Pericardial effusion

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Pericardial effusion
Pericardial effusion with tamponade (cropped).gif
A 2D echo transthoracic echocardiogram of pericardial effusion. The "swinging" heart.
Specialty Cardiac surgery

A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of the serous membrane enclose the pericardial cavity (the potential space) between them. [1] This pericardial space contains a small amount of pericardial fluid, normally 15-50 mL in volume. [2] The pericardium, specifically the pericardial fluid provides lubrication, maintains the anatomic position of the heart in the chest, and also serves as a barrier to protect the heart from infection and inflammation in adjacent tissues and organs. [3] [4]

Contents

By definition, a pericardial effusion occurs when the volume of fluid in the cavity exceeds the normal limit. [5] If large enough, it can compress the heart, causing cardiac tamponade and obstructive shock. [6] Some of the presenting symptoms are shortness of breath, chest pressure/pain, and malaise. Important etiologies of pericardial effusions are inflammatory and infectious (pericarditis), neoplastic, traumatic, and metabolic causes. Echocardiogram, CT and MRI are the most common methods of diagnosis, although chest X-ray and EKG are also often performed. Pericardiocentesis may be diagnostic as well as therapeutic (form of treatment).

Signs and symptoms

Pericardial effusion presentation varies from person to person depending on the size, acuity and underlying cause of the effusion. [5] Some people may be asymptomatic and the effusion may be an incidental finding on an examination. [1] Others with larger effusions may present with chest pressure or pain, dyspnea, shortness of breath, and malaise (a general feeling of discomfort or illness). Yet others with cardiac tamponade, a life-threatening complication, may present with dyspnea, low blood pressure, weakness, restlessness, hyperventilation (rapid breathing), discomfort with lying flat, dizziness, syncope or even loss of consciousness. [2] This causes a type of shock, called obstructive shock, which can lead to organ damage. [6]

Non-cardiac symptoms may also present due to the enlarging pericardial effusion compressing nearby structures.  Some examples are nausea and abdominal fullness, dysphagia and hiccups, due to compression of stomach, esophagus, and phrenic nerve respectively. [4]

Causes

Any process that leads to injury or inflammation of the pericardium and/or inhibits appropriate lymphatic drainage of the fluid from the pericardial cavity leads to fluid accumulation. [4] Pericardial effusions can be found in all populations worldwide but the predominant etiology has changed over time, varying depending on the age, location, and comorbidities of the population in question. [2] Out of all the numerous causes of pericardial effusion, some of the leading causes are inflammatory, infectious, neoplastic and traumatic. These causes can be categorized into various classes, but an easy way to understand them is dividing them into inflammatory versus non-inflammatory. [ citation needed ]

A pericardial effusion due to pericarditis PericardialeffusionUS.PNG
A pericardial effusion due to pericarditis

Inflammatory

  1. Infectious:
    • Viral: coxsackie A and B viruses, HIV (seen in 5-43% of HIV patients), [2] hepatitis viruses, parvovirus B19
    • Bacterial: Mycobacterium (tuberculosis), gram positive cocci (Streptococcus, Staphylococcus), Mycoplasma, Neisseria (meningitides, gonorrhea), Coxiella burnetii. Tuberculosis is the leading cause of pericardial effusion in the developing world, with the mortality rate ranging from 17 to 40%. [4]
    • Fungal: Histoplasma, Candida
    • Protozoal: Echinococcus, Trichinosis, Toxoplasma
  2. Cardiac injury syndromes: Heart surgery [7] (postpericardiotomy syndrome), post-myocardial infarction (Dressler's syndrome), coronary interventions such as drug eluting stents. Post-cardiac surgery pericardial effusions contribute to 54% of total effusions in the pediatric population.
  3. Cardiac inflammation: idiopathic pericarditis is the most common inflammatory cause of pericardial effusion in the United States. [8] [9]
  4. Autoimmune: lupus, rheumatoid arthritis, [10] Sjögren syndrome, scleroderma, Dressler's syndrome, sarcoidosis
  5. Drug hypersensitivity/ side effects: Chemotherapy drugs (doxorubicin and cyclophosphamide), Minoxidil
  6. Others: kidney failure, uremia

Non-Inflammatory

  1. Neoplastic: pericardial effusions may present as primary manifestations of underlying malignancy. [4]
    • Primary tumor: the most common primary pericardial tumor is mesothelioma. Various imaging appearances such as solid and cystic components could be encountered on CT scan on those with mesothelioma. Other less common primary tumors are sarcoma, lymphoma, and primitive neuroectodermal tumour. [11]
    • Secondary cancers: that have spread to the pericardium such as breast and lung cancer. Pericardial irregular thickening and/or nodularity, focal, or diffuse FDG uptake on PET scan and lack of preserved fat plane with an adjacent tumor are strongly suggestive of cancer spread from other parts of the body. [11]
  2. Metabolic: hypothyroidism (myxedema coma), severe protein deficiency
  3. Traumatic: penetrating or blunt chest trauma, aortic dissection
  4. Reduced lymphatic drainage: congestive heart failure, nephrotic syndrome

