After completing this course, the participant should be able to
Sanjay Kumar, M.D., F.A.S.H., F.A.C.P.
Division of Cardiovascular Medicine
SUNY Downstate Medical Center
Brooklyn, NY 11203
Adam S. Budzikowski, M.D., Ph. D., F.H.R.S
Division of Cardiovascular Medicine
SUNY Downstate Medical Center
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Course: PERICARDIAL EFFUSION
Physicians, sonographers and others who perform and/or interpret ultrasound.
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The pericardium is a fibrous structure consisting of two layers that envelope the heart. Developmentally, the heart grows into the pericardial sac (a balloon like structure) from behind resulting in complete envelopment of the most of the heart. The inner layer is adherent to the myocardium called visceral pericardium; the outer layer adjoins the mediastinal structure called the parietal pericardium.
A small amount of fluid (15-25 ml) of fluid is present between the two layers of pericardium. Normally, pericardium has limited elasticity that allows the expansion of ventricles during diastole. The fluid between the two layers of pericardium provides necessary lubrication for the heart to slide during the cardiac cycle. Attachment of pericardium to mediastinum, diaphragm and the sternum helps keep the heart suspended in the thorax.
Fluid formation in the pericardium happens due to secretion and absorption of fluid from pericardial layers. The hydrostatic pressure favors and oncotic (related to the albumin levels) pressure prevents secretion of fluid from the capillaries in the visceral pericardium. The lymphatics in parietal pericardium help in the drainage of the fluid out of the pericardial space.
Function of pericardium:
Acting as a covering of the myocardium, it may protect the heart from mediastinal infection or infiltration (barrier function). Although, pericardium has limited capacity to expand (stretch), it allows filling of the ventricles in diastole. It also allows for the pressure balance between the right and left ventricle (ventricular inter-dependence). Due to only limited capacity of pericardium to stretch in the short term, it prevents acute dilatation of the heart.
Origin of pericardial effusion:
The fine balance between secretion and drainage maintains the normal amount of fluid in the space. Congestive heart failure (CHF), where capillary hydrostatic pressure is elevated, or nephrotic syndrome, where oncotic pressure is low, creates an excess of pericardial fluid, or effusion. In the case of malignancy, an effusion can be caused by tumor cells invading the lymphatics and preventing drainage.
As mentioned, pericardium has limited capacity to stretch. The pericardial pressure usually parallels intra-thoracic pressure, with intra-pleural pressure being around -5 mm Hg and intra-pericardial pressure being around -3 mm Hg. This level of pressure in the pericardium is lower than that of the cardiac chambers during diastole. Therefore, pericardial pressure does not press upon the atria or the ventricles and does not impede filling of the ventricles. A normal filling of the ventricle translates into a normal stroke volume for both ventricles.
A rise in pericardial pressure can happen due to accumulation of fluid. The level of pressure would be determined by the rapidity of fluid accumulation, fluid quality and the ability of the pericardium to stretch. In acute situations a relatively small amount of excess pericardial fluid (>150 ml) can cause a dangerous rise in pericardial pressure. In chronic situations fluid can accumulate over weeks in a large quantity (up to 2000 ml) but pericardial pressure may not increase enough to impair ventricular filling.
The most concerning aspect of pericardial effusion is its compressive effect on the cardiac chamber leading to impaired filling and hemodynamic collapse. Pericardial tamponade is a life-threatening hemodynamic condition that results from increased pericardial pressure. In cardiac tamponade pericardial fluid compresses and restricts cardiac filling leading to both forward (reduced cardiac output) and backward (elevated filling pressures) failure.
9. Trauma- chest contusion, penetrating injury, cardiac surgery
Malignancy, idiopathic and uremia are common causes of effusion in clinical practice. These causes are associated with large effusions. Sometime loculated effusion related to surgery or trauma can produce tamponade symptoms as well.
Physical examination -
1. Tachycardia- heart rate greater than 90 beats per minute is often seen.
Medications may prevent tachycardia.
2. Hypotension- pulsus paradoxus (decrease in systolic blood pressure greater than
10 mm of Hg on inspiration). However, normotension and even hypertension
should not be used to rule out the diagnosis of tamponade. Approximately one third
of patients, especially when associated with renal disease or prior history
of hypertension, may present with tamponade and paradoxical hypertension. This
is probably related to intense sympathetic discharge and increase peripheral
vascular resistance. In fact, drainage of fluid lowered the blood pressure in
3. Increased jugular venous pressure- which decreases during inspiration.
4. Increased area of dullness on percussion in the back (left infra-scapular area;
Beck’s triad is a combination of three physical signs; jugular venous distension, hypotension and distant heart sound suggestive of tamponade.
