pericardial/Tamponade

Pericardial Disease and Pericardial Effusion

Pericardial Effusion

Definition

• Pericardial effusion: An abnormal accumulation of fluid within the pericardial cavity or between serosal layers.

• Normal pericardial serous fluid volume: 15 to 50 mL.

• Classification of pericardial effusions:

  • Transudative

  • Exudative

  • Hemorrhagic

  • Malignant

  • Classified by temporal development: acute, subacute, and chronic (>3 months).

Etiology

• Idiopathic

• Infections:

  • Mycobacterium tuberculosis

  • Bacterial:

  • Examples: Staphylococcus, Streptococcus, pneumococcus, Hemophilus, Neisseria, Chlamydia

  • Viral:

  • Examples: Coxsackie virus, echovirus, adenovirus, CMV, HIV

• Malignancies:

  • Metastatic (e.g., lung cancer, breast cancer, lymphoma, leukemia, melanoma)

• Iatrogenic Causes:

  • Pacemaker, ICD, or CRT insertion

  • Post-ablation intervention

  • Percutaneous coronary intervention

  • Post-cardiac surgery and CPR

• Connective Tissue Diseases:

  • Systemic lupus erythematosus (SLE), rheumatoid arthritis, scleroderma

• Metabolic Diseases:

  • Hypothyroidism, chronic renal failure

• Other Causes:

  • Pericarditis, blunt chest trauma, penetrating chest wall injury, aortic dissection, myocarditis, post-myocardial infarction

History

Symptoms Related to Pericardial Effusion:

• Chest Pain

• Dyspnea (may indicate cardiac tamponade or constrictive pericarditis)

• Fatigue

• Fever, Sweats, Chills

• Edema

Physical Examination

• Signs indicating possible complications:

  • Tachypnea (may indicate cardiac tamponade)

  • Palpitations (due to atrial arrhythmias)

  • Odynophagia (suggests large effusion)

• Cardiovascular Findings:

  • Quiet, hypodynamic heart with cardiomegaly

  • Elevated jugular venous pressure

Complications:

• Cardiac Tamponade

Cardiac Auscultation:

• Distant Heart Sounds

• Ewart's Sign (suggests large effusion)

Electrocardiogram Findings:

• Sinus Tachycardia

• Low voltage of QRS complexes throughout the ECG

• Electrical Alternans (suggests large effusion)

• Arrhythmias: supraventricular and/or ventricular

Imaging Studies:

1. Chest X-ray/CMR/CT:

   • Normal (suggests no, small, or moderate effusions)

   • Cardiomegaly with clear lungs (may indicate pericardial effusion)

   • Globular-shaped heart (“water bottle heart”) due to pericardial effusion

   • CMR/CT allows evaluation of pericardial effusion, type of effusion (e.g., bloody vs. exudative), pericardial thickness, and echocardiographic signs of cardiac tamponade.

2. Cardiac Catheterization:

   • Limited role

   • Increased and equalized diastolic intracardiac pressures with decreased stroke volume suggests cardiac tamponade.

Medical Treatment:

• Treat underlying etiology

• Medications:

  • NSAIDs, Colchicine, Corticosteroids

Surgical Treatment:

• Procedures:

  • Pericardiocentesis (to identify etiology or relieve cardiac tamponade)

  • Pericardial window

  • Pericardiectomy

Imaging Techniques (M-mode/2D):

• Echocardiography:

  • Echo-free space between the epicardium and the pericardium, less than 15 to 35 mL needed to detect this space.

  • Swinging Heart: Suggests large effusion.

  • Loculated Effusion: Especially relevant post-cardiac surgery/trauma.

  • Fibrin Strands: May indicate long-standing effusion or inflammatory, hemorrhagic, malignant etiology.

  • Inferior vena cava plethora may indicate increased right atrial pressure.

  • To semi-quantitate the amount of pericardial effusion:

    • Measure maximal diastolic diameters and multiply by 100.

  • 3D Echocardiography: Provides information regarding fluid location and volume.

Doppler Studies:

• PW/CW Doppler:

  • Respiratory variation of mitral valve and tricuspid valve peak velocities and velocity time integrals suggest cardiac tamponade.

Transesophageal Echocardiography:

• May improve the detection of loculated effusions or hematoma, especially post-cardiac surgery or trauma.

Differential Diagnosis

• Loculated effusion can mimic a pericardial cyst. Differentiation:

  • Cysts are distinct from the pericardial layer, typically visible with a discrete pericardial layer surrounding the cyst, usually located at the right costophrenic angle.

• Fat Deposits:

  • TTE can visualize epicardial fat layer, paracardial fat layer, and pericardial fat layers.

  • Epicardial fat appears on echocardiogram as anterior echo-free space and may be confused with pericardial effusion.

