DESCRIPTION

• Pericardial tamponade is fluid accumulation in the pericardial space, resulting in an increase in intrapericardial pressure.
• Clinical syndrome of hypotension, tachycardia, and symptoms of dyspnea occurring when intrapericardial pressure exceeds intracardiac pressure.
• Slowly developing effusion results in pericardial stretch with tamponade occurring after the development of large volumes (1.0–1.5 L).
• Rapidly developing effusion leaves no time for pericardial stretch resulting in tamponade with small volumes (100–200 mL).
• Right heart chamber compression commonly seen in tamponade is specific but not sensitive for a diagnosis. Other 2D and Doppler findings are more sensitive and permit earlier diagnosis.
• Commonly, there is concordance of intrathoracic and intrapericardial pressure.
• 2D features of tamponade include: RA diastolic compression, RV diastolic compression, abnormal septal motion, dilated IVC, and a swinging heart.
• Doppler features of tamponade include: Inspiratory decline in mitral and pulmonary venous inflow, decreasing LVOT velocities, and hepatic vein diastolic flow reversal during systole.

EPIDEMIOLOGY

Incidence and prevalence are unknown

RISK FACTORS

Dissecting aortic aneurysm, cancer, MI, cardiac surgery, cardiac tumors, hypothyroidism, renal failure, radiation to the chest, connective tissue disorders, effusions, and trauma.

ETIOLOGY

• Tamponade occurs when intrapericardial pressure exceeds intrathoracic pressure.
• Most common causes of tamponade include trauma, malignancy, renal failure, post cardiac surgery, and idiopathic causes.
• Less common causes include viral syndromes, connective tissue disorders, radiation injury, MI, pacemaker placement, invasive electrophysiology studies, post interventional cardiac procedures, aortic dissection, and infection.

Outline

• Description
• Epidemiology
• Risk Factors
• Etiology

Signs and symptoms:

• Presentation is variable but often includes dyspnea, hypotension, and shock.

Physical Exam

• Nonspecific findings of tachycardia, tachypnea, and pulsus paradoxus (>12 mm Hg) are frequently present
• Beck’s triad consist of: 1) decreased BP, 2) increased central venous pressure, and 3) muffled diminished cardiac sounds. This is more common in acute rather than insidious cardiac tamponade.
• Kussmaul’s sign: Absence of the normally expected decrease, or paradoxical increase in central venous pressure with inspiration

DIAGNOSTIC TESTS & INTERPRETATION

EKG:

• Tachycardia, generally no tachycardia means no tamponade
• Diffuse low-voltage QRS on the precordial and limb leads
• Nonspecific PR and ST segment changes
• Nonspecific ST segment or T wave changes
• Electrical alternans is rare but highly specific periodic variation of the P-QRS complex amplitude.

Imaging

• CXR: Nonspecific findings of a globular cardiac silhouette or change in the patient’s usual cardiac silhouette
• Transthoracic echo (TTE): Most sensitive and specific noninvasive diagnostic test, see previously described 2D and Doppler findings
• Transesophageal echo (TEE): May be helpful in locating loculated effusions or clots that are difficult to visualize by TTE, especially post chest surgery or trauma
• Alternative diagnostic procedures: Right and left cardiac catheterization: Reveals equalization of chamber pressures in diastole

DIFFERENTIAL DIAGNOSIS

Hypovolemia, hemorrhage, sepsis, tension pneumothorax, pulmonary embolus, MI, systolic or diastolic heart failure, aortic dissection, and constrictive pericarditis

Outline

• Information
• Physical Exam
• Diagnostic Tests & Interpretation
  • Imaging
• Differential Diagnosis

First Line

• No definite proven drug therapy to prevent recurrent pericardial effusion
• Intrapericardial steroids are used to treat uremic pericarditis
• Intrapericardial tetracycline or chemotherapeutic agents are used to treat malignant pericardial effusions.
• Instillation of agents into the pericardial space may cause atrial or ventricular rhythm disturbance and may cause pericardial constriction.

SURGERY

Percutaneous techniques: Needle pericardiocentesis guided by echo, fluoroscopy, or both.

• EKG monitoring and complete cardiopulmonary resuscitative equipment are mandatory.
• Pericardiocentesis should only be performed by a skilled operator.
• Pericardiocentesis may be followed by placement of an indwelling catheter with a closed drainage system in which continuous drainage can occur.
• Invasive techniques:
• Pericardectomy (pericardial window): Performed by a surgeon with the advantage of pericardial biopsy for diagnosis in addition to culture and cell analysis.
• Pericardiectomy: Extensive removal of the pericardium, which requires a thoracotomy or median sternotomy.

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Clinical evaluation with history, physical exam, and follow-up echo.

PATIENT EDUCATION

Physicians, nursing staff

PROGNOSIS

• Variable and dependent upon etiology
• Affected by whether or not constrictive pericarditis develops leading to impairment of cardiac function (diastolic) and need for further surgical treatment.

COMPLICATIONS

• Myocardial rupture during pericardiocentesis
• Pneumothorax
• Coronary artery perforation
• Infection
• Pericardial fluid reaccumulation

Outline

• Follow-Up Recommendations
  • Patient Monitoring
• Patient Education
• Prognosis
• Complications

CODES

ICD9

423.3 Cardiac tamponade

SNOMED

35304003 cardiac tamponade (disorder)

ADDITIONAL READING

• Gilon D, Mehta R, Oh J, et al. Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection. Am J Cardiol. 2009;103(7):1029–1031.
• Holmes DR Jr, Nishimura R, et al. Iatrogenic pericardial effusion and tamponade in the percutaneous intracardiac intervention era. J Am Coll Cardiol Interv. 2009;2:705–717.
• Oh JK, Sewand JB, Tajik AJ. The Echo Manual (Ch. 17). Philadelphia: Lippincott Williams & Wilkins, 2007.
• Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684–690.
• Tsang TSM, et al. Diagnosis and management of cardiac tamponade in the era of echocardiography. Clinical Cardiology. 1999;22:446–452.

Sala R. Pradhan

Timothy E. Paterick