Pericardial Tamponade DRTEIMOURI H

Cardiac Tamponade 3 possible pericardial compression syndromes accumulation of pericardial fluid under pressure and may be acute or subacute Constrictive pericarditis scarring and consequent loss of elasticity of the pericardial sac Effusive-constrictive pericarditis constrictive physiology with a coexisting pericardial effusion Chicken or egg? Elevated wedge and Rt sided pressures s/p drainage

Cardiac Tamponade Compression of all cardiac chambers due to increased pericardial pressure Pericardium has some compliance with increased pressure, but once that is exceeded it begins to impair diastolic compliance, reducing cardiac filling Much of the pressure is transmitted to the Rt Vent/Atrium (lower pressure systems) which causes which causes bulging of interventricular septum and decreased Lt ventricular compliance and filling

Pericardial Effusion Pericardium typically has 20-50 ml of fluid Acuity of fluid accumulation plays a large role in pericardial compliance Rapid accumulation (trauma) gives pericardium no time to adjust, therefore a small amount of fluid can cause tamponade Slow accumulation allows pericardial compliance to increase allowing a larger volume of fluid into sac However, when pericardial pressures > Rt ventricular pressure tamponade physiology can occur

Causes of Pericardial Tamponade Malignancy HIV infection Infection - Viral, bacterial (tuberculosis), fungal Drugs - Hydralazine, procainamide, isoniazid, minoxidil Postcoronary intervention (ie, coronary dissection and perforation) Trauma Cardiovascular surgery (postoperative pericarditis) Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome) Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis Radiation therapy Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation, pericardiocentesis, or central line insertion Uremia Idiopathic pericarditis Complication of surgery at the esophagogastric junction such as antireflux surgery Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)

Symptoms Dyspnea, tachycardia, tachypnea Cold, clammy extremities Malignancy – weight loss, fatigue, anorexia Chest pain – pericarditis, MI Joint pain – connective tissue Renal failure – uremia Medications – drug related lupus Recent procedure – pacemaker, central line TB – night sweats, fever Radiation – cancer history

Physical Exam Findings Beck’s Triad – JVD, hypotension, diminished heart sounds Hepatomegaly Evidence of chest wall trauma Pulsus paradoxsus > 12 mm Hg Kussmaul sign - paradoxical increase in venous distention and pressure during inspiration Abolished y descent

Diagnosis EKG – low voltage, sinus tach, PR depression, electrical alternans

Diagnosis CXR enlarge cardiac silhouette, water bottle shaped heart

Diagnosis Echocardiogram (tamponade is clinical diagnosis) Pericardial effusion Early diastolic collapse of the right ventricular free wall Late diastolic compression/collapse of the right atrium Swinging of the heart in its sac LV pseudohypertrophy

Diagnosis Rt Heart Catheterization If patient is stable and diagnosis is in doubt can perform a Rt heart catheterization to measure Rt sided pressures In tamponade, near equalization (within 5 mm Hg) of the right atrial, right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure Rt atrial pressure tracings show abolished systolic y descent

Treatment What to do while your waiting on CT Surgery… Oxygen Volume expansion with blood, plasma, or saline to maintain adequate intravascular volume Bed rest with leg elevation This may help increase venous return. Inotropic drugs (i.e. dobutamine) Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.

Treatment Once CT Surgery or Cardiology arrives Recurrent effusion Pericardiocentesis can be fluoroscopically or TTE guided Pericardial window involves the surgical opening of a communication between the pericardial space and the intrapleural space Recurrent effusion Pericardectomy Pericardial-peritoneal shunt Pericardiodesis - corticosteroids, tetracycline, or antineoplastic drugs can be instilled into the pericardial space sclerosing the pericardium

Treatment No one shows up and cardiac arrest is called Emergency subxiphoid percutaneous drainage A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%

References Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684. Chou, TC. Electrocardiography in Clinical Practice: Adults and Pediatrics, 4th ed, WB Saunders, Philadelphia 1996 Reydel, B, Spodick, DH. Frequency and significance of chamber collapses during cardiac tamponade. Am Heart J 1990; 119:1160 Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004; 363:717. Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade: hemodynamic observations in man. Circulation 1978; 58:265. Bruch, C, Schmermund, A, Dagres, N, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol 2001; 38:219. Gillam, LD, Guyer, DE, Gibson, TC, et al. Hydrodynamic compression of the right atrium: A new echocardiographic sign of cardiac tamponade. Circulation 1983; 68:294. Fitchett, DH, Sniderman, AD. Inspiratory reduction in left heart filling as a mechanism of pulsus paradoxus in cardiac tamponade. Can J Cardiol 1990; 6:348