Cardiac tamponade and management Dr. Md. Rezwanul Hoque MBBS, MS, FCPS, FRCSG, FRCSEd Associate Professor Department of Cardiac Surgery BSMMU, Dhaka, Bangladesh. © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Definition Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Cardiac tamponade is a medical emergency. 

Cardiac Tamponade Pericardial compression syndromes- 3 causes 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

Pathophysiology The Primary abnormality is rapid or slow compression of all cardiac chambers secondary to increased intrapericardial pressure. The pericardium can stretch over time but at any instant it is inextensible making the heart compete with the increased pericardial contents for the fixed intrapericardial volume. The key elements are the rate of fluid accumulation relative to pericardial stretch and the effectiveness of compensatory mechanisms. The true filling pressure of the heart is the myocardial “transmural pressure” which is intracardiac pressure minus pericardial pressure. During inspiration , the right heart increases its filling at the expense of the left heart, so that its transmural pressure transiently improves and then reverts during expiration. Much of the pressure is transmitted to the Right Vent/Atrium (lower pressure systems) which causes bulging of interventricular septum and decreased Lt ventricular compliance and filling.

Slow vs. rapid fluid accumulation The amount of pericardial fluid needed to impair the diastolic filling of the heart depends on the rate of fluid accumulation and the compliance of the pericardium. Rapid accumulation of as little as 150 mL of fluid can result in a marked increase in pericardial pressure and can severely impede cardiac output , whereas 1000 mL of fluid may accumulate over a longer period without any significant effect on diastolic filling of the heart. This is due to adaptive stretching of the pericardium over time. A more compliant pericardium can allow considerable fluid accumulation over a longer period without hemodynamic insult. Spodick, D. H. N Engl J Med 2003;349:684-690

Acute vs. Chronic Pericardium-relatively stiff Reserve Volume 10-20cc Compromise volume 150cc Slow accumulation - pericardial stretch Volumes to 2 liters reported in chronic disease Spodick, D. (1985) Threshold of pericardial constraint. J Am Coll Cardiol. 6, 296-297.

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)

Postoperative pericardial effusion The management of postoperative pericardial effusion is a common problem in clinical practice—50% to 85% of patients develop effusion after cardiac surgery. Cardiac tamponade, the most feared complication, occurs in approximately 2% of patients and is observed even among those who have a subacute course and are beyond 7 days after surgery. The pathogenesis of postoperative effusions is not completely understood. Early effusions (within 5 to 7 days of surgery) are probably related to pericardial bleeding and perioperative trauma, whereas late effusions are considered the possible consequence of pericarditis. These late effusions often characterize the so-called “postpericardiotomy syndrome” reported after 10% to 45% of heart surgery cases. Massimo Imazio, Annals of int. med. February 2, 2010vol. 152 no. 3 186-187

Postperiocardiotomy syndrome The postpericardiotomy syndrome was initially described as a condition that followed surgery for rheumatic mitral stenosis  and congenital heart defects. It is an example of the pericardial injury syndrome, a term that includes different pericardial diseases (late post–myocardial infarction pericarditis and posttraumatic and iatrogenic pericarditis) characterized by an initial insult, usually with pericardial bleeding followed 1 to 3 weeks later by pericarditis with effusion. The pathogenesis of the postpericardiotomy syndrome is presumed to be autoimmune, but alternative hypotheses implicate acquired infection. Diagnosis requires the presence of at least 2 of the following: fever lasting beyond the first postoperative week without other causes, pleuritic chest pain, friction rub, pleural effusion, and new or worsening pericardial effusion . Massimo Imazio, Annals of int. med. February 2, 2010vol. 152 no. 3 186-187

Symptoms Dyspnea, tachycardia, tachypnea Air hunger, anorexia, fatigue, dysphagia. 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

Cardiac Tamponade 1873 Dr. Kussmaul Beck’s triad Kussmaul sign-inspiratory jugular venous distention Pulsus Paradoxus- “pulse simultaneously slight and irregular, disappearing during inspiration and reappearing upon expiration Beck’s triad Decreasing arterial pressure, increasing venous pressure and quiet heart Kussmaul, A, & Stern M. (1873) Pericarditis and the paradox pulse. Berl Klin Woehenscher. 8. Beck, C. (1935) Two cardiac compression triads. JAMA. 104, 714-716.

