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Pericardial effusion and cardiac tamponade

Last updated: October 4, 2021

Summarytoggle arrow icon

Pericardial effusion is the acute or chronic accumulation of fluid in the pericardial space (between the parietal and the visceral pericardium) and is often associated with a variety of underlying disorders. The fluid can be either bloody (e.g., following aortic dissection) or serous (usually idiopathic). As the pericardium is rather stiff, the capacity of the pericardial space is limited. In chronic effusion, the pericardium can stretch to a certain degree, accommodating slightly more fluid. In the acute setting, however, the added volume quickly exceeds the maximum capacity of the pericardial space. In both cases, the end result is often cardiac tamponade: compression of the heart that can lead to a life-threatening reduction in cardiac output. Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. Echocardiography is the most important diagnostic procedure and usually reveals an anechoic pericardial space. Treatment depends on hemodynamic stability: unstable patients require quick pericardial fluid drainage, through either pericardiocentesis or surgery, whereas in stable patients, treatment focuses on the underlying disease.

Cardiac tamponade: pericardial fluid collection (e.g., bloody or serous) → ↑ pressure in the pericardial space compression of the heart (especially of the right ventricle due to its thinner wall) → interventricular septum shift toward the left ventricle chamber ↓ ventricular diastolic filling stroke volume (and venous congestion) → cardiac output and equal end-diastolic pressures in all 4 chambers [3]

Pericardial effusion [4]

Tamponade [4]

Approach

In unstable patients and those in cardiac arrest with suspected tamponade, pericardiocentesis should not be delayed for diagnostic confirmation.

Echocardiography

Echocardiography is a quick and safe diagnostic tool for detecting pericardial effusions and pericardial tamponade.

Epicardial fat can be mistaken for pericardial fluid on echocardiography. However, unlike fluid, it tends to be brighter, moves along with the myocardium, and does not collect in dependent regions. [9]

ECG

Imaging

∼ 250 mL of pericardial fluid must be present before an effusion is visible on chest x-ray!

Investigation of the underlying etiology

Pericardiocentesis with pericardial fluid analysis [15][16]

Interpretation of pericardial fluid samples
Fluid type Appearance Etiology [15]
Transudate
  • Clear

Exudate

  • Cloudy, chylous
Blood
  • Hemorrhagic
Purulent [19]
  • Thick, yellowish-white, cloudy

Laboratory studies and specific investigations [12]

Investigation of underlying etiology in pericardial effusion
Suspected etiology Additional investigations to consider
Acute pericarditis
Uremic pericardial effusion
Autoimmune disease
Malignancy
Hypothyroidism
Aortic dissection
Postpericardiotomy syndrome
Trauma

Approach

Procedures

Pericardiocentesis

Obtain an erect chest x-ray after pericardiocentesis to exclude iatrogenic pneumothorax and pneumopericardium! [26]

Treat hemopericardium due to penetrating chest injury surgically, e.g., with pericardial window, as soon as possible. Only consider pericardiocentesis as a temporizing measure if surgery is unavailable. [23]

Surgical procedures [12]

These are commonly performed for patients with traumatic, purulent, loculated, rapidly reaccumulating, or malignant effusions. [12]

Acute pericardial effusion with pericardial tamponade is a life-threatening condition that requires immediate pericardial decompression.

Rapid evaluation of unstable patients

Cardiac tamponade is a clinical diagnosis, however, clinical features are poorly sensitive and the diagnosis is often confirmed retrospectively. [30]

The most common underlying causes of cardiac tamponade are cardiac interventions (e.g., PCI, pacemaker implantation), malignancy, infectious or inflammatory pericarditis, mechanical complications of MI, and aortic dissection. [34]

Cardiac arrest due to suspected cardiac tamponade

See also “Cardiac arrest and cardiopulmonary resuscitation.”

Urgent pericardial fluid drainage

Hemodynamic support

Manage as obstructive shock.

Positive pressure ventilation can lead to hemodynamic decompensation in patients with cardiac tamponade.

Subsequent management

  • Identify and treat the underlying cause: See “Investigation of underlying etiology” in “Diagnostics.”
  • Monitor for complications and reaccumulation.
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