Skip to main content
Top
Published in: Current Cardiology Reports 7/2017

01-07-2017 | Pericardial Disease (AL Klein, Section Editor)

Pericardial Effusion and Cardiac Tamponade in the New Millennium

Author: Brian D. Hoit

Published in: Current Cardiology Reports | Issue 7/2017

Login to get access

Abstract

Purpose of Review

The purpose of this paper is to review current approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.

Recent Findings

Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have refined our approaches to the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. New diagnostic and triage strategies have been proposed, and recent data have advanced our ability to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and establish its cause.

Summary

Despite these recent findings, there is a paucity of evidence-based data to guide the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is unquestioned, there are increasing niche roles for multimodality imaging.
Literature
1.
go back to reference • Adler Y, Charron P, Imazio M, Badano L, Baron-Esquivias G, Bogaert J, 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;36:2921–64. An exhaustive, authoritative document offering guidelines and recommendations (most representing a consensus of experts and/or small studies, retrospective studies, and registries) for all manifestations of pericardial disease. CrossRefPubMed • Adler Y, Charron P, Imazio M, Badano L, Baron-Esquivias G, Bogaert J, 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;36:2921–64. An exhaustive, authoritative document offering guidelines and recommendations (most representing a consensus of experts and/or small studies, retrospective studies, and registries) for all manifestations of pericardial disease. CrossRefPubMed
2.
go back to reference Hoit BD. Diagnosis and treatment of pericardial effusion. www.uptodate.com. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 3/23/17.) Copyright © 2016 UpToDate, Inc. For more information visit www.uptodate.com. Hoit BD. Diagnosis and treatment of pericardial effusion. www.​uptodate.​com. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 3/23/17.) Copyright © 2016 UpToDate, Inc. For more information visit www.​uptodate.​com.
3.
go back to reference • Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013;34:1186–97. A critical evaluation of the pathophysiology, clinical presentation diagnosis, treatment, and follow-up of pericardial effusions. CrossRefPubMed • Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013;34:1186–97. A critical evaluation of the pathophysiology, clinical presentation diagnosis, treatment, and follow-up of pericardial effusions. CrossRefPubMed
4.
go back to reference Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56:623–30.CrossRefPubMed Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56:623–30.CrossRefPubMed
5.
go back to reference Sagrista-Sauleda J, Merce J, Permanyer-Maralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med. 2000;109:95–101.CrossRefPubMed Sagrista-Sauleda J, Merce J, Permanyer-Maralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med. 2000;109:95–101.CrossRefPubMed
6.
go back to reference Corey GR, Campbell PT, VanTrigt P, Kenney RT, O’Connor CM, Sheikh KH, et al. Etiology of large pericardial effusion. Am J Med. 1993;95:209–13.CrossRefPubMed Corey GR, Campbell PT, VanTrigt P, Kenney RT, O’Connor CM, Sheikh KH, et al. Etiology of large pericardial effusion. Am J Med. 1993;95:209–13.CrossRefPubMed
7.
go back to reference Levy PY, Corey R, Berger P, Habib G, Bonnet JL, Levy S, et al. Etiologic diagnosis of 204 pericardial effusion. Medicine (Baltimore). 2003;82:385–91.CrossRef Levy PY, Corey R, Berger P, Habib G, Bonnet JL, Levy S, et al. Etiologic diagnosis of 204 pericardial effusion. Medicine (Baltimore). 2003;82:385–91.CrossRef
8.
go back to reference • Ma W, Liu J, Chen S, Chen S, Zheng Y, Ye S, et al. Causes of moderate to large pericardial effusion requiring pericardiocentesis in 140 Han Chinese patients. Herz. 2012;37:183–7. A contemporary review of the clinical characteristics and etiologies of moderate to large pericardial effusions that required drainage. Malignancy, infection, and iatrogenic were the three leading causes. CrossRefPubMed • Ma W, Liu J, Chen S, Chen S, Zheng Y, Ye S, et al. Causes of moderate to large pericardial effusion requiring pericardiocentesis in 140 Han Chinese patients. Herz. 2012;37:183–7. A contemporary review of the clinical characteristics and etiologies of moderate to large pericardial effusions that required drainage. Malignancy, infection, and iatrogenic were the three leading causes. CrossRefPubMed
