Pericardial effusion and Cardiac tamponade

1. Pericardial effusion and Cardiac tamponade Sunitha Daniel

2. Outline • Brief Overview • Causes • Clinical Presentation • Investigations • Management Update

3. Overview • Abnormal amount of and/or an abnormal character to fluid in the pericardial space. • Normal fluid 15-50ml • Among malignancies lung-highest prevalance(37%)

4. Causes Primary • Acute inflammatory pericarditis (infectious-viral(HIV),bacterial,fungal autoimmune) • Previously unknown neoplasia • Idiopathic Secondary • Acute MI • Cardiac surgery • Trauma • Metastasis • Chest irradiation • End-stage renal failure • Hypothyroidism • Autoimmune diseases • Pulm HTN • Chylopericardium • Drugs : procainamide, hydralazine, INH, minoxidil, phenytoin, anticoagulants

6. Clinical features Symptoms • Chest pain. • Syncope • Palpitations • Cough • Dyspneoa • Hoarseness Signs • Beck triad • Pulsusparadoxus • Pericardial friction rub • Tachycardia • Hepatojugularreflux • Tachypnea • Decreased breath sounds • Ewart sign • Weakened peripheral pulses, edema, and cyanosis.

7. ecg Stage I - Diffuse ST-segment elevation and PR-segment depression Stage II - Normalization of the ST and PR segments Stage III - Widespread T-wave inversions: Stage IV - Normalization of the T waves

8. cxr • Enlarged cardiac silhouette (water-bottle heart) • Pericardial fat stripe. • Pleural effusion(1/3)

9. echocardiography • Echo-free space between the visceral and parietal pericardium • Small effusions < 10 mm and are generally seen posteriorly • Moderate 10-20 mm and are circumferential. • Large :>20 mm

10. CT &MRI • loculatedpericardial effusions. • CT detects 50ml fluid • MRI 30ml fluid. • MRI for hemorrhagic and non hemaorrhagic

11. treatment • Based on etiology • Medical • Surgical

12. medical • Aspirin/NSAIDs – viral/idiopathic • Colchicine –relapsing pericarditis • Steroids- systemic inflammation/pregnancy/autoimmune • Antibiotics • Chemotherapy

13. Management strategy

14. INDICATIONS FOR PERICARDIAL DRAINAGE PROCEDURES • Diagnostic or therapeutic purposes • Not routinely for diagnosis-poor yield. • Strong suspicion of purulent or tuberculouspericarditis. • Malignancy • Asymptomatic patients with massive idiopathic chronic pericardial effusion

15. PROCEDURES OF PERICARDIAL DRAINAGE • Pericardiocentesis: idiopathic/viral • Indwelling pericardial catheter: neoplastic • Percutaneousballonpericardiotomy • Subxiphoidpericardiotomy: purulent • Pleuropericardial window • Partial pericardiectomy • Wide anterior pericardiectomy

16. neoplastic pericardial involvement • relapses in as many as 40%-50% of patients • terminal patients-pericardiocentesis alone • patients with a longer expected survival-Indwelling pericardial catheters( 75% success rate) • Balloon pericardiotomy

17. Management strategy

18. references • Diagnosis and management of pericardial effusion World J Cardiol. 2011 May 26; 3(5): 135–143. • Management of pericardial effusion Eur Heart J first published online November 2, 2012 doi:10.1093/eurheartj/ehs372 • http://emedicine.medscape.com/article/157325-overview