Cardiac Tamponade Dr. Mohammad AlGhamdi Consultant cardiologist King AbdulAziz Cardiac Center National Guard- Riyadh

Cardiac Tamponade Life threatening Cardiac compression syndrome Due to pericardial fluid accumulation

Predisposing conditions 60% of cases have known underlying conditions Neoplasm-related conditions Pericarditis (viral, uremic, TB, SLE,…) Trauma (medical & non-medical) Unrelated to effusion size, but to the rate of accumulation one-third of asymptomatic large chronic effusions develop unexpected cardiac tamponade

Tamponade pathophysiology Pathological process Mechanical Hemodynamic Clinical Echo External mechanical compression. Pericardial pressure equal to or exceeds intracardiac pressure. Low cardiac output state due to reduced cardiac filling. Echo/Doppler findings attributed to hemodynamic abnormalities.

Hemodynamic instability Clinical approach + Hemodynamic instability pericardial effusion Clinical picture Basic investigations Imaging studies SOB Tachycardia Low BP High JVP Diminished HS Pulsus paradoxus Clear lungs ECG CXR Trans-thoracic echo TEE, CT scan, MRI

Limitations of clinical assessment Diminished HS Hypotension Low voltage EKG Pulsus Paradoxus PRESENT Asthma/COPD P. Embolism CHF Mitral Stenosis Hypovolemia Ascites Obesity ABSENT Hypotension P. adhesions AR ASD RVH Sensitivity <50% Dyspnea Tachycardia Elevated JVP Pulsus Paradoxus Cardiomegaly on CXR Sensitivity = 70%

Basic investigations Low voltage Electrical alternans Enlarged cardiac silhouette

CT or MRI Effusions measured by CT/MRI tend to be larger than in echocardiography

Echocardiographic findings

√ X Just remember that … Tamponade is a clinical description not an echo diagnosis Echo findings would support or refute clinical suspicion √ X 10

Detecting Pericardial Effusion Echo-free space surrounding the heart Variable degrees of severity 11

Differential diagnosis of pericardial echo-free space Common Left pleural effusion Loculated Pericardial effusion Intrapericardial hematoma Epicardial fat pads Rare Pericardial cyst Desc. aortic aneurysm LV pseudoaneurysm Hiatus hernia Massive LAE 12

Important landmarks Pericardial effusion is seen anterior to the descending aorta in PLA view Left pleural effusion is posterior to the descending aorta

Tamponade by 2-D echo Pericardial effusion Heart swinging (chronic) Late RA diastolic collapse Early RV diastolic collapse Dilated IVC with reduced collapsibility 14

RA collapse RA Inversion (collapse) Begins in late diastole and continues into systole Sensitive but not specific for clinical tamponade Increased specificity if lasting >1/3 of systole Brief inversion can occur without clinical tamponade

RV collapse Occurs in early diastole Duration of collapse is proportional to the severity Indicates impending or existing clinical tamponade

Limitations of RV collapse May be affected by: Intravascular volume Low pressure tamponade RV Pressure/volume load RVH and PHTN ASD, TR, PI RV compliance Ischemia, Trauma, Pericardial adhesions

Doppler findings

Tamponade by Doppler flow Exaggerated respiratory variations Inspiration: Tricuspid flow increases Mitral flow decreases Expiration: Tricuspid flow decreases Mitral flow increases Mitral peak flow velocity variations of >25% Tricuspid peak flow velocity variations of >45%

Doppler timing 80-40÷80= 50% 120-75÷120= 38% 20

Hepatic vein flow Mitral inflow HV flow

Echo-guided perecardiocentesis Confirm presence and hemodynamic effect of pericardial effusion Check the window of maximum fluid collection (apical or subcostal) Measure the depth from transducer (skin) to effusion

Echo-guided perecardiocentesis Guide the operator for the needle direction Confirm the presence of catheter in pericardial space Check mechanical and hemodynamic improvement after drainage Assess the residual pericardial effusion Surgical drainage for post op collection/hematoma

Echo cases of tamponade To follow ….