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

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

3. 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

4. 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.

5. 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

6. 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%

7. Basic investigations Low voltage Electrical alternans
Enlarged cardiac silhouette

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

9. Echocardiographic findings

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

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

12. 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

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

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

15. 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

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

17. 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

18. Doppler findings

19. 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%

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

21. Hepatic vein flow
Mitral inflow
HV flow

22. 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

23. 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

24. Echo cases of tamponade
To follow ….