Elevated JVD Kussmaul’s sign x descent is preserved y descent is decreased or absent Kussmaul’s sign This was described by Adolph Kussmaul as a paradoxical increase in venous distention and pressure during inspiration. This sign is usually observed in patients with constrictive pericarditis but occasionally is observed in patients with effusive-constrictive pericarditis and cardiac tamponade.

Pulsus Paradoxus >10 mmHg decrease in SBP on inspiration Present in: pulmonary embolism, asthma, COPD Absent in: rapid heart rate, irregular rhythm, ASD, severe AR, regional tamponade, increased LV diastolic pressure

Pulsus paradoxus or paradoxical pulse This is an exaggeration (>12 mm Hg or 9%) of the normal inspiratory decrease in systemic blood pressure. To measure the pulsus paradoxus, patients are often placed in a semirecumbent position; respirations should be normal. The blood pressure cuff is inflated to at least 20 mm Hg above the systolic pressure and slowly deflated until the first Korotkoff sounds are heard only during expiration. At this pressure reading, if the cuff is not further deflated and a pulsus paradoxus is present, the first Korotkoff sound is not audible during inspiration. As the cuff is further deflated, the point at which the first Korotkoff sound is audible during both inspiration and expiration is recorded. If the difference between the first and second measurement is greater than 12 mm Hg, an abnormal pulsus paradoxus is present. The paradox is that while listening to the heart sounds during inspiration, the pulse weakens or may not be palpated with certain heartbeats, while S1is heard with all heartbeats.

Tamponade physiology

Pulsus Paradoxus Normal Tamponade RV preload, inspiration  LV preload, inspiration  or   RV fills at expense of RV free wall LV Pulmonary blood flow  

Ewart sign The y descent Also known as the Pins sign, this is observed in patients with large pericardial effusions. It is described as an area of dullness, with bronchial breath sounds and bronchophony below the angle of the left scapula. The y descent The y descent is abolished in the jugular venous or right atrial waveform. This is due to an increase in intrapericardial pressure, preventing diastolic filling of the ventricles.

CVS Other Tachycardia Hypotension (occasionally hypertensive) Cool extremities Pericardial rub (30%) Muffled heart sounds Other Tachypnea with clear lung sounds Hepatomegally

  Suggested diagnostic algorithm for evaluation of patients suspected to have cardiac tamponade. Restrepo C S et al. Radiographics 2007;27:1595-1610 ©2007 by Radiological Society of North America

Overview of the diagnosis and management of cardiac tamponade Overview of the diagnosis and management of cardiac tamponade. E = early diastolic filling; ECG = electrocardiography; IVC = inferior vena cava; IVRT = isovolumic relaxation time; JVP = jugular venous pressure; LA = left atrium; RA = right atrium; RV = right ventricle. Mayo Clin Proc. 2010 June; 85(6): 572–593. doi: 10.4065/mcp.2010.0046

World J Cardiol. 2011 May 26;3(5):135-43

ECG Sinus Tachycardia Low Voltage Electrical alternans

Pericarditis Diffuse upsloping ST segment elevations leads II, III, AVF, and V3 to V6 ST concave upwards PR segment elevation in AVR and PR segment depression in other limb leads, V5 and V6

Chest X Ray www.clinic-clinic.com

Echocardiography Pericardial effusion Collapse of right atrium and right ventricle during diastole Left atrial collapse in 25% patients Dilatation of IVC and < 50% decrease in diameter during inspiration Respiratory variation of mitral/ tricuspid velocities and RV/ LV volumes.

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

P denotes pericardium, and LV left ventricle Swinging of the Heart with a Large Pericardial Effusion (PE), Causing Electrical Alternation and Consequent Tamponade Spodick, D. H. N Engl J Med 2003;349:684-690 Swinging of the Heart with a Large Pericardial Effusion (PE), Causing Electrical Alternation and Consequent Tamponade. In Panel A, the heart swings to the right, and lead II shows a small QRS complex. In Panel B, the heart swings to the left, and the QRS complex is larger. P denotes pericardium, and LV left ventricle

  Cardiac tamponade secondary to tuberculosis in a 32-year-old man with acquired immunodeficiency syndrome. Restrepo C S et al. Radiographics 2007;27:1595-1610 ©2007 by Radiological Society of North America