9.
go back to reference Seferovic PM, Ristic AD, Imazio M, Maksimovic R, Simeunovic D, Trinchero R, et al. Management strategies in pericardial emergencies. Herz. 2006;31:891–900.CrossRefPubMed Seferovic PM, Ristic AD, Imazio M, Maksimovic R, Simeunovic D, Trinchero R, et al. Management strategies in pericardial emergencies. Herz. 2006;31:891–900.CrossRefPubMed
10.
go back to reference Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg. 2002;74:1148–53.CrossRefPubMed Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg. 2002;74:1148–53.CrossRefPubMed
11.
go back to reference •• Meurin P, LeLay-Kubas S, Pierre B, Pereira H, Pavy B, Iliou MC, et al. Colchicine for post-operative pericardial effusion. J Am Coll Cardiol. 2015;66:1198–9. A letter which describes the preliminary results of the POPE-2 study. In patients with a moderate to large pericardial effusion persisting one week after cardiac surgery, colchicine had no significant effect on the size of the effusion. CrossRefPubMed •• Meurin P, LeLay-Kubas S, Pierre B, Pereira H, Pavy B, Iliou MC, et al. Colchicine for post-operative pericardial effusion. J Am Coll Cardiol. 2015;66:1198–9. A letter which describes the preliminary results of the POPE-2 study. In patients with a moderate to large pericardial effusion persisting one week after cardiac surgery, colchicine had no significant effect on the size of the effusion. CrossRefPubMed
12.
go back to reference Freeman GL, LeWinter MM. Pericardial adaptations during chronic cardiac dilation in dogs. Circ Res. 1984;54:294–300.CrossRefPubMed Freeman GL, LeWinter MM. Pericardial adaptations during chronic cardiac dilation in dogs. Circ Res. 1984;54:294–300.CrossRefPubMed
13.
go back to reference •• Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, 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;26:965–1012. A detailed, well-illustrated expert consensus statement from the ASE offering recommendations for integrated multimodality imaging in all manifestations of pericardial disease. CrossRefPubMed •• Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, 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;26:965–1012. A detailed, well-illustrated expert consensus statement from the ASE offering recommendations for integrated multimodality imaging in all manifestations of pericardial disease. CrossRefPubMed
14.
go back to reference Verhaert D, Gabriel RS, Johnston D, Lytle BW, Desai MY, Klein AL. The role of multimodality imaging in the management of pericardial diseases. Circ Cardiovasc Imaging. 2010;3:333–43.CrossRefPubMed Verhaert D, Gabriel RS, Johnston D, Lytle BW, Desai MY, Klein AL. The role of multimodality imaging in the management of pericardial diseases. Circ Cardiovasc Imaging. 2010;3:333–43.CrossRefPubMed
16.
go back to reference Brown J, MacKinnon D, King A, Vanderbush E. Elevated arterial blood pressure in cardiac tamponade. N Engl J Med. 1992;327:463–6.CrossRefPubMed Brown J, MacKinnon D, King A, Vanderbush E. Elevated arterial blood pressure in cardiac tamponade. N Engl J Med. 1992;327:463–6.CrossRefPubMed
17.
go back to reference Reddy PS, Curtiss EI, O'Toole JD, Shaver JA. Cardiac tamponade: hemodynamic observations in man. Circulation. 1978;58:265–72.CrossRefPubMed Reddy PS, Curtiss EI, O'Toole JD, Shaver JA. Cardiac tamponade: hemodynamic observations in man. Circulation. 1978;58:265–72.CrossRefPubMed
18.
go back to reference Cogswell TL, Bernath GA, Raff H, Hoffmann RG, Klopfenstein HS. Total peripheral resistance during cardiac tamponade: adrenergic and angiotensin roles. Am J Phys. 1986;251:R916–22. Cogswell TL, Bernath GA, Raff H, Hoffmann RG, Klopfenstein HS. Total peripheral resistance during cardiac tamponade: adrenergic and angiotensin roles. Am J Phys. 1986;251:R916–22.
19.
go back to reference Sagrista-Sauleda J, Angel J, Sambola A, Alguersuari J, Permanyer-Miralda G, Soler-Soler J. Low-pressure cardiac tamponade: clinical and hemodynamic profile. Circulation. 2006;114:945–52.CrossRefPubMed Sagrista-Sauleda J, Angel J, Sambola A, Alguersuari J, Permanyer-Miralda G, Soler-Soler J. Low-pressure cardiac tamponade: clinical and hemodynamic profile. Circulation. 2006;114:945–52.CrossRefPubMed
20.
go back to reference Vaska K, Wann LS, Sagar K, Klopfenstein HS. Pleural effusion as a cause of right ventricular diastolic collapse. Circulation. 1992;86:609–17.CrossRefPubMed Vaska K, Wann LS, Sagar K, Klopfenstein HS. Pleural effusion as a cause of right ventricular diastolic collapse. Circulation. 1992;86:609–17.CrossRefPubMed
21.
