Transcript 10/07 Cardiac Tamponade

Cardiac Tamponade
Francesca N. Delling
October 17, 2007
Tamponade
• Etiology
• Physiology
- comparison with constrictive pericarditis
• Types of tamponade
• Diagnosis
- clinical presentation, physical exam, EKG, CXR, echo
• Treatment
Etiologies
• Infectious
– Viral (coxsackie B, echovirus, influenza)
– Bacterial
– Others: TB, fungal, toxoplasmosis
• Neoplastic
• Uremic
• Trauma / cardiac surgery / aortic dissection /
cardiac procedures
• Radiation
• Connective tissue disease (RA, SLE, scleroderma)
• Myocardial ischemia / infarct
• Myxedema
• Idiopathic
Physiology
• Exaggerated ventricular
interaction
• During inspiration 
greater RV inflow and
outflow and concurrent
decrease in LV size,
outflow tract flow
velocity profile and mitral
valve inflow
• During expiration  LV
filling and LV outflow
augmented at the expense
of reduced RV volume and
Doppler flow velocities
Physiology
Normal pericardium
Increasing pericardial
pressure
Increasing filling
pressures
RVEDP = LVEDP
Equalization of
diastolic pressures
Comparison with constrictive pericarditis
• Features in common
- diastolic dysfunction and preserved ventricular ejection
fraction
- heightened ventricular interaction
- increased respiratory variation of ventricular inflow and
outflow manifested clinically by pulsus paradoxus (less
frequent in constrictive pericarditis)
- equally elevated central venous, pulmonary venous, and
ventricular diastolic pressures
• Distinctive features
- tamponade  pericardial space is open and transmits
respiratory variation in thoracic pressure to heart
(pericardium does not see fluctuation in thoracic pressure in
constrictive pericarditis)
- constrictive pericarditis: venous return does not increase
with inspiration. Diminished LV and increased RV volume are
2/2 lesser pressure gradient from the pulmonary veins
Types of tamponade
• Acute tamponade
- Due to trauma, rupture of the heart or aorta or
complication of an invasive diagnostic or therapeutic
intervention
- Sudden in onset
- Hypotension common
• Subacute tamponade
- Pericardial fluid accumulates slowly
- Hypotension with a narrow pulse pressure, reflecting limited
stroke volume. However, patients with preexisting
hypertension may remain hypertensive due to increased
sympathetic activity
Acute vs chronic tamponade
Types of tamponade
(continued)
• Low pressure tamponade
- Severely hypovolemic pts (hemorrhage, hemodyalisis, or
overdiuresis)  intracardiac and pericardial diastolic
pressures are only 6 to 12 mmHg  fluid challenge usually
elicits typical tamponade hemodynamics
• Regional tamponade
- caused by a loculated, eccentric effusion
- typical physical, hemodynamic, and echocardiographic signs
of tamponade may be absent
Clinical Presentation
• Tachypnea and exertional dyspnea  rest
air hunger
• Weakness
• Presyncope
• Dysphagia
• Cough
• Anorexia
• (Chest pain)
Physical Exam Findings
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•
•
•
Tachycardia
Hypotension  shock
Elevated JVP with blunted y descent
Muffled heart sounds
Pulsus paradoxus
(Pericardial friction rub)
JVP and pulsus paradoxus in tamponade
Y descent blunted because of limited or absent lated diastolic
filling of the right ventricle
Other causes of pulsus paradoxus
• Obstructive airway disease
– Acute and chronic
• Constriction
• Restriction
• Pulmonary embolism
• RV infarction
• Circulatory failure
EKG pericarditis
EKG tamponade
EKG electrical alternans
Chest X-ray
Echocardiography

•
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•
2D and M-mode
RV diastolic collapse
RA collapse/inversion
IVC plethora
 Doppler
• Exaggerated respiratory variation in mitral
and tricuspid inflow velocities
