Malignant cardiac tamponade — case discussion

Presentation

Practice case (not a real patient). A 67-year-old man in Sydney with metastatic lung cancer presents to the emergency department with 10 days of exertional dyspnoea progressing to orthopnoea, and a feeling of fullness in the chest.^[1] He is tachycardic with a blood pressure of 88/62 mmHg, an elevated jugular venous pressure, quiet heart sounds and a pulsus paradoxus of 18 mmHg.^[1] His ECG shows sinus tachycardia, low QRS voltages and electrical alternans.^[1]

Step 1 — Is this tamponade?

Discussion:

• ESC 2025 calls tamponade a clinical diagnosis based on a suggestive history, symptoms, signs and imaging confirmation by echocardiography.^[1]
• He has the Beck triad of hypotension, increased JVP and quiet heart sounds, plus pulsus paradoxus (an inspiratory fall in systolic pressure of at least 10 mmHg).^[1]
• His ECG fits: ESC 2025 says tamponade usually shows tachycardia, low QRS voltages and electrical alternans, from the damping effect of the fluid and the swinging heart.^[1]
• Bedside echocardiography shows a circumferential 27 mm effusion with diastolic right atrial and right ventricular collapse; ESC 2025 Table 17 gives these signs a specificity of 33%–100% and 72%–100%.^[1]

Step 2 — How urgent, and what now?

Discussion:

• Figure 12 scoring: malignant disease 2, orthopnoea 3, dyspnoea 1, pulsus paradoxus over 10 mmHg 2, circumferential large effusion 3, right atrial collapse 1 and right ventricular collapse 1.5, well over 6 points from all three categories.^[1]
• Immediate pericardiocentesis should be considered when there are more than 6 points from at least two categories (criteria based on expert consensus); he is also unstable, so drainage should be done without delay.^[1]
• He is admitted: ESC 2025 says tamponade identifies high-risk patients who should be admitted for therapy and monitoring.^[1]
• While the team prepares, avoid positive airway pressure ventilation and diuretics; temporary fluid can help to stabilise him.^[1]
• C-reactive protein is sent before the procedure, because ESC 2025 says it can increase afterwards.^[1]

Step 3 — Drainage

Discussion:

• ESC 2025 recommends pericardiocentesis for patients with cardiac tamponade to relieve symptoms and establish the diagnosis of malignant pericardial effusion (Class I, Level C).^[1]
• An experienced operator uses echocardiographic guidance and a needle, usually 16–20 gauge, into the sub-xiphoid space.^[1]
• Whenever possible, pericardiocentesis should not drain a large amount of fluid (usually under 500 mL), to prevent pericardial decompression syndrome.^[1]
• Extended pericardial drainage (3–6 days) is recommended for suspected or definite neoplastic effusion to prevent recurrence (Class I, Level B).^[1]
• Cytological analysis of pericardial fluid is recommended in neoplastic pericarditis to confirm malignant pericardial disease (Class I, Level C), remembering that in almost two-thirds of patients with documented malignancy, pericardial involvement is caused by non-malignant diseases.^[1]

Step 4 — After the drain

Discussion:

• His blood pressure recovers. ESC 2025 defines effusive–constrictive pericarditis haemodynamically as right atrial pressure failing to fall by 50% or more, or to below 10 mmHg, despite intrapericardial pressure lowered to near 0 mmHg by pericardiocentesis; tricuspid regurgitation or right heart failure may also cause a persistently raised right atrial pressure after effective pericardiocentesis.^[1]
• Cytology confirms malignant cells. Systemic antineoplastic treatment is recommended in confirmed neoplastic aetiology (Class I, Level C), planned by a multidisciplinary team.^[1]
• Malignant effusions show a high recurrence rate (more than 50%); additional interventions for recurrent effusions may include pericardiotomy, a pericardial window and percutaneous balloon pericardiotomy, all palliative.^[1]
• Sclerosing agents such as talc should not be used, because of reduced efficacy compared with a pericardial window or pericardiectomy and the risk of inducing constriction.^[1]

Step 5 — Prognosis and the Australian picture

Discussion:

• ESC 2025 says tamponade with cancer and metastatic pericardial involvement has a bad short-term prognosis, as a sign of advanced disease.^[1]
• In the New South Wales cohort of patients hospitalised with pericardial disease (2004–2021, retrospective observational), malignancy was associated after adjustment with much higher in-hospital mortality (OR 4.33 when pericardial disease was the primary diagnosis).^[5]
• In a retrospective cohort of all hospitalised patients with pericardial disease in the NSW Admitted Patient Data Collection (2004–2021), constriction found during follow-up was more common after pericardiocentesis (HR 3.6).^[6]