go back to reference • Ristic AD, Imazio M, Adler Y, Anastasakis A, Badano LP, Brucato A, et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2014;35:2279–84. A proposal for a step-wise scoring system based on the etiology, clinical presentation and imaging of pericardial effusions that identifies high risk patients requiring urgent pericardiocentesis and those patients that should be transferred to hospitals specializing in pericardial disease. CrossRefPubMed • Ristic AD, Imazio M, Adler Y, Anastasakis A, Badano LP, Brucato A, et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2014;35:2279–84. A proposal for a step-wise scoring system based on the etiology, clinical presentation and imaging of pericardial effusions that identifies high risk patients requiring urgent pericardiocentesis and those patients that should be transferred to hospitals specializing in pericardial disease. CrossRefPubMed
22.
go back to reference 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;12:1470–7.CrossRefPubMed 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;12:1470–7.CrossRefPubMed
23.
go back to reference Singh S, Wann LS, Klopfenstein HS, Hartz A, Brooks HL. Usefulness of right ventricular diastolic collapse in diagnosing cardiac tamponade and comparison to pulsus paradoxus. Am J Cardiol. 1986;57:652–6.CrossRefPubMed Singh S, Wann LS, Klopfenstein HS, Hartz A, Brooks HL. Usefulness of right ventricular diastolic collapse in diagnosing cardiac tamponade and comparison to pulsus paradoxus. Am J Cardiol. 1986;57:652–6.CrossRefPubMed
24.
go back to reference Gillam LD, Guyer DE, Gibson TC, King ME, Marshall JE, Weyman AE. Hydrodynamic compression of the right atrium: a new echocardiographic sign of cardiac tamponade. Circulation. 1983;68:294–301.CrossRefPubMed Gillam LD, Guyer DE, Gibson TC, King ME, Marshall JE, Weyman AE. Hydrodynamic compression of the right atrium: a new echocardiographic sign of cardiac tamponade. Circulation. 1983;68:294–301.CrossRefPubMed
25.
go back to reference 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;68:612–20.CrossRefPubMed 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;68:612–20.CrossRefPubMed
26.
go back to reference Merce J, Sagrista-Sauleda J, Permanyer-Miralda G, Evangelista A, Soler-Soler J. 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;138:759–64.CrossRefPubMed Merce J, Sagrista-Sauleda J, Permanyer-Miralda G, Evangelista A, Soler-Soler J. 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;138:759–64.CrossRefPubMed
27.
go back to reference Hoit BD, Fowler NO. Influence of acute right ventricular dysfunction on cardiac tamponade. J Am Coll Cardiol. 1991;18:1787–93.CrossRefPubMed Hoit BD, Fowler NO. Influence of acute right ventricular dysfunction on cardiac tamponade. J Am Coll Cardiol. 1991;18:1787–93.CrossRefPubMed
28.
go back to reference Hoit BD, Gabel M, Fowler NO. Cardiac tamponade in left ventricular dysfunction. Circulation. 1990;82:1370–6.CrossRefPubMed Hoit BD, Gabel M, Fowler NO. Cardiac tamponade in left ventricular dysfunction. Circulation. 1990;82:1370–6.CrossRefPubMed
29.
go back to reference Chuttani K, Tischler MD, Pandian NG, Lee RT, Mohanty PK. Diagnosis of cardiac tamponade after cardiac surgery: relative value of clinical, echocardiographic, and hemodynamic signs. Am Heart J. 1994;127:913–8.CrossRefPubMed Chuttani K, Tischler MD, Pandian NG, Lee RT, Mohanty PK. Diagnosis of cardiac tamponade after cardiac surgery: relative value of clinical, echocardiographic, and hemodynamic signs. Am Heart J. 1994;127:913–8.CrossRefPubMed
30.
go back to reference Hoit BD, Shaw D. The paradoxical pulse in tamponade: mechanisms and echocardiographic correlates. Echocardiography. 1994;11:477–87.CrossRefPubMed Hoit BD, Shaw D. The paradoxical pulse in tamponade: mechanisms and echocardiographic correlates. Echocardiography. 1994;11:477–87.CrossRefPubMed
31.
go back to reference Seferović PM, Ristić AD, Maksimović R, Tatic V, Ostojic M, Kanjuh V. Diagnostic value of pericardial biopsy: improvement with extensive sampling enabled by pericardioscopy. Circulation. 2003;107:978–83.CrossRefPubMed Seferović PM, Ristić AD, Maksimović R, Tatic V, Ostojic M, Kanjuh V. Diagnostic value of pericardial biopsy: improvement with extensive sampling enabled by pericardioscopy. Circulation. 2003;107:978–83.CrossRefPubMed
32.
go back to reference 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;23:1503–8.CrossRefPubMed 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;23:1503–8.CrossRefPubMed
33.
