological process

HemodynamicHemodynamic ClinicalClinical EchoEcho

External mechanical compression.

MechanicalMechanical

Clinical approachClinical approach

Hemodynamic instability

Clinical picture Basic investigations Imaging studies

pericardial effusion+

SOB

Tachycardia

Low BP

High JVP

Diminished HS

Pulsus paradoxus

Clear lungs

ECG

CXR

Trans-thoracic echo

TEE, CT scan, MRI

Limitations of clinical assessmentLimitations of clinical assessment

DyspneaTachycardia

Elevated JVPPulsus Paradoxus

Cardiomegaly on CXR

Diminished HSHypotension

Low voltage EKGSensitivity <50%

Sensitivity = 70%

PRESENTPRESENTAsthma/COPDAsthma/COPD

P. EmbolismP. Embolism

CHFCHF

Mitral StenosisMitral Stenosis

Hypovolemia Hypovolemia

AscitesAscites

ObesityObesity

ABSENTABSENTHypotensionHypotension

P. adhesionsP. adhesions

ARAR

ASDASD

RVHRVH

Pulsus P

aradoxus

Basic investigations

Low voltageLow voltage Electrical alternansElectrical alternans

Enlarged cardiac Enlarged cardiac silhouettesilhouette

CT or MRICT or MRI

Effusions measured by CT/MRI tend to be larger than in echocardiography

Echocardiographic Echocardiographic findingsfindings

Just remember thatJust remember that… …

Tamponade is a Tamponade is a clinical descriptionclinical description

not an echo diagnosis not an echo diagnosis

Echo findings would Echo findings would support or refute support or refute clinical suspicionclinical suspicion

√ X

Detecting Pericardial EffusionDetecting Pericardial Effusion

Echo-free space Echo-free space surrounding the surrounding the heartheart

Variable degrees Variable degrees of severityof severity

Differential diagnosis of pericardial Differential diagnosis of pericardial echo-free space echo-free space

CommonCommon Left pleural effusion Left pleural effusion Loculated Loculated

Pericardial effusionPericardial effusion Intrapericardial Intrapericardial

hematomahematoma Epicardial fat padsEpicardial fat pads

RareRare Pericardial cystPericardial cyst Desc. aortic Desc. aortic

aneurysmaneurysm LV pseudoaneurysmLV pseudoaneurysm Hiatus herniaHiatus hernia Massive LAE Massive LAE

Important landmarksImportant landmarks

Pericardial effusion Pericardial effusion is seen anterior to is seen anterior to the descending the descending aorta in PLA viewaorta in PLA view

Left pleural effusion Left pleural effusion is posterior to the is posterior to the descending aortadescending aorta

Tamponade by 2-D echoTamponade by 2-D echo

Pericardial effusionPericardial effusion

Heart swinging (chronic)Heart swinging (chronic)

Late RA diastolic collapseLate RA diastolic collapse

Early RV diastolic collapse Early RV diastolic collapse

Dilated IVC with reduced Dilated IVC with reduced collapsibility collapsibility

RA collapseRA collapse

RA Inversion (collapse)RA Inversion (collapse) Begins in late diastole and Begins in late diastole and

continues into systole continues into systole

Sensitive but not specific for Sensitive but not specific for clinical tamponadeclinical tamponade Increased specificity if lasting Increased specificity if lasting

>1/3 of systole>1/3 of systole

Brief inversion can occur without Brief inversion can occur without clinical tamponadeclinical tamponade

RV collapseRV collapse Occurs in early diastoleOccurs in early diastole

Duration of collapse is Duration of collapse is proportional to the severityproportional to the severity

Indicates impending or Indicates impending or existing clinical tamponadeexisting clinical tamponade

Limitations of RV collapseLimitations of RV collapse May be affected by:May be affected by:

Intravascular volumeIntravascular volume• Low pressure tamponadeLow pressure tamponade

RV Pressure/volume loadRV Pressure/volume load• RVH and PHTNRVH and PHTN• ASD, TR, PI ASD, TR, PI

RV complianceRV compliance• Ischemia, Trauma, Ischemia, Trauma,

Pericardial adhesionsPericardial adhesions

Doppler findingsDoppler findings

Tamponade by Doppler flowTamponade by Doppler flow

Exaggerated respiratory variationsExaggerated respiratory variations Inspiration:Inspiration:

• Tricuspid flow increasesTricuspid flow increases• Mitral flow decreasesMitral flow decreases

Expiration:Expiration:• Tricuspid flow decreasesTricuspid flow decreases• Mitral flow increasesMitral flow increases

Mitral peak flow velocity variations of >25%Mitral peak flow velocity variations of >25%

Tricuspid peak flow velocity variations of >45%Tricuspid peak flow velocity variations of >45%

Doppler timingDoppler timing

120-75÷120= 38%80-40÷80= 50%

Hepatic vein flowHepatic vein flow

Mitral inflow

HV flow

Echo-guided perecardiocentesisEcho-guided perecardiocentesis

Confirm presence and Confirm presence and hemodynamic effect of hemodynamic effect of pericardial effusionpericardial effusion

Check the window of Check the window of maximum fluid collection maximum fluid collection (apical or subcostal)(apical or subcostal)

Measure the depth from Measure the depth from transducer (skin) to transducer (skin) to effusioneffusion

Echo-guided perecardiocentesisEcho-guided perecardiocentesis

Guide the operator for the Guide the operator for the needle directionneedle direction

Confirm the presence of Confirm the presence of catheter in pericardial spacecatheter in pericardial space

Check mechanical and Check mechanical and hemodynamic improvement hemodynamic improvement after drainageafter drainage

Assess the residual Assess the residual pericardial effusionpericardial effusion

Surgical drainage for post op Surgical drainage for post op collection/hematomacollection/hematoma

Echo cases of Echo cases of tamponadetamponade

To followTo follow.… .…