• Other Considerations:

  • A pericardial effusion is anterior to the descending thoracic aorta, while pleural effusions are posterior. Effusions do not change with respiration; pleural effusions may change with respiration.

Important Note

• A large effusion can obscure the visibility of certain diagnoses until the effusion resolves.

• It collects first behind the right atrium and is best visualized in specific echocardiographic views.

• The pericardial effusion may also collect in various existing sinuses.

• Severity of effusion can be classified into:

  • Small (<100 mL)

  • Moderate (100-500 mL)

  • Large (>500 mL)

  • Very Large (>2.5 cm)

Pericarditis

Definition

• Pericarditis: Inflammation of the pericardium; may lead to pericardial effusion.

• Types: Acute, subacute, recurrent.

Etiology

• Idiopathic

• Infectious causes:

  • Viral (e.g., echovirus, coxsackievirus, adenovirus, cytomegalovirus, hepatitis B, infectious mononucleosis, HIV/AIDS)

  • Bacterial (e.g., pneumococcus, staphylococcus, streptococcus, mycoplasma, Lyme disease, hemophilus influenzae)

  • Mycobacteria (e.g., mycobacterium tuberculosis)

  • Fungal (e.g., histoplasmosis, coccidiomycosis)

  • Protozoal infections

• Immune-Inflammatory Conditions:

  • Including connective tissue diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis, scleroderma)

  • Arteritis (e.g., polyarteritis nodosa, temporal arteritis)

• Post-Myocardial Infarction:

  • Early and late (Dressler syndrome)

• Trauma:

  • Blunt or penetrating, post-cardiopulmonary resuscitation

• Congenital: Cysts; congenital absence

• Miscellaneous: Chronic renal failure, hypothyroidism, amyloidosis, aortic dissection, heart failure, pregnancy, pulmonary hypertension, Trisomy 21 (Down syndrome).

History

• Symptoms vary depending on the etiology:

  • Positional Chest Pain: Precordial, sharp, severe, worsens with inspiration, coughing, or lying down; relief upon sitting upright or leaning forward.

  • Dyspnea (possible indication of cardiac tamponade or constrictive pericarditis)

  • Cough

  • Fever, Sweats, Chills

  • Tachypnea

  • Palpitations (due to atrial arrhythmias)

Physical Examination

• Quiet, hypodynamic heart with cardiomegaly suggests pericardial effusion.

Complications

• Cardiac Tamponade

• Chronic pericarditis: May lead to constrictive pericarditis.

Cardiac Auscultation Findings

• Pericardial Friction Rub: Cardinal sign (may require exercise/continuity of auscultation with posture changes to elicit).

• Distant Heart Sounds: Suggests pericardial effusion.

• Ewart's Sign: Suggests large effusion.

Laboratory Findings

• Elevated White Blood Count

• Elevated Cardiac Enzymes (e.g., troponin)

• Elevated C-reactive Protein and Erythrocyte Sedimentation Rate: Confirms inflammation.

Electrocardiogram Findings

• Elevated ST Segments with upright T waves (hours to days; classic finding).

• PR Segment Depression: Common finding.

• Sinus Tachycardia

• Reduced QRS Voltage throughout the ECG.

• Electrical Alternans: Suggests large effusion.

• Rhythm disturbances (e.g., atrial fibrillation, atrial flutter, supraventricular tachycardia).

Imaging Studies

Chest X-ray/CMR/CT

• Cardiomegaly with clear lungs may indicate pericardial effusion.

• Noncalcified pericardial thickening.

• Enhancement of the thickened visceral and parietal surfaces of the pericardial sac with contrast.

• CMR/CT may assist in characterizing the effusion.

Cardiac Catheterization

• Limited role; assess diastolic intracardiac pressures.

Medical Treatment

• Treat underlying etiology (e.g., uremia).

• Restrictions on exercise.

• Analgesics (e.g., aspirin, indomethacin, ibuprofen).

• Steroid Therapy: (e.g., prednisone).

• Immunosuppression Therapy for recurrent pericarditis (e.g., colchicine, azathioprine).

Surgical Treatment

• Procedure Options:

  • Pericardiocentesis: To relieve tamponade or identify the etiology.

  • Pericardial Window: May allow for biopsy.

  • Pericardiectomy.

Imaging Techniques (M-mode/2D)

• Echocardiography:

  • Shows echo-free space and swinging heart may suggest large effusion.

• Doppler Studies:

  • Significant respiratory variation of valvular peak velocities suggests cardiac tamponade.

• Transesophageal Echocardiography may improve detection.

Important Note

• Patients with pericarditis may not show pericardial effusion on echocardiography (dry pericarditis).

• Large effusions can obscure diagnosis accuracy until resolved; certain findings suggest full workup delays.