Pathophysiology

Pericardial effusion progresses to cardiac tamponade when the accumulated fluid compresses the heart Pericarditis can progress to pericardial effusion and eventually cardiac tamponade.jpg
Pericardial effusion progresses to cardiac tamponade when the accumulated fluid compresses the heart

How much fluid is stored in the pericardial sac at one particular time is based on the balance between production and reabsorption. Studies have shown that much of the fluid that accumulates in the pericardial sac is from plasma filtration of the epicardial capillaries and a small amount from the myocardium, while the fluid that is drained is mostly via the parietal lymphatic capillaries. [3] Pericardial effusion usually results from a disturbed equilibrium between these two processes or from a structural abnormality that allows excess fluid to enter the pericardial cavity. [3] Because of the limited amount of anatomic space in the pericardial cavity and the limited elasticity of the pericardium, fluid accumulation beyond the normal amount leads to an increased intrapericardial pressure which can negatively affect heart function. [ citation needed ]

A pericardial effusion with enough pressure to adversely affect heart function is called cardiac tamponade. [1] Pericardial effusions can cause cardiac tamponade in acute settings with fluid as little as 150mL. In chronic settings, however, fluid can accumulate anywhere up to 2L before an effusion causes cardiac tamponade. The reason behind this is the elasticity of the pericardium. When fluid fills the cavity rapidly, the pericardium cannot stretch rapidly, but in chronic effusions, the gradual fluid collection provides the pericardium enough time to accommodate and stretch with the increasing fluid levels. [2]

Diagnosis

Patients with pericardial effusion may have unremarkable physical exams but often present with tachycardia, distant heart sounds and tachypnea. [5] A physical finding specific to pericardial effusion is dullness to percussion, bronchial breath sounds and egophony over the inferior angle of the left scapula. This phenomenon is known as Ewart's sign and is due to compression of the left lung base. [2]

Patients with concern for cardiac tamponade may present with abnormal vitals and what's classically known as the Beck's triad, which consists of hypotension (low blood pressure), jugular venous distension and distant heart sounds. Though these are the classical findings; all three occur simultaneously in only a minority of patients. [1] Patients presenting with cardiac tamponade may also be evaluated for pulsus paradoxus. Pulsus paradoxus is a phenomenon in which systolic blood pressure drops by 10 mmHg or more during inspiration. In cardiac tamponade, the pressure within the pericardium is significantly higher, hence decreasing the compliance of the chambers (the capacity to expand/ conform to volume changes). During inspiration, right ventricle filling in increased, which causes the Interventricular septum to bulge into the left ventricle, hence leading to reduced left ventricular filling and consequently reduced stroke volume and low systolic blood pressure. [2]

Exams

Chest X-ray showing a massive pericardial effusion: Water bottle sign Massivepericarialeffusion.png
Chest X-ray showing a massive pericardial effusion: Water bottle sign
EKG: sinus tachycardia with low QRS voltage and electrical alternans Pericardial effusion with tamponade.png
EKG: sinus tachycardia with low QRS voltage and electrical alternans

Some patients with pericardial effusions may present with no symptoms and the diagnosis can be an incidental finding due to imaging of other illnesses. Patients who present with dyspnea or chest pain have a broad differential diagnosis and it may be necessary to rule out other causes like myocardial infarction, pulmonary embolism, pneumothorax, acute pericarditis, pneumonia, and esophageal rupture. [2] Initial tests include electrocardiography (ECG) and chest x-ray.

Chest x-ray: is non-specific and may not help identify a pericardial effusion but a very large, chronic effusion can present as "water-bottle sign" on an x-ray, which occurs when the cardiopericardial silhouette is enlarged and assumes the shape of a flask or water bottle. [2] Chest radiograph is also helpful in ruling out pneumothorax, pneumonia, and esophageal rupture. [ citation needed ]

ECG: may present with sinus tachycardia, low voltage QRS as well as electrical alternans. [2] Due to the fluid accumulation around the heart, the heart is further away from the chest leads, which leads to the low voltage QRS. Electrical alternans signifies the up-and-down change of the QRS amplitude with every beat due to the heart swinging in the fluid (as displayed in the ultrasound image in the introduction) . [1] These three findings together should raise suspicion for impending hemodynamic instability associated with cardiac tamponade. [ citation needed ]

