Pericardial Disease — Tamponade, Pericarditis & Constriction

Cardiac tamponade

Definition. Cardiac tamponade is a life-threatening, slow or rapid compression of the heart due to the pericardial accumulation of fluid, pus, blood, clots or gas, as a result of inflammation, trauma, rupture of the heart or aortic dissection. ^[1]

Rate matters more than volume. The normal pericardial sac holds 10–50 mL of fluid. When fluid accumulates rapidly, as after wounds or iatrogenic perforation, even small amounts of blood can raise intrapericardial pressure within minutes and cause overt tamponade. Slow accumulation allows a large effusion to collect over days to weeks before pericardial pressure rises enough to cause symptoms. ^[1]

Tamponade is a last-drop phenomenon. The pericardial pressure–volume curve has an initial slow ascent followed by an almost vertical rise. The final increment of fluid produces critical cardiac compression, and the first decrement during drainage produces the largest relative decompression. ^[1]

Clinical signs

The signs. Clinical signs of tamponade include tachycardia, hypotension, pulsus paradoxus, raised jugular venous pressure, muffled heart sounds, decreased ECG voltage with electrical alternans, and an enlarged cardiac silhouette on chest X-ray when the effusion accumulated slowly. ^[1]

Pulsus paradoxus is the key bedside finding. It is conventionally defined as an inspiratory fall in systolic arterial pressure of more than 10 mmHg during normal breathing. It results from exaggerated ventricular interdependence: the total volume of the cardiac chambers is fixed, so the inspiratory increase in venous return to the right heart reduces left-sided volume and systemic blood pressure. ^[1]

What sets the severity. The magnitude of the clinical and haemodynamic abnormalities depends on the rate of accumulation and amount of pericardial contents, the distensibility of the pericardium, and the filling pressures and compliance of the cardiac chambers. ^[1]

Echocardiography and other tests

Echocardiography is the single most useful diagnostic tool. It identifies the effusion and estimates its size, location and haemodynamic impact, and it guides pericardiocentesis. ^[1]

Effusion size. On echo, effusions are graded semiquantitatively as mild (under 10 mm), moderate (10–20 mm) or large (over 20 mm). ^[1]

ECG and catheterisation. The ECG may show low QRS voltage and electrical alternans, both attributed to the damping effect of the fluid and the swinging heart. Catheterisation is rarely needed; it shows equilibration of average diastolic pressures and respiratory reciprocation of right and left pressures. Except in low-pressure tamponade, diastolic pressures throughout the heart are usually 15–30 mmHg. CT and CMR are generally unnecessary unless Doppler echocardiography is not feasible. ^[1]

Drainage

Drain without delay when unstable. Tamponade is treated by draining the pericardial fluid, preferably by needle pericardiocentesis with echocardiographic or fluoroscopic guidance. Surgical drainage is an alternative, especially for purulent pericarditis or urgent situations with bleeding into the pericardium. ^[1]

Guided, not blind. Pericardiocentesis should be guided by fluoroscopy or echocardiography under local anaesthesia. Blind procedures should not be used, because of the risk of laceration of the heart or other organs, except in very rare immediately life-threatening situations. ^[1]

The Mayo Clinic series. Over 21 years, 1127 therapeutic echo-guided pericardiocenteses were performed in 977 patients. Procedural success was 97%, with a total complication rate of 4.7% (major 1.2%, minor 3.5%). Cardiothoracic surgery replaced malignancy as the leading cause of effusions needing drainage, and with malignancy and catheter-procedure perforation accounted for nearly 70%. Extended catheter drainage rose from 23% to 75% of procedures while effusion recurrence and pericardial surgery fell. ^[4]

Tamponade in special settings

After cardiac surgery. Tamponade in the first hours after cardiac surgery is usually due to haemorrhage into the pericardial space, and surgical reintervention is mandatory. Later moderate to large postoperative effusions may progress to tamponade in about 10% of cases 1 month after surgery. ^[1]

Aortic dissection with haemopericardium. Confirm with emergency transthoracic echocardiography or CT. Controlled drainage of very small amounts of the haemopericardium can be attempted to stabilise the patient temporarily, to maintain blood pressure at about 90 mmHg. ^[1]

Recurrent effusions. A pericardial window drains a pericardial effusion, usually malignant, into the pleural cavity. Its main indication is recurrent large effusions or tamponade when pericardiectomy is high risk or life expectancy is reduced, as in neoplastic disease. Its results are less definitive, because the communication may close. ^[1]

Fluid analysis. Haemorrhagic fluid occurs in malignant, post-pericardiotomy, rheumatological, traumatic, idiopathic and viral effusions, and with iatrogenic injury. Cytology separates malignant from non-malignant effusions; bacterial culture can be diagnostic in sepsis, TB or HIV; and PCR for microbial agents on fluid and tissue can give a definite aetiological diagnosis. ^[1]

References15ShowHide

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