Pericardial Effusion and Cardiac Tamponade

Patrick Selakovich, M.D.PGY-1

Pericardial EffusionEtiologies –

Acute pericarditis (viral, bacterial, tuberculous, or idiopathic in origin)Autoimmune diseasePostmyocardial infarction or cardiac surgery; sharp or blunt chest trauma, including a cardiac diagnostic or interventional procedureMalignancy, mostly metastatic; chemo, radiation to the chestUremia; MyxedemaAortic dissection extending to the pericardiumCertain drugs

Clinical Presentation

Significant symptoms only present with effusion leading to tamponade

fatigue, dyspnea, chest discomfort, elevated jugular venous pressure, edema

ECG findings — most commonly – sinus tachycardia, low QRS voltage, and electrical alternans

Enlarged cardiac silhouette seen on CXR with significant effusions

Electrical Alternans

Diagnosis

Establishing the presence of pericardial effusionEchocardiogram (either TTE or TEE)

Can see fluid collections and atrial collapse as well as depressed wall motion

CT or MRI

Establish the size by either echo or MRI/CT (better)

Assess hemodynamic impactAcute cardiac tamponadeChronic tamponade

Cardiac Tamponade

AcuteSymptoms include chest pain and dyspneaSigns include tachycardia, hypotension, elevated JVP, pulsus paradoxus and muffled heart sounds

Chronic/SubacuteMild shortness of breath, fatigue, and possible peripheral edemaNarrow pulse pressure and mild hypotension

TreatmentIf patient is unstable, emergent pericardiocentesis is indicated

Pericardiocentesis is usually done under ultrasound/echocardiogram guidance or using direct fluoroscopy

A pigtail drainage catheter is typically placed

It can also be done surgically: subxiphoid, VATS for pericardial window, pericardio-peritoneal drainage and pericardiectomy

These surgical approaches are typically reserved for more stable/chronic effusions

References

Hoit, Brian D. “Diagnosis and treatment of pericardial effusion.” Up to Date. 20 November 2013.

Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. (2008). Harrison's Principles of Internal Medicine (17th ed.). New York: McGraw-Hill Medical Publishing Division