Cardiac Tamponade: Pathophysiology, Diagnosis & Treatment Options

Cardiac tamponade  is a fatal condition where there is an abrupt accumulation of the fluid in Pericardial space Rapid increase in the pericardial pressure leads to the obstruction of the inflow of the blood into ventricles from atria.

In this blog, we’ll cover the pathophysiology, diagnostic criteria, and treatment options for cardiac tamponade.

PATHOLOGY

Venous return will be increased during the inspiration. JVP is elevated, but absence of kussmaul sign

Diastolic Dysfunction

Pressure is increased in the Pericardial spaces→Relaxation of the ventricles will not occur, leading to diastolic dysfunction and an increase in diastolic pressure of the ventricles→ increase Atrial pressure -> right ventricular pressure: increase in Jugular vein distension→ during inspiration venous return increase->shift interventricular septum to LV lumen→  lumen volume decreases, RV volume increase →  Blood from the right atrium moves into the right ventricle-> venous return increase.

Also read: Therapies for Acute Decompensated Heart Failure (ADHF) 

Diastolic Collapse

Decrease in systolic BP: >10 mmHg

• Pulsus paradoxus: Increase in the Intracardiac pressure  -> maximum stretch of ventricles are not achieved ->  result Diastolic collapse of the right ventricle will occur-> Decrease in the LV and LVEDV-> Cardiac output is decreased during inspiration (SBP decreases)->  Hypotension Increased fluid around the heart-> heart sounds will be muffled.

Becks Triad 

1. Hypotension: Reduced cardiac output
2. Absent/muffled heart sounds: Increased fluid in the

Pericardial space: Jugular Distention: Increased right arterial pressure

• Has prominent X defect

® Atrial relaxation

• Absent Y wave

® Diastolic collapse of the ventricle

Clinical Features of Cardiac Tamponade

1. Dyspnea: Sudden onset
2. Pulmonary edema
   1. Fatigue
   2. Weakness
   3. Hypotension
   4. Giddiness and syncope
3. Chest pain
   • Pericardial pain
   • Diaphoresis

ECG Findings

Paradoxical pulse-present, Equal RT and LT-sided pressure: present, Systemic venous

Morphology Absence of  Y wave , Inspiratory change in SVP (decreased), square root sign- (absent)

Also read: Constrictive Pericarditis: Pathogenesis, Etiology 

Diagnosis 

First line: 2D Echo

• M mode
• Doppler echocardiography
• Establish a prompt diagnosis

Circumferential Effusion 

Echo free space 

Small : <10 mm during diastole

Moderate : 10 to 20 mm

Severe >20 mm

Frondlike and Shaggy Appearance

Presence of clots

• Chronic inflammation within the Pericardial space
• Neoplastic Pericardial processes

Diagnosis of Loculated Effusion

• Not clear in the 2D Echo
• Best diagnosis: CT or Cardiac MRI
• Other method: Transesophageal echocardiography

Treatment of Cardiac Tamponade

• Patients with actual or threatened tamponade should be considered a medical emergency.
• Pericardiocentesis is recommended
• Observe the patient in
  • Large Pericardial effusion
• Hospital admission
• Careful hemodynamic examination
• Echocardiographic monitoring Pericardiocentesis
• Best approach: Subxiphoid
• Required for the treatment of cardiac tamponade
• Mild tamponade: No exaggerated increased pressure
  • NSAIDs
  • Colchicine
  • Reduce the shrinking effusion rapidly
• Mild tamponade secondary to:

• Connective tissue disorders
• Inflammatory disorders
  • Corticosteroids are recommended (Prednisolone)
• Small effusion

Also read: Paroxysmal Supraventricular Tachycardia  

Etiology

1. Bacterial infection
2. Bleeding

Treatment of Cardiac Tamponade

• Conservative treatment and careful monitoring is required
• Pericardiocentesis is not recommended

Hemodynamic Monitoring 

• Before, during, and after the pericardiocentesis ,  Measure
  • Central venous pressure (JVP)
  • Pulmonary artery pressure
• Placement of PAP catheter
• Recommended in threatened conditions
• After pericardiocentesis: Measure the re-accumulation

