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Cardiac tamponade

DEFINITIONS

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 is characterized by the accumulation of pericardial fluid under pressure and may be acute or subacute. Variants also occur and include low pressure (occult) and regional 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. The pathological changes are chronic inflammation, sometimes with calcification. Grossly, the pericardium is considerably thicker than normal in approximately 80 percent of cases.
  • Effusive-constrictive pericarditis — This variant is characterized by constrictive physiology with a coexisting pericardial effusion, usually with tamponade [1]. Such patients may be mistakenly thought to have only tamponade, however elevation of the right atrial and pulmonary wedge pressures persists after drainage of the pericardial fluid.

An important pathophysiologic feature of both 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.

The physiology, clinical presentation, diagnosis, and treatment of the cardiac tamponade will be reviewed here. Issues related to pericardial constriction and the evaluation and management of pericardial diseases that do not compromise hemodynamics are discussed separately. (See "Constrictive pericarditis" and "Diagnosis and treatment of pericardial effusion" and "Evaluation and management of acute pericarditis".)

PHYSIOLOGY

Tamponade — In tamponade, the primary abnormality is compression of all cardiac chambers due to increased pericardial pressure [2,3]. The pericardium has some degree of elasticity; but once the elastic limit is reached, the heart must compete with the intrapericardial fluid for the fixed intrapericardial volume. As tamponade progresses, the cardiac chambers become smaller and chamber diastolic compliance is reduced. The following consequences result from this increase in constraint to cardiac filling:
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