Pericardial Effusion

and
Cardiac Tamponade
ELMER S. JABAGAT, M.D.

CASE
46

YO F with a history of metastatic

adenocarcinoma of the breast
3

days increasing dyspnea with exertion

and generalized weakness.

She

denies chest pain, cough/congestion,

any fevers/chills.

She

is currently between
chemotherapeutic courses

not

currently undergoing radiation

treatment.

She

presents awake/alert, not in

T 97.7 P 105 BP 110/80 O2

96% RR 20
Gen: WDWN, thin
CV: Tachycardic, RR,
Pulm: Lungs Clear bilateral,
chest wall shows left-sided
mastectomy.
Neck no JVD, trachea
midline

Chest X-Ray

Definition: Pericardial Effusion

Pericardial

effusion("fluid
around the heart")
abnormal

accumulation of fluid in
thepericardialcavity.

Intrapericardial

pressure which can

negatively affect heart function.

blood or fluid collects

in the pericardium.

prevents the heart

ventricles from
expanding fully.

The excess pressure

from the fluid prevents
the heart from working
properly.

As a result, the body

does not get enough
blood.

Definition: Cardiac Tamponade

Pressure on the heart

increases

Prevents heart from

expanding

Fails to receive returning

blood

Lesser amount of blood

pumped

Lesser oxygen supply

Incidence
Cardiac

tamponade occurs in about 2 out of

10,000 people due to disease.

Cardiac Tamponade

Acute
Symptoms

include chest pain and

dyspnea
Signs

include tachycardia,
hypotension, elevated JVP, pulsus
paradoxus and muffled heart sounds

Chronic/Subacute
Mild

shortness of breath, fatigue, and

possible peripheral edema

Narrow

pulse pressure and mild

hypotension

Etiology: Pericardial Effusion

o

Acute pericarditis (viral, bacterial,

tuberculous, or idiopathic in origin)

Autoimmune disease

Postmyocardial infarction or cardiac

surgery

cardiac diagnostic or interventional

procedure

Trauma: sharp or blunt chest trauma

Malignancy, mostly metastatic; chemo,

radiation to the chest

Uremia; Myxedema (Hypothyroidism)

Aortic dissection extending to the

pericardium

Etiology: Cardiac Tamponade

Dissecting aortic aneurysm(thoracic) - blood

End-stage lung cancer - effusion

Heart attack (acute MI) rupture / blood

Heart surgery - Bleeding

Pericarditiscaused by bacterial or viral

infections

Fluid from Exudates or transudates

Wounds to the heart - blood

Cardiac trauma

Dissecting thoracic aneurysm

Other possible causes include:

Heart tumors

Hypothyroidism

Kidney failure

Leukemia

Placement of central lines

Radiation therapyto the chest

Recent invasive heart procedures

Recent open heart surgery

Systemic lupus erythematosus

Acute Tamponade
intrapericardial

hemorrhage from
penetrating trauma
invasive cardiac procedures / post
surgery
rupture of an ascending aortic
dissection
myocardial infarction.

Clinical Presentation
Significant

symptoms only present if effusion

leads to tamponade

fatigue,

dyspnea, chest
discomfort, elevated jugular
venous pressure, edema

Symptoms

Anxiety, restlessness

Sharpchest painthat is felt in the neck, shoulder, back, or abdomen

Chest pain that gets worse with deep breathing or coughing

Problems breathing

Discomfort, sometimes relieved by sitting upright or leaning forward

Fainting, light-headedness

Pale, gray, or blue skin

Palpitations

Rapid breathing

Swelling of the abdomen or other areas

Other symptoms that may occur with this

disorder:

Dizziness
Drowsiness
Weak

or absent pulse

Cardiac Tamponade

Acute
Symptoms

include chest pain and

dyspnea
Signs

include tachycardia,
hypotension, elevated JVP, pulsus
paradoxus and muffled heart sounds

Chronic/Subacute
Mild

shortness of breath, fatigue, and

possible peripheral edema

Narrow

pulse pressure and mild

hypotension

Physical Examination: may

show
Blood pressure that falls (pulsus paradoxus)
when breathing deeply

(>10 mm Hg) during inspiration

Rapid breathing

Heart rate over 100 (normal is 60 to 100 beats

per minute)

Heart sounds are only faintly heard through a

stethoscope

Neck veins that may be bulging (distended) but

the blood pressure is low

Weak or absentperipheralpulses

Beck's triad (Acute Tamponade)

systemic hypotension
2. elevated systemic venous pressure
3. muffled heart sounds
1.