 Cardiac tamponade in a newborn with respiratory distress syndrome who developed pneumopericardium associated with barotrauma from mechanical ventilation. Restrepo C S et al. Radiographics 2007;27:1595-1610 ©2007 by Radiological Society of North America

  Pneumopericardium with cardiac tamponade in an adult patient with blunt thoracic trauma. Restrepo C S et al. Radiographics 2007;27:1595-1610 ©2007 by Radiological Society of North America

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

Anesthetic goals for tamponade Monitor ABP invasively Have surgeon scrub Prep & drape patient before induction Maintain preload Maintain spontaneous ventilation Epinephrine / Dobutamine available Maintain tachycardia Avoid dramatic increase in afterload

Anesthetic options Local General Mask LMA ETT SV DL f/b PPV Awake fiberoptic Asleep blind nasal DL f/b PPV

Treatment 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 Pericardiocentesis: Blindly in the case of an emergency With ECHO, fluoroscopy or CT guidance 2. Pericardiotomy: If the heart cannot be reached by a needle/catheter. Indicated in patients with intrapericardial bleeding, clotted hemopericardium. 3. Positive airway pressure should be avoided as it decreases cardiac output.

Treatment Recurrent effusion Pericardial window involves the surgical opening of a communication between the pericardial space and the intrapleural space or to the exterior. This is usually a subxiphoid approach with resection of xiphoid. Recently, a left paraxiphoidian approach with preservation of xiphoid has been described.]Open thoracotomy and/or pericardiotomy may be required in some cases. Recurrent effusion Pericardial-peritoneal shunt Pericardiodesis - corticosteroids, tetracycline, or antineoplastic drugs can be instilled into the pericardial space sclerosing the pericardium Pericardiectomy: Resection of the pericardium (pericardiectomy) through a median sternotomy or left thoracotomy is rarely required to prevent recurrent pericardial effusion and tamponade.

Gross anatomic features of relapsing pericarditis Gross anatomic features of relapsing pericarditis. Left, Anterior view of fibrinous pericardium in a patient with recurrent pericarditis. Right, Thickened fibrinous pericardium after surgical pericardiectomy. Photograph courtesy of William D. Edwards, MD. Mayo Clin Proc. 2010 June; 85(6): 572–593. doi: 10.4065/mcp.2010.0046

Overview of the management of relapsing pericarditis Overview of the management of relapsing pericarditis. CMR = cardiac magnetic resonance imaging; CRP = C-reactive protein; CT = computed tomography; ESR = erythrocyte sedimentation rate; NSAID = nonsteroidal anti-inflammatory drug; WBC = white blood cell count. *Corticosteroids should not be routinely used initially unless there is a rheumatologic etiology or NSAIDs and colchicine are contraindicated. Mayo Clin Proc. 2010 June; 85(6): 572–593. doi: 10.4065/mcp.2010.0046

Figure 3. Most Common Sites of Blind and Image-Guided Insertion of the Needle for Pericardiocentesis. In the paraxiphoid approach, the needle should be aimed toward the left shoulder. In the apical approach, the needle is aimed internally. Spodick, D. H. N Engl J Med 2003;349:684-690 Paraxiphoid: The needle is inserted between the xiphoid process and left costal margin. It is inserted at an angle of 15 degrees to bypass the costal margin. The hub is depressed so that it is pointed towards the left shoulder. The needle is advanced slowly until the pericardium is pierced and fluid is aspirated. A 16-18 guage sheathed needle is used to leave the sheath in the pericardial space. For prolonged drainage a pigtail angiographic catheter is placed in the pericardial space. Follow up Doppler to assess reaccumulation of fluid.

Intraoperative aspect. Motas C et al. Interact CardioVasc Thorac Surg 2010;10:4-5 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

After care After pericardiocentesis, leave the intrapericardial catheter in place after securing it to the skin using sterile procedure and attaching it to a closed drainage system via a 3-way stopcock. Periodically check for reaccumulation of fluid, and drain as needed. The catheter can be left in place for 1-2 days and can be used for pericardiocentesis. Serial fluid cell counts can be useful for helping discover an impending bacterial catheter infection, which could be catastrophic. If the WBC count rises significantly, the pericardial catheter must be removed immediately. A Swan-Ganz catheter can be left in place for continuous monitoring of hemodynamics and to assess the effect of reaccumulation of pericardial fluid. A repeat echocardiogram should be performed within 24 hours. A repeat chest radiograph should be performed within 24 hours.

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