go back to reference Ben-Horin S, Bank I, Shinfeld A, Kachel E, Guetta V, Livneh A. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007;99:1294–7.CrossRefPubMed Ben-Horin S, Bank I, Shinfeld A, Kachel E, Guetta V, Livneh A. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007;99:1294–7.CrossRefPubMed
34.
go back to reference Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocentesis: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429–36.CrossRefPubMed Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocentesis: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429–36.CrossRefPubMed
35.
go back to reference • Imazio M, Belli R, Beqaraj F, et al. DRainage Or Pericardiocentesis alone for recurrent nonmalignant, nonbacterial pericardial effusions requiring intervention: rationale and design of the DROP trial, a randomized, open-label, multicenter study. J Cardiovasc Med. 2014;15:510–4. Methodology of a multicenter trial that is randomizing patients with hemodynamically significant nonmalignant, nonbacterial pericardial effusions to pericardiocentesis vs. pericardiocentesis plus prolonged drainage. The primary end-points are incidence of recurrent pericardial effusion and the need for additional pericardiocentesis or cardiac surgery at 12 months. CrossRef • Imazio M, Belli R, Beqaraj F, et al. DRainage Or Pericardiocentesis alone for recurrent nonmalignant, nonbacterial pericardial effusions requiring intervention: rationale and design of the DROP trial, a randomized, open-label, multicenter study. J Cardiovasc Med. 2014;15:510–4. Methodology of a multicenter trial that is randomizing patients with hemodynamically significant nonmalignant, nonbacterial pericardial effusions to pericardiocentesis vs. pericardiocentesis plus prolonged drainage. The primary end-points are incidence of recurrent pericardial effusion and the need for additional pericardiocentesis or cardiac surgery at 12 months. CrossRef
36.
go back to reference Ziskind AA, Pearce AC, Lemmon CC, Burstein S, Gimple LW, Herrmann HC, 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;21:1–5.CrossRefPubMed Ziskind AA, Pearce AC, Lemmon CC, Burstein S, Gimple LW, Herrmann HC, 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;21:1–5.CrossRefPubMed
37.
go back to reference Mitiku TY, Heidenreich PA. A small pericardial effusion is a marker of increased mortality. Am Heart J. 2011;161:152–7.CrossRefPubMed Mitiku TY, Heidenreich PA. A small pericardial effusion is a marker of increased mortality. Am Heart J. 2011;161:152–7.CrossRefPubMed
38.
go back to reference • Frohlich GM, Keller P, Schmid F, et al. Haemodynamically irrelevant pericardial effusion is associated with increased mortality in patients with chronic heart failure. Eur Heart J. 2013;34:1414–23. In this retrospective observational study of nearly 900 patients with heart failure, the presence of a hemodynamically insignificant pericardial effusion was independently associated with a ~ 2-fold hazard of death at one year. CrossRefPubMed • Frohlich GM, Keller P, Schmid F, et al. Haemodynamically irrelevant pericardial effusion is associated with increased mortality in patients with chronic heart failure. Eur Heart J. 2013;34:1414–23. In this retrospective observational study of nearly 900 patients with heart failure, the presence of a hemodynamically insignificant pericardial effusion was independently associated with a ~ 2-fold hazard of death at one year. CrossRefPubMed
39.
go back to reference 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;341:2054–9.CrossRefPubMed 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;341:2054–9.CrossRefPubMed
40.
go back to reference Hoit BD. Diagnosis and management of pericardial disease. J Intensive Care Med. 2000;15(1):14–28.CrossRef Hoit BD. Diagnosis and management of pericardial disease. J Intensive Care Med. 2000;15(1):14–28.CrossRef
Metadata
Title
Pericardial Effusion and Cardiac Tamponade in the New Millennium
Author
Brian D. Hoit
Publication date
01-07-2017
Publisher
Springer US
Published in
Current Cardiology Reports / Issue 7/2017
Print ISSN: 1523-3782
Electronic ISSN: 1534-3170
DOI
https://doi.org/10.1007/s11886-017-0867-5

Other articles of this Issue 7/2017

Current Cardiology Reports 7/2017 Go to the issue

Myocardial Disease (A Abbate, Section Editor)

Myocarditis: A Clinical Overview

Lipid Abnormalities and Cardiovascular Prevention (G De Backer, Section Editor)

Dyslipidemias and Cardiovascular Prevention: Tailoring Treatment According to Lipid Phenotype

Cardio-Oncology (SA Francis, Section Editor)

Cardiovascular Risk in Survivors of Cancer

Nuclear Cardiology (V Dilsizian, Section Editor)

Targeted Nuclear Imaging Probes for Cardiac Amyloidosis