Pericardial effusion and tamponade

Assessment

• History
  • • Symptoms of the effusion – hoarseness, dysphagia, cough, hiccups, SOB, nausea
    • Symptoms of pericarditis
    • Recent ACS-like pain
    • Past medical history – CRF, CCF, malignancy, amyloid, autoimmune (60% of effusions occur due to a known underlying disease or condition)
    • Symptoms of autoimmune disease
    • Trauma
    • Infective symptoms
    • Often asymptomatic
• Examination
  • • Pericardial rub
    • Distant heart sounds
    • Signs of tamponade
      • • Pulsus paradoxus (decrease in BP of > 12mmHg during inspiration)
        • Elevated JVP

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Size

• Small if < 10mm, 50-100ml of fluid
• Moderate 10-20mm, 100-50ml of fluid
• Large > 20mm, > 500ml of fluid

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Causes

• Malignancy (30%) – especially lung, breast, haematological
• Pericarditis / Infection (15%)
  • • TB (common cause in developing world)
    • viral (eg EBV, CMV, parvovirus, coxsackie, usually not large effusions)
    • Purulent bacterial (staph, strep)
    • Chagas myocarditis
• Autoimmune disease
  • • Especially SLE
    • Also RA, hypothyroidism
• Uraemia (or in fluid overloaded dialysis patients)
• Dressler’s
• Post-surgery/iatrogenic (15%) – eg. PPM insertion, AF ablation
• Trauma
• Type A aortic dissection (effusions occur in 10%)
• Drugs
  • • Chemotherapy (anthracyclines, cyclophosphamide, ATRA)
    • Checkpoint inhibitors
    • Hydralazine, Procainamide, Isoniazid – all cause drug induced SLE
• Previous radiotherapy
• Heart Failure – usually small and tamponade does not occur
• Cardiac amyloid
• Idiopathic – common

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Investigations

• CxR – Globular silhouette / cardiomegaly
• ECG – Low voltage and electrical alternans
• CT – for evidence of cancer, or systemic disease
• Bloods
  • • CRP (if normal, chance of cancer rises), troponin, TFTs, coagulation, immunoglobulins (amyloid), blood cultures, HIV
    • Autoantibodies (esp ANA, dsDNA, anti-smith), anti-histone antibodies if suspected drug induced SLE
• Pericardiocentesis
  • • For suspected TB, malignancy, purulent pericarditis, HIV, uncertain diagnosis
    • Send cytology, AFBs, PCR, ADA (adenosine deaminase) – 93% sensitive and specific for TB

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General management strategy

• If moderate/large, symptomatic and suspected bacterial or neoplastic cause (or tamponade) – pericardiocentesis
• If concomitant pericarditis – treat as pericarditis
• If concomitant systemic disease – treat systemic disease
• If large (>20mm), chronic (>3 months) and symptomatic with raised CRP – pericardiocentesis with drain and empiric anti-inflammatories
• If asymptomatic and mild idiopathic effusion – no specific follow up
• If asymptomatic with at least moderate effusion – could follow-up every 6 months
• Prognosis is related to aetiology

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Tamponade

• Increased pericardial pressure limits filling
• More likely if effusion has developed rapidly (and especially in haemopericardium)
• Most common causes – cancer, trauma/iatrogenic, pericarditis, TB
• Less common causes – autoimmune disease, pericardial injury syndrome, acute MI, aortic dissection, uraemia, bacterial infection, pneumocardium
• Features (biventricular failure)
  • • SOB, tachycardic, hypotensive
    • Elevated JVP and distended neck veins
    • Kussmaul’s sign (BP rises with inspiration – neck veins distend as you breath in)
    • Pulsus paradoxus (inspiratory reduction of the systolic blood pressure by at least 10 mmHg)
    • Muffled heart sounds and pericardial rub
    • Can be subclinical
• On echo
  • • Pericardial effusion
    • Right atrial collapse in systole, RV collapse in diastole
    • Swinging heart
    • IVC congestion
    • But echo can overdiagnose
• Avoid positive pressure ventilation (decreases cardiac output even further)

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If definite tamponade – assess for high-risk features 

• If score >6, often proceed to pericardiocentesis, if not, might postpone
• Aetiology
  • • Malignant disease or TB – 2 points
    • Recent radiotherapy, viral infection, recurrent pleural effusion, ESRF, immunosuppression – 1 point
    • Hypothyroidism and systemic autoimmune disease –minus 1 point
• Presentation
  • • Orthopnoea – 3 points
    • Pulsus paradoxus, rapid worsening of symptoms – 2 points
    • Dyspnoea/tachycardia, oliguria – 1 point
    • Hypotension, pericardial chest pain, friction rub – 0.5 points
    • Slow disease evolution – minus 1 point
• Imaging
  • • Circumferential large pericardial effusion – 3 points
    • LA collapse – 2 points
    • IVC dilated not collapsable, RV collapse – 1.5 points
    • Cardiomegaly on CxR, low voltage on ECG, moderate pericardial effusion, RA collapse, mitral/tricuspid respiratory flow variations, swinging heart – 1 point
    • Electrical alternans – 0.5 points
    • Small pericardial effusion – minus 1 point

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Emergency pericardiocentesis

• For tamponade, but not for haemopericardium
• Only for haemodynamically unstable patients
• Removing a few mls can significantly improve stroke volume and filling pressures
• Contraindications
  • • No absolute contraindications
    • Relative – aortic dissection, post infarction rupture of free wall, coagulopathy / anticoagulants, thrombocytopenia
• Use US guidance
• Approaches
  • • Subxiphoid approach most used
    • Apical
    • Parasternal
• Technique (Subxiphoid)
  • • Use local
    • Green needle (or large spinal needle) and 10ml syringe, inserted between xiphoid process and left costal margin at 45-degree angle, aiming for left mid clavicle.
    • Once below cartilage cage, lower to 15-20 degree angle
    • Needle will go towards anterior wall of RV
    • Aspirate as you go (advance at 1-2mm until fluid back). Best to make tiny jabs or risk tenting the pericardium
    • You should feel needle penetrate pericardium
    • Pericardium lies 2-3cm below skin in most people, more if obese
• If you have time – can use pericardiocentesis kit
  • • More likely done by cardiology in the cath lab
    • Uses Seldinger technique and a guidewire advanced through the sheath. Remove sheath, make small incision, dilate, catheter, aspirate
    • Semi reclined position of patient at 30 degrees, slightly rotated to left
    • Sterile field
    • Aspirate every 4-6 hours to avoid blocking, and drain up to 72 hours
    • CxR to exclude pneumothorax
• Apical approach
  • • Insert needle 1-2cm lateral to apex beat (between 5^th/6^th/7^th ICS).
    • Go over the rib, aiming for right clavicle.
    • Shorter path than subcostal approach. Might be easier.
• Parasternal approach – 5^th ICS near sternal margin, bit riskier.
• Complications
  • • Subxiphoid – Peritoneal cavity perforation, RA puncture, liver puncture
    • Apical – LV puncture, pneumothorax
    • Arrythmias
    • Laceration of coronary arteries
    • Pericardial decompression syndrome