ECG may show small voltage in the precordial and limb leads. A cyclical fluctuation in P, QRS and T wave amplitude (total alternans) can be seen. An example of rhythmic variation in the QRS complex is seen in Figure 1. Electrical alternans is a feature of swinging movement of the heart in the pericardium and is often seen with large volume effusion. It is not necessarily a feature of elevated pressure in the pericardium.
Figure 1. ECG strip showing declining and rising QRS amplitude in a patient
with pericardial effusion
Chest X ray can show cardiomegaly if sufficient fluid is present. Relative decrease in pulmonary vascularity with cardiomegaly may suggest pericardial effusion. A decrease in cardiomegaly can be seen after removal of pericardial fluid (Figure 2). On lateral view an increased space between the anterior aspect of the heart and the posterior aspect of the sternum is often noted.
Figure 2: The left panel shows pericardial effusion (tamponade state) in a patient and the right panel shows the finding after drainage of the fluid. The ECG shows resolution of electrical alternans. Chest X ray shows reduction in cardomegaly. Chest CT shows reduction in pericardial fluid (PEF) as well as expansion of right atrial size. Lines in the right atrium show the dimensions. CXR=chest X ray, CT=computerized tomography, RA=right atrium, RV=right vertricle.
Transthoracic echocardiography (TTE) is the diagnostic modality of choice for the evaluation of pericardial effusion. The diagnosis of pericardial effusion is based on echo free space between parietal pericardium and the heart. If the fluid amount of fluid is massive the entire heart can be seen swinging within the pericardium.
Based on the amount and extent of fluid covering the heart, pericardial effusion is categorized into three groups.
3. Large - >2cm; Fluid extends all around the heart, usually >500ml (Figure 3)
Once effusion has been diagnosed, it is important to determine its hemodynamic effect. TTE can show echocardiographic evidence of tamponade. Although pericardial tamponade is a clinical diagnosis, echocardiography often is helpful in demonstrating the compressive effects of elevated pericardial pressure. TTE can also assist in the drainage of pericardial fluid. The set of findings associated with echocardiographic tamponade are:
2D and M-mode
Diastolic RV collapse (very specific; Figure 4 A)
RA collapse/inversion (very sensitive and seen early during tamponade
Engorged inferior vena cava (IVC )
Exaggerated respiratory variation in inflow velocity (Figure 4 B)
Mitral Inflow- Normal respiratory variation in peak velocity of <15% but in tamponade: > 25% decrease during inspiration; Tricuspid Inflow- Normal respiratory variation in peak velocity of <25% but in tamponade: > 40% increase during inspiration)
Phasic variation in RV/LV outflow tract flow
Exaggerated respirator variation in IVC flow
Hepatic vein flow limited to inspiration
Computerized Tomography (CT) Scan:
CT provides excellent visualization of the pericardium. The distribution and size or etiology (malignancy) can be appreciated on CT scan. Attenuation of fluid can suggest if the fluid is transudate or blood. A CT scan of pericardial effusion is shown in figure 2.
Magnetic Resonance Imaging (MRI):
Although not commonly used for this condition, it has similar advantage of CT scan. It allows examination of the pericardium in multiple planes.
Therapy of pericardial effusion depends on clinical presentation and laboratory findings. Tapping of pericardial effusion (pericardiocentesis) is indicated in infection, if malignancy is suspected, or if associated with a very large effusion. If the diagnosis is clear with systemic analysis or examination, pericardiocentesis may not be needed. Because of dependence of RV filling on preload, dehydration or vasodilator (causing hypotension) should be avoided.
Pericardial tamponade is an emergency requiring therapeutic pericardiocentesis. Needle based percutaneous drainage guided by echocardiography is often the method of pericardiocentesis. If tamponade is associated with ventricular rupture or aortic dissection a surgical approach to address the underlying cause would be needed. In case of very large effusion, or where recurrence is suspected (i.e. malignancy related), surgical drainage of fluid and creation of a connection between pericardium and pleura (pericardial window) is performed. Anticoagulation should be avoided until the pericardial effusion has resolved.
Maisch B et al. Guidelines on the diagnosis and management of pericardial diseases. European Heart Journal 2004;1–28
Goldstein JA. Cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Curr Probl Cardiol 2004;29:503-67
Argulian E. Paradoxical hypertension with cardiac tamponade. Am J Cardiol 2012;110:1066–1069