- Brian D Hoit, MD
Brian D Hoit, MD
- Professor of Medicine and Physiology and Biophysics
- Case Western Reserve University and University Hospitals of Cleveland
- Section Editors
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
The normal pericardium is a fibroelastic sac containing a thin layer of fluid that surrounds the heart. When larger amounts of fluid accumulate (pericardial effusion) or when the pericardium becomes scarred and inelastic, one of three pericardial compressive syndromes may occur:
●Cardiac tamponade – Cardiac tamponade, which may be acute or subacute, is characterized by the accumulation of pericardial fluid under pressure. Variants include low pressure (occult) and regional cardiac tamponade.
●Constrictive pericarditis – Constrictive pericarditis is the result of scarring and consequent loss of elasticity of the pericardial sac. Pericardial constriction is typically chronic, but variants include subacute, transient, and occult constriction.
●Effusive-constrictive pericarditis – Effusive-constrictive pericarditis is characterized by underlying constrictive physiology with a coexisting pericardial effusion, usually with cardiac tamponade. Such patients may be mistakenly thought to have only cardiac tamponade; however, elevation of the right atrial and pulmonary wedge pressures after drainage of the pericardial fluid points to the underlying constrictive process.
In both cardiac tamponade and constrictive pericarditis, cardiac filling is impeded by an external force. The normal pericardium can stretch to accommodate physiologic changes in cardiac volume. However, after its reserve volume is exceeded, the pericardium markedly stiffens. An important pathophysiologic feature of both cardiac tamponade and constrictive pericarditis is greatly enhanced ventricular interaction or interdependence, in which the hemodynamics of the left and right heart chambers are directly influenced by each other to a much greater degree than normal.
- Spodick DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.
- Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717.
- Reddy PS, Curtiss EI, O'Toole JD, Shaver JA. Cardiac tamponade: hemodynamic observations in man. Circulation 1978; 58:265.
- Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart 2004; 90:252.
- Figueras J, Barrabés JA, Serra V, et al. Hospital outcome of moderate to severe pericardial effusion complicating ST-elevation acute myocardial infarction. Circulation 2010; 122:1902.
- Gilon D, Mehta RH, Oh JK, et al. Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection. Am J Cardiol 2009; 103:1029.
- Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol 1990; 66:1487.
- Sagristà-Sauleda J, Angel J, Sambola A, et al. Low-pressure cardiac tamponade: clinical and hemodynamic profile. Circulation 2006; 114:945.
- Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
- Shabetai R, Fowler NO, Fenton JC, Masangkay M. Pulsus paradoxus. J Clin Invest 1965; 44:1882.
- Fitchett DH, Sniderman AD. Inspiratory reduction in left heart filling as a mechanism of pulsus paradoxus in cardiac tamponade. Can J Cardiol 1990; 6:348.
- Chou TC. Electrocardiography in Clinical Practice: Adults and Pediatrics, 4th ed, WB Saunders, Philadelphia 1996.
- Bruch C, Schmermund A, Dagres N, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol 2001; 38:219.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline for the clinical application of echocardiography www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Plotnick GD, Rubin DC, Feliciano Z, Ziskind AA. Pulmonary hypertension decreases the predictive accuracy of echocardiographic clues for cardiac tamponade. Chest 1995; 107:919.
- Reydel B, Spodick DH. Frequency and significance of chamber collapses during cardiac tamponade. Am Heart J 1990; 119:1160.
- Leimgruber PP, Klopfenstein HS, Wann LS, Brooks HL. The hemodynamic derangement associated with right ventricular diastolic collapse in cardiac tamponade: an experimental echocardiographic study. Circulation 1983; 68:612.
- Gillam LD, Guyer DE, Gibson TC, et al. Hydrodynamic compression of the right atrium: a new echocardiographic sign of cardiac tamponade. Circulation 1983; 68:294.