The complete triad is rarely present

laboratory tests:
Echocardiogramis

very often used to help make

the diagnosis.
Other

tests may include:

Chest

CTorMRI of chest

Chest

x-ray

Coronary

angiography

ECG
Right

heart catheterization

Labs than can be done bedside in emergency

cases.
ECG

findingsmost commonly

sinus
low

tachycardia

QRS voltage

electrical

Enlarged

alternans

cardiac silhouette seen on CXR

with significant effusions

Enlarged cardiac silhouette seen on CXR with significant

effusions

Electrical Alternans and Low

Voltage QRS

Additional Images

EKG showing low voltage in the limb

leads (<5 mm). There is slight beatto-beat variation in the QRS
amplitude of leads V1, V4 and V5
(electrical alternans).

EKG after pericardiocentesis and

drainage of the pericardial effusion
showing increased QRS amplitude.

Diagnosis: Pericardial Effusion

-Pericardial effusion causes an enlarged heart shadow that is

often globular shaped (transverse diameter is disproportionately
increased).
A lateral film and close-up of a pericardial effusion showing the
anterior mediastinal fat (blue arrows)and epicardial fat (red
arrows) separated by a soft tissue stripe ( "fat pad" sign)
reflecting the pericardial effusion seen edge-on.

Echocardiogram (long axis left

parasternal view) confirming a
moderate pericardial effusion (1 cm
thickness) both anterior and posterior
to the heart (arrows).

Pearls

Pulsus paradoxicus, an accentuated

fall in the systolic pulse pressure (>10
mm Hg) during inspiration, is not
present in one-quarter of patients with
tamponade.

EKG in the setting of tamponade often

shows sinus rhythm with low voltage
(QRS amplitude in the limb leads <5
mm) suggestive of tamponade
physiology.

Electrical alternans, a more specific

sign of tamponade occurs when there is
a very large pericardial effusion in
which the heart swings during cardiac

Pearls: Diagnosis
Although

an effusion is often described as

producing a globular-shaped heart, it is usually not
possible to differentiate a pericardial effusion from
cardiac enlargement on a chest radiograph

Approximately

250 ml of fluid must be in the

pericardium to lead to a detectable change in the
size of the heart shadow on PA CXR

Small

effusions (100200 mL) may not cause

cardiomegaly even though they can cause
tamponade when they accumulate rapidly or when
the pericardial membrane is stiffened from fibrosis

Pearls: Presentation
In

the postoperative patient, a pericardial

effusion can be a sign of?
bleeding,

necessitating a return to the OR.

Tamponade

has a spectrum of presentations

depending on the rate of fluid collection.
mildly

reduced cardiac output with symptoms

of dyspnea and chest or abdominal
discomfort

circulatory

collapse

Diagnosis

Establishing the presence of pericardial effusion

Echocardiogram

(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 impact

Acute

cardiac tamponade

CASE
46

YO F with a history of metastatic

adenocarcinoma of the breast
3

days increasing dyspnea with exertion

and generalized weakness.

She

denies chest pain, cough/congestion,

any fevers/chills.

She

is currently between
chemotherapeutic courses

not

currently undergoing radiation

treatment.

She

presents awake/alert, not in

T 97.7 P 105 BP 110/80 O2

96% RR 20
Gen: WDWN, thin
CV: Tachycardic, RR,
Pulm: Lungs Clear bilateral,
chest wall shows left-sided
mastectomy.
Neck no JVD, trachea
midline

Treatment
If

patient is unstable, emergent

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

pigtail drainage catheter is typically placed

can also be done surgically:

subxiphoid,

VATS for pericardial window, pericardioperitoneal 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