Pericardial effusion and Cardiac tamponade

Pericardial effusion and Cardiac tamponadeSunitha DanielOutlineBrief OverviewCausesClinical PresentationInvestigationsManagement Update

OverviewAbnormal amount of and/or an abnormal character to fluid in the pericardial space.Normal fluid 15-50mlAmong malignancies lung-highest prevalance(37%)

CausesPrimaryAcute inflammatory pericarditis (infectious-viral(HIV),bacterial,fungal autoimmune)Previously unknown neoplasiaIdiopathic

SecondaryAcute MICardiac surgeryTraumaMetastasisChest irradiationEnd-stage renal failureHypothyroidismAutoimmune diseasesPulm HTNChylopericardiumDrugs : procainamide, hydralazine, INH, minoxidil, phenytoin, anticoagulants

Corey et alColombo et alSagrist-Sauleda et alCorey et alEffusion> 5 mm> 10 mm> 10 mmNot reportedn5725322106Tamponade (%)Not reported4437Not reportedIdiopathic (%)7322025Chronic idiopathic effusion (%)??9?Neoplastic (%)23361337Uremia (%)122064Iatrogenic (%)00160Post-acute myocardial infarction (%)0880Viral (%)14007Collagen vascular disease (%)12055Tuberculosis (%)0022Other (%)942120Clinical featuresSymptomsChest pain.SyncopePalpitationsCoughDyspneoaHoarsenessSignsBeck triadPulsus paradoxus Pericardial friction rubTachycardiaHepatojugular reflux TachypneaDecreased breath soundsEwart signWeakened peripheral pulses, edema, and cyanosis.ecgStage I - Diffuse ST-segment elevation and PR-segment depressionStage II - Normalization of the ST and PR segmentsStage III - Widespread T-wave inversions: Stage IV - Normalization of the T waves

cxrEnlarged cardiac silhouette (water-bottle heart)Pericardial fat stripe. Pleural effusion(1/3)

echocardiographyEcho-free space between the visceral and parietal pericardiumSmall effusions < 10 mm and are generally seen posteriorly Moderate 10-20 mm and are circumferential.Large :>20 mm

CT &MRIloculated pericardial effusions.CT detects 50ml fluidMRI 30ml fluid.MRI for hemorrhagic and non hemaorrhagic

treatmentBased on etiologyMedicalSurgicalmedicalAspirin/NSAIDs viral/idiopathicColchicine relapsing pericarditisSteroids- systemic inflammation/pregnancy/autoimmuneAntibioticsChemotherapyManagement strategy

Pp purulent13INDICATIONS FOR PERICARDIAL DRAINAGE PROCEDURESDiagnostic or therapeutic purposes Not routinely for diagnosis-poor yield.Strong suspicion of purulent or tuberculous pericarditis.MalignancyAsymptomatic patients with massive idiopathic chronic pericardial effusion14

PROCEDURES OF PERICARDIAL DRAINAGEPericardiocentesis: idiopathic/viralIndwelling pericardial catheter: neoplasticPercutaneous ballon pericardiotomySubxiphoid pericardiotomy: purulentPleuropericardial windowPartial pericardiectomyWide anterior pericardiectomy

neoplastic pericardial involvement relapses in as many as 40%-50% of patientsterminal patients-pericardiocentesis alonepatients with a longer expected survival-Indwelling pericardial catheters( 75% success rate)Balloon pericardiotomy Management strategy

referencesDiagnosis and management of pericardial effusion World J Cardiol. 2011 May 26; 3(5): 135143.Management of pericardial effusion Eur Heart J first published online November 2, 2012 doi:10.1093/eurheartj/ehs372http://emedicine.medscape.com/article/157325-overview