- Kerber RE, Gascho JA, Litchfield R, et al. Hemodynamic effects of volume expansion and nitroprusside compared with pericardiocentesis in patients with acute cardiac tamponade. N Engl J Med 1982; 307:929.
- Torelli J, Marwick TH, Salcedo EE. Left atrial tamponade: diagnosis by transesophageal echocardiography. J Am Soc Echocardiogr 1991; 4:413.
- Fusman B, Schwinger ME, Charney R, et al. Isolated collapse of left-sided heart chambers in cardiac tamponade: demonstration by two-dimensional echocardiography. Am Heart J 1991; 121:613.
- Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2013; 26:965.
- Bhagwat AR, Hoit BD. Respiratory variation of carotid artery flow in cardiac tamponade. Am Heart J 1996; 132:1068.
- Himelman RB, Kircher B, Rockey DC, Schiller NB. Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol 1988; 12:1470.
- Mercé J, Sagristà-Sauleda J, Permanyer-Miralda G, et al. Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: implications for the diagnosis of cardiac tamponade. Am Heart J 1999; 138:759.
- Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics 2007; 27:1595.
- Gold MM, Spindola-Franco H, Jain VR, et al. Coronary sinus compression: an early computed tomographic sign of cardiac tamponade. J Comput Assist Tomogr 2008; 32:72.
- Kolski BC, Kakimoto W, Levin DL, Blanchard DG. Echocardiographic assessment of the accuracy of computed tomography in the diagnosis of hemodynamically significant pericardial effusions. J Am Soc Echocardiogr 2008; 21:377.
- Traylor JJ, Chan K, Wong I, et al. Large pleural effusions producing signs of cardiac tamponade resolved by thoracentesis. Am J Cardiol 2002; 89:106.
- Meyer TE, Sareli P, Marcus RH, et al. Mechanism underlying Kussmaul's sign in chronic constrictive pericarditis. Am J Cardiol 1989; 64:1069.
- Uramoto H, Hanagiri T. Video-assisted thoracoscopic pericardiectomy for malignant pericardial effusion. Anticancer Res 2010; 30:4691.
- Gumrukcuoglu HA, Odabasi D, Akdag S, Ekim H. Management of Cardiac Tamponade: A Comperative Study between Echo-Guided Pericardiocentesis and Surgery-A Report of 100 Patients. Cardiol Res Pract 2011; 2011:197838.
- Wolfe MW, Edelman ER. Transient systolic dysfunction after relief of cardiac tamponade. Ann Intern Med 1993; 119:42.
- Uemura S, Kagoshima T, Hashimoto T, et al. Acute left ventricular failure with pulmonary edema following pericardiocentesis for cardiac tamponade--a case report. Jpn Circ J 1995; 59:55.
- Armstrong WF, Feigenbaum H, Dillon JC. Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis for relief of cardiac tamponade. Am Heart J 1984; 107:1266.
- Sagristà-Sauleda J, Angel J, Sambola A, Permanyer-Miralda G. Hemodynamic effects of volume expansion in patients with cardiac tamponade. Circulation 2008; 117:1545.
- Little WC, Freeman GL. Pericardial disease. Circulation 2006; 113:1622.
- CLINICAL PRESENTATION
- Acute cardiac tamponade
- Subacute cardiac tamponade
- Low pressure cardiac tamponade
- Regional cardiac tamponade
- PHYSICAL FINDINGS
- Sinus tachycardia
- Elevated jugular venous pressure
- Pulsus paradoxus
- Pericardial rub
- Chest radiograph
- CT and CMR
- Cardiac catheterization
- DIFFERENTIAL DIAGNOSIS
- Approach to the diagnosis
- Comparison with constrictive pericarditis
- Choosing percutaneous or surgical drainage
- - Relative contraindications to pericardial fluid drainage
- Evaluation of the removed fluid
- Monitoring post-procedure
- - Complications of fluid removal
- Additional therapies
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS