Diagnosis and treatment of pericardial effusion
- 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
- Martin M LeWinter, MD
Martin M LeWinter, MD
- Section Editor — Myopericardial Disease
- Professor of Medicine and Molecular Physiology and Biophysics
- University of Vermont
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
The normal pericardium is a fibroelastic sac surrounding the heart that contains a thin layer of fluid. A pericardial effusion is considered to be present when accumulated fluid within the sac exceeds the small amount that is normally present. Pericardial effusion can develop in patients with virtually any condition that affects the pericardium, including acute pericarditis and a variety of systemic disorders. The development of a pericardial effusion may have important implications for prognosis (as in patients with intrathoracic neoplasm), diagnosis (as in myopericarditis or acute pericarditis), or both (as in dissection of the ascending aorta).
Pericardial effusions may develop rapidly (acute) or more gradually (subacute or chronic). The normal pericardium can stretch to accommodate increases in pericardial volume, with the amount of stretch related to how quickly the effusion develops. The ability to stretch is greater with slowly developing effusions. However, regardless of how quickly an effusion develops, with ongoing accumulation of pericardial fluid into a closed space, eventually the intrapericardial pressure begins to increase. When the intrapericardial pressure becomes high enough to impede cardiac filling, cardiac function becomes impaired, and cardiac tamponade can be considered to be present. (See "Cardiac tamponade".)
A general overview of the diagnosis and treatment of pericardial effusion will be presented here. The full spectrum of causes of pericardial disease, management of specific causes of pericardial disease, and the details of pericardial fluid drainage are discussed separately. (See "Etiology of pericardial disease" and "Clinical presentation and diagnostic evaluation of acute pericarditis" and "Emergency pericardiocentesis".)
●Acute pericarditis (viral, bacterial, tuberculous, or idiopathic in origin)
- Ewart W. Practical Aids in the Diagnosis of Pericardial Effusion, in Connection with the Question as to Surgical Treatment. Br Med J 1896; 1:717.
- 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.
- Weiss JM, Spodick DH. Association of left pleural effusion with pericardial disease. N Engl J Med 1983; 308:696.
- Authors/Task Force Members, Adler Y, Charron P, 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.
- 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.
- Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart 2004; 90:255.
- Brown J, MacKinnon D, King A, Vanderbush E. Elevated arterial blood pressure in cardiac tamponade. N Engl J Med 1992; 327:463.
- Sagristà-Sauleda J, Mercé J, Permanyer-Miralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med 2000; 109:95.
- Corey GR, Campbell PT, Van Trigt P, et al. Etiology of large pericardial effusions. Am J Med 1993; 95:209.
- Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003; 82:385.
- Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985; 56:623.
- Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol 1995; 75:378.
- Tuon FF, Litvoc MN, Lopes MI. Adenosine deaminase and tuberculous pericarditis--a systematic review with meta-analysis. Acta Trop 2006; 99:67.
- Levy PY, Fournier PE, Charrel R, et al. Molecular analysis of pericardial fluid: a 7-year experience. Eur Heart J 2006; 27:1942.
- Ben-Horin S, Bank I, Shinfeld A, et al. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol 2007; 99:1294.
- Ntsekhe M, Mayosi BM. Tuberculous pericarditis with and without HIV. Heart Fail Rev 2013; 18:367.
- Nugue O, Millaire A, Porte H, et al. Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients. Circulation 1996; 94:1635.
- Pankuweit S, Wädlich A, Meyer E, et al. Cytokine activation in pericardial fluids in different forms of pericarditis. Herz 2000; 25:748.
- Seferović PM, Ristić AD, Maksimović R, et al. Diagnostic value of pericardial biopsy: improvement with extensive sampling enabled by pericardioscopy. Circulation 2003; 107:978.
- Maisch B, Ristić AD, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J 2002; 23:1503.
- Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J 2013; 34:1186.
- Kopecky SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardial catheter drainage: report of 42 consecutive cases. Am J Cardiol 1986; 58:633.
- Tsang TS, Barnes ME, Gersh BJ, et al. Outcomes of clinically significant idiopathic pericardial effusion requiring intervention. Am J Cardiol 2003; 91:704.
- Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002; 77:429.
- Ziskind AA, Pearce AC, Lemmon CC, et al. Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. J Am Coll Cardiol 1993; 21:1.
- El Haddad D, Iliescu C, Yusuf SW, et al. Outcomes of Cancer Patients Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion. J Am Coll Cardiol 2015; 66:1119.
- Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clin Proc 1998; 73:647.
- Callahan JA, Seward JB, Tajik AJ. Cardiac tamponade: pericardiocentesis directed by two-dimensional echocardiography. Mayo Clin Proc 1985; 60:344.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- 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.
- Tsang TS, Freeman WK, Barnes ME, et al. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol 1998; 32:1345.
- Tsang TS, Barnes ME, Hayes SN, et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998. Chest 1999; 116:322.
- Rafique AM, Patel N, Biner S, et al. Frequency of recurrence of pericardial tamponade in patients with extended versus nonextended pericardial catheter drainage. Am J Cardiol 2011; 108:1820.
- Mercé J, Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J. Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade? Am J Med 1998; 105:106.
- Sagristà-Sauleda J, Angel J, Permanyer-Miralda G, Soler-Soler J. Long-term follow-up of idiopathic chronic pericardial effusion. N Engl J Med 1999; 341:2054.
- CLINICAL PRESENTATION
- Signs and symptoms
- ECG findings
- Chest radiograph
- DIAGNOSTIC APPROACH
- Establishing the presence of effusion
- Quantification of the pericardial effusion
- Assessing hemodynamic impact
- - Acute versus subacute cardiac tamponade
- - Diagnosis of cardiac tamponade
- Establishing the cause of the effusion
- - Clinical assessment
- - Laboratory tests
- - Pericardial fluid analysis and biopsy
- Pericardial fluid drainage
- - Indications and objectives
- - Percutaneous pericardiocentesis versus surgical drainage
- - Preparation for elective pericardiocentesis
- Clotting and bleeding disorders
- Procedure location
- - Pericardiocentesis technique
- - Complications of pericardiocentesis
- - Management following pericardiocentesis
- Underlying disease
- Initial management of asymptomatic patients with large effusions
- Chronic and recurrent effusions
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS