What is the Diagnosis and Management of Cardiac Tamponade?

By Kandan Viswalingam

Pathophysiology of Acute Cardiac Tamponade

Defn: a life threatening, slow or rapid compression of the heart due to the pericardial accumulation of fluid, pus, blood, clots or gas, as a result of effusion, trauma, or rupture of the heart.1 Pathophysiology:2
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The Primary abnormality is rapid or slow compression of all cardiac chambers secondary to increased intrapericardial pressure. The pericadium can stretch over time but at any instant it is inextensible making the heart compete with the increased pericardial contents for the fixed intrapericardial volume. The key elements are the rate of fluid accumulation relative to pericardial stretch and the effectiveness of compensatory mechanisms. ie. Cardiac rupture and stiff pericardium vs. inflammatory effusion with slow increase in size of effusion. The true filling pressure of the heart is the myocardial transmural pressure which is intracardiac pressure minus pericardial pressure. During inspiration and expiration, the right heart increases its filling at the expense of the left heart, so that its transmural pressure transiently improves and then reverts during expiration. In florid Tamponade this mechanism cannot compensate for the the reduced stroke volume.

Cardiac Tamponade

Pericardial Pressure-Volume curves in Cardiac Tamponade. Reveal an initial slow ascent, followed by an almost vertical rise. The steep rise makes tamponade a last drop phenomenon, The final increment produces critical cardiac compression and first decrement during drainage produces the largest relative decompression.
Spodick, D. H. N Engl J Med 2003;349:684-690

Diagnosis:
Clinical Features:
1. Suspect in patients with wounds of the chest, upper abdomen with associated hypotension, signs/symptoms/history of pericarditis. 2. Symptoms: Tachypnea, DOE, air hunger, anorexia, fatigue, dysphagia. 3. Signs: Tachycardia, hypotension, signs of shock like cool arms, legs, peripheral cyanosis, JVD is the rule, venous waves lack the normal early diastolic y-descent.

Pulsus Paradoxus:

Pulsus Paradoxus: An inspiratory systolic fall in arterial pressure > 10mmHg during normal breathing. When pericardial compliance determines diastolic pressure in both ventricles, the relative filling of the ventricles will be competitive and determined by their respective venous pressures (pulmonary vs systemic), which vary with respiration and alternately favor right and left ventricular filling. This results in pulsus paradoxus.3

This Ventricular interdependence is increased with raised pericardial pressure and this increased coupling is due primarily to an increased ventricular-pericardialventricular coupling. This increased coupling may help to explain the paradoxical pulse observed in cardiac tamponade.4

Dx. Cont.
1. Cardiac Catheterization: Equilibration of the average diastolic pressures characteristic respiratory reciprocation of cardiac pressures: an inspiratory increase on the right and a concomitant decrease in the left. 2. Chest Radiography: Enlarged cardiac silhouette with clear lung zones. 200cc of fluid are necessary to affect the silhouette.

3. Electrocardiogram: Electrical alternans Every other QRS is of smaller voltage, often with reversed polarity.
4. ECHO: Circumferential fluid layer On inspiration, both the ventricular and atrial septa move sharply leftward, reversing on expiration. Specific sign is chamber collapse: During early diastole, the right ventricular free wall invaginates and at end diastole, the right atrium wall invaginates. Secondary to the chamber pressures, temporarily falling below the pericardial pressures.5 ECHO is particularly important to rule out pericardial tamponade before attempting reperfusion therapy with a thrombolytic agent or with angioplasty which would involve administering heparin.6

Longo, M. J. et al. N Engl J Med 1999;341:2060

Swinging of the Heart with a Large Pericardial Effusion (PE), Causing Electrical Alternation and Consequent Tamponade

Spodick, D. H. N Engl J Med 2003;349:684-690

Figure 2. Swinging of the Heart with a Large Pericardial Effusion (PE), Causing Electrical Alternation and Consequent Tamponade. Apical four-chamber two-dimensional echocardiograms show the extremes of oscillation and the resultant effect on the QRS complex. In Panel A, the heart swings to the right, and lead II shows a small QRS complex. In Panel B, the heart swings to the left, and the QRS complex is larger. P denotes pericardium, and LV left ventricle

Management:
Pericardiocentesis: Blindly in the case of an emergency With ECHO, fluoroscopy or CT guidance 2. Pericardiotomy: If the heart cannot be reached by a needle/catheter. Indicated in patients with intrapericardial bleeding, clotted hemopericardium. 3. Positive airway pressure should be avoided as it decreases cardiac output.
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Spodick, D. H. N Engl J Med 2003;349:684-690

Paraxiphoid: The needle is inserted between the xiphoid process and left costal margin. It is inserted at an angle of 15 degrees to bypass the costal margin. The hub is depressed so that it is pointed towards the the left shoulder. The needle is advanced slowly until the pericardium is pierced and fluid is aspirated. A 16-18 guage sheathed needle is used to leave the sheath in the pericardial space. For prolonged drainage a pigtail angiographic catheter is placed in the pericardial space. Follow up doppler to assess reaccumulation of fluid.

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The NEJM, 2003 Aug;14(7):684-690 Acute Cardiac Tamponade D.H. Spodick, M.D., D.Sc. As above Circulation Vol. 58 1978 265-272 Cardiac Tamponade: Hemodynamic observations in man PS Reddy, EI Curtiss, JD OToole and JA Shave Cardiovasc Res. 1990 Sep;24(9):768-76 Effects of increased pericardial pressure on the coupling between the ventricles Santamore WP, Li KS, Nakamoto T, Johnston WE. Source as number 1 above. The NEJM, 1996 Feb;1(5):319-321 A broken heart Doron Zahger, M.D., and Eliyahu Milgalter M.D. The NEJM, 1999;341:2060 Longo, M.J. et al.