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Pericardial effusion and cardiac tamponade

Last updated: January 2, 2021

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Pericardial effusion is the acute or chronic accumulation of fluid in the pericardial space (between the parietal and the visceral pericardium) and is often associated with a variety of underlying disorders. The fluid can be either bloody (e.g., following aortic dissection) or serous (usually idiopathic). As the pericardium is rather stiff, the capacity of the pericardial space is limited. In chronic effusion, the pericardium can stretch to a certain degree, accommodating slightly more fluid. In the acute setting, however, the added volume quickly exceeds the maximum capacity of the pericardial space. In both cases, the end result is often cardiac tamponade: compression of the heart that can lead to a life-threatening reduction in cardiac output. Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. Echocardiography is the most important diagnostic procedure and usually reveals an anechoic pericardial space. Treatment depends on hemodynamic stability: unstable patients require quick pericardial fluid drainage, through either pericardiocentesis or surgery, whereas in stable patients, treatment focuses on the underlying disease.

Cardiac tamponade: pericardial fluid collection (e.g., bloody or serous) → ↑ pressure in the pericardial space compression of the heart (especially of the right ventricle due to its thinner wall) → interventricular septum shift toward the left ventricle chamber → ↓ ventricular diastolic filling stroke volume (and venous congestion) → cardiac output and equal end-diastolic pressures in all 4 chambers [3]

Pericardial effusion [4]

Tamponade [4]

Approach

In unstable patients and those in cardiac arrest with suspected tamponade, pericardiocentesis should not be delayed for diagnostic confirmation.

Echocardiography

Echocardiography is a quick and safe diagnostic tool for detecting pericardial effusions and pericardial tamponade.

ECG

Imaging

Investigation of the underlying etiology

Pericardiocentesis with pericardial fluid analysis [12][13]

Interpretation of pericardial fluid samples
Fluid type Appearance Etiology [12]
Transudate
  • Clear

Exudate

  • Cloudy, chylous
Blood
  • Hemorrhagic
Purulent [16]
  • Thick, yellowish-white, cloudy

Laboratory studies and specific investigations [10]

Investigation of underlying etiology in pericardial effusion
Suspected etiology Additional investigations to consider
Acute pericarditis
Uremic pericardial effusion
Autoimmune disease
Malignancy
Hypothyroidism
Aortic dissection
Postpericardiotomy syndrome
Trauma

In cardiac tamponade, the mainstay of treatment is urgent decompression of the heart. In pericardial effusion, treatment is focused on management of the underlying cause with a more limited role for pericardial fluid drainage.

Cardiac tamponade

Acute pericardial effusion with pericardial tamponade is a life-threatening condition that requires immediate pericardial decompression.

Positive pressure ventilation can lead to hemodynamic decompensation in patients with cardiac tamponade.

Pericardial effusion

Small pericardial effusions may resolve with treatment of the underlying cause. In an uncertain diagnosis or with larger effusions that are causing symptoms, pericardial fluid drainage should be performed.

Pericardial fluid drainage

Pericardiocentesis

Pericardial window

Pericardiotomy [10]

  • Description: surgical or percutaneous opening is made in the pericardial sac to drain pericardial fluid
  • Indications
  • Complications: The mortality rate varies from 8–19%, depending on the underlying etiology. [26]
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