• Phasic variation in right ventricular outflow
tract/left ventricular outflow tract flow
• Exaggerated respiratory variation in
inferior vena cava flow
Echocardiogram: RVDC
• Most commonly involves the RV outflow tract
(more compressible area of RV)
• Occurs in early diastole, immediately after closure
of the pulmonary valve, at the time of opening of
the tricuspid valve
• When collapse extends form outflow tract to the
body of the right ventricle, this is evidence that
intrapericardial pressure is elevated more
substantially
Parasternal long axis view
M-mode
Beginning of systole
ES DC
Short axis view
4 chamber view
Subcostal view
M-mode
Beginning of systole
ES DC
Echocardiogram: RA Inversion
• Right atrium normally contracts in volume with atrial systole
• In the presence of marked elevation of intrapericardial
pressure, RA wall will remain collapsed throughout atrial
diastole (early ventricular systole)
• Isolated RA inversion occurs during late diastole
– Very sensitive but specificity = 86%
– Positive predictive value = 50%
• RA Inversion Time Index (RAITI)
Total # frames with inversion
- Calculated by dividing
Total # frames in the cardiac cycle
- Using 33% as the threshold
• Specificity = 100%
• Sensitivity = 94%
M-mode across RA
Peak velocity of mitral inflow varies > 15%
with respiration
Peak velocity of tricuspid inflow varies
> 25% with respiration
IVC plethora
Predictable hierarchy of events
Exaggerated respiratory variation of tricuspid inflow
Exaggerated respiratory variation of mitral inflow
Abnormal right atrial collapse
Right ventricular free wall collapse
Instances when echo abnormalities
are not seen
• Significant RV hypertrophy, usually due to
PHTN
• Thickening of the ventricular wall due to
malignancy, overlying inflammatory
response or thrombus in hemorrhagic
pericarditis
• Low-pressure tamponade (hypovolemic
patients)
Echocardiogram: Additional roles
• Confirm size of the pericardial effusion
– Small defined as < 100 mL
– Moderate defined as 100 – 500 mL
– Large defined as > 500 mL
• Confirm location of the pericardial effusion
– Rule out loculated effusions
• Assist pericardiocentesis
Assessment of the patient
• Insignificant effusion
– Flat neck veins
– Normal BP, HR, RR, good perfusion
• Hemodynamically significant-Compensated
– Elevated JVP
– Mild paradox, No hypotension or tachycardia
– Good perfusion
– Mild RV collapse
Assessment of the patient
• Hemodynamically Severe-Max Compensation
– Elevated JVP
– Prominent paradox, Tachycardia
– No hypotension-adequate perfusion
– Chamber collapse on ECHO
• Hemodynamically Severe-Decompensated
– Elevated JVP
– Tachycardia, tachypnea
– Hypotension with paradox
– Chamber collapse, swinging heart
Pericardiocentesis
•
•
•
Usually performed if more
than 1 cm effusion
Also performed if effusion
smaller in the setting of
acute trauma and
hemodynamic compromise
Pericardial window if need
for biopsies and if
evidence of coaugulopathy
RB
74 yo male with recently diagnosed adenocarcinoma
of undetermined primary who presented to ED on 10/6
with chest pain
RB
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BP 125/65, pulsus paradoxus of 12
JVP 12 cm
PMI located in 5th ICS, distant heart sounds
Faint crackles lung bases
RB
• CT chest consistent with large pericardial
effusion and moderate compression of right
ventricle
• Worsened metastatic disease including
enlargement of subclavicular, mediastinal,
right hilar lymph nodes and pulmonary nodules
• Stat echo showing…
10/6 TTE
10/6 TTE
10/6 TTE
10/6 pericardiocentesis
• Drainage of 400 cc of bloody fluid
• Pre-procedure: pulsus 20 mmHg, cardiac
output 3.8
• Post-procedure: pulsus < 10 mmHg, cardiac
output 5.0
TTE post-procedure
Thank you