Insertion of the catheter into the central circulation

                      ↓

Not allowed to delay the definitive treatment. Pericardiocentesis if started then

• Hydration (IV normal saline)
• Positive inotropes
  • Norepinephrine are recommended
  • No delay of Pericardiocentesis

Closed pericardiocentesis

• Treatment of choice
• Exception: Clot or fibrous materials
• In such cases, an open approach is recommended (Safe & Easy)

Closed vs Open Pericardiocentesis 

Disadvantage of closed pericardiocentesis

1. Reduction in the intrapericardial pressure
2. Further bleed enters into the pericardial space
3. Source of the cardiac tamponade is not corrected

Open Pericardiocentesis

It is recommended in case of

• Trauma,  Rupture of the LV valve (MI)

Bleeding is slow in the Procedural coronary perforation

                             ↓

Slow accumulation of fluid into the Pericardial space

                           ↓

Closed Pericardiocentesis is recommended

Also read: Takotsubo Cardiomyopathy : Definition, Pathogenesis 

Closed Pericardiocentesis 

Approach: Subxiphoid

needle is inserted in the Subxiphoid area towards the left shoulder (45°)

                                ↓

50 to 150 ml of the fluid is taken out with syringe

                                 ↓

Advantage: Instantaneous hemodynamic improvement

                                ↓

Insert the guide wire through the needle and plunger is taken back

                                ↓

Catheter is passed through the guide wires 

                                ↓

If epicardium is punctured, ST segment elevation of the ECG

• ECG monitoring should be done during the procedure.
• Should be performed in cardiac catheterization lab (Fluoroscopy) Hemodynamic monitoring

• Insert the pulmonary artery catheter
• Monitor the PA, RA, and RV pressure
• Also monitor the pulmonary capillary wedge pressure
• Monitor pericardial fluid pressure before, during, and after the procedure
  • After: Baseline measure
  • Re-accumulation of the fluid, pericardial pressure increases

Following Pericardiocentesis

• Repeat Echo
• Duration of monitoring: 24 hours
• intrapericardial catheter is recommended
  • Placed for 3 to 4 days
  • Continuous drainage in case of re-accumulation

Open Pericardiocentesis 

Indications

1. Trauma
2. Rupture if LV free wall secondary to Myocardial infarct
3. Loculated effusion: Entire fluid will not come out
4. Recurrent effusions

Biopsy: To determine the cause of recurrent effusion

Create a Pericardial window

↓

This will eliminate the future tamponade and recurrence Percutaneous balloon technique, drainage of the pericardial fluid.

Indication

1. Useful for malignant effusion
2. Reduce the recurrence
3. Surgery is not recommended

Plane of Percutaneous Balloon Pericardiotomy

Skin entry-abdominal wall (One cm below xiphoid process)

               ↓

Parietal peritoneum

               ↓

Diaphragmatic peritoneum

               ↓

Anterior aspect of the diaphragm

              ↓

Para-cardiac fat

              ↓

Sternopericardial/Pericardial-diaphragmatic ligaments

              ↓

Parietal pericardium

              ↓

Pericardial space

Pericardioscopy and Percutaneous Biopsy

• Scope passed directly into the pericardial space
• Visualize the pathology of the pericardium
• biopsy is taken from the area to determine the etiology
• Routine use of Pericardioscopically guided biopsy is advocated in patients of pericardial effusion without causative agent
• Studies are done for comparison between pericardioscopy and fluoroscopy-guided percutaneous biopsy to make out the etiology.
• Pericardioscopy-based biopsy: safer and more efficient than the fluoroscopy-guided biopsy

Also read: Cardiac Resynchronization Therapy  

Prognosis 

It is a serious medical condition, usually with or without a fatal outcome. The only key is timing. Intervention is to get the best prognosis and outcome.

Reference

National Library of Medicine

FAQ’S

Q. Which of the following is not a triad in Beck's triad?

Ans.

1. Hypotension
2. Muffled heart sounds
3. Distended Neck Veins
4. Hypertension

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