Echocardiogram (ultrasound): when pericardial effusion is suspected, echocardiography usually confirms the diagnosis and allows assessment of the size, location and signs of hemodynamic instability. [4] A transthoracic echocardiogram (TTE) is usually sufficient to evaluate pericardial effusion and it may also help distinguish pericardial effusion from pleural effusion and MI. Most pericardial effusions appear as an anechoic area (black or without an echo) between the visceral and the parietal membrane. [1] Complex or malignant effusions are more heterogeneous in appearance, meaning they may have variations in echo on ultrasound. [5] TTE can also differentiate pericardial effusion based on the size. Although it's difficult to define size classifications because they vary with institutions, most commonly they are as follows: small <10, moderate 10–20, large >20. [5] An echocardiogram is urgently needed for evaluation when there is concern for hemodynamic compromise, a rapidly developing effusion or history of recent cardiac surgery/procedures. [1]

Cardiac CT and MRI scans: cross-sectional imaging with computed tomography (CT) can help localize and quantify the effusion, especially in a loculated effusion (an effusion contained to one area). [12] CT imaging also helps assess for pericardial pathology (pericardial thickening, constrictive pericarditis, malignancy-associated pericarditis). [1] Whereas cardiac MRI is reserved for patients with poor echocardiogram findings and for assessing pericardial inflammation, especially for patients with continued inflammation despite treatment. [5] CT and MRI imaging can also be used for continued follow up on patients. [ citation needed ]

Pericardiocentesis: is a procedure in which fluid is aspirated from the pericardial cavity with a needle and catheter. This procedure can be used to analyze the fluid but more importantly can also provide symptomatic relief, especially in patients with hemodynamic compromise. Pericardiocentesis is usually guided by an echocardiogram to determine the exact location of the effusion and the optimal location of puncture site to minimize risk of complications. [5] After the procedure, the aspirated fluid is analyzed for gross appearance (color, consistency, bloody), cell count, and concentration of glucose, protein, and other cellular components (for example lactate dehydrogenase). [13] Fluid may be also sent for gram stain, acid fast stain, or culture if high suspicion of infectious cause. [1] Bloody fluids may also be evaluated for malignant cells. [13]

Fluid analysis may result in:

Treatment

Treatment depends on the underlying cause and the severity of the heart impairment. [1] For example, pericardial effusion from autoimmune etiologies may benefit from anti-inflammatory medications. Pericardial effusion due to a viral infection usually resolves within a few weeks without any treatment. [8] Small pericardial effusions without any symptoms don't require treatment and may be watched with serial ultrasounds. [2] If the effusion is compromising heart function and causing cardiac tamponade, it will need to be drained. [1] Fluid can be drained via needle pericardiocentesis as discussed above or surgical procedures, such as a pericardial window. [2] The intervention used depends on the cause of pericardial effusion and the clinical status of the patient.[ citation needed ]

Pericardiocentesis is the choice of treatment in unstable patients: it can be performed at the bedside and in a timely manner. [4] A drainage tube is often left in place for 24 hours or more for assessment of re-accumulation of fluid and also for continued drainage. [4] Patients with cardiac tamponade are also given IV fluids and/or vasopressors to increase systemic blood pressure and cardiac output. [1]

But in localized or malignant effusions, surgical drainage may be required instead. This is most often done by cutting through the pericardium and creating a pericardial window [1] This window provides a path for the fluid to be drained directly into the chest cavity, which prevents future development of cardiac tamponade. In localized effusions, it might be difficult to get safe access for pericardiocentesis, hence a surgical procedure is preferred. In case of malignant effusions, the high likelihood of recurrence of fluid accumulation is the main reason for a surgical procedure. [4] Pericardiocentesis is not preferred for chronic treatment options due to risk of infection.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Pleural cavity</span> Thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung

The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the membranes, and also to create a pressure gradient.

<span class="mw-page-title-main">Pericardium</span> Double-walled sac containing the heart and roots of the great vessels

The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue, and an inner layer made of serous membrane. It encloses the pericardial cavity, which contains pericardial fluid, and defines the middle mediastinum. It separates the heart from interference of other structures, protects it against infection and blunt trauma, and lubricates the heart's movements.

<span class="mw-page-title-main">Cardiac tamponade</span> Buildup of fluid around the heart

Cardiac tamponade, also known as pericardial tamponade, is a compression of the heart due to pericardial effusion. Onset may be rapid or gradual. Symptoms typically include those of obstructive shock including shortness of breath, weakness, lightheadedness, and cough. Other symptoms may relate to the underlying cause.

<span class="mw-page-title-main">Constrictive pericarditis</span> Medical condition

Constrictive pericarditis is a condition characterized by a thickened, fibrotic pericardium, limiting the heart's ability to function normally. In many cases, the condition continues to be difficult to diagnose and therefore benefits from a good understanding of the underlying cause.

<span class="mw-page-title-main">Pericarditis</span> Medical condition

Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sitting up and more severe when lying down or breathing deeply. Other symptoms of pericarditis can include fever, weakness, palpitations, and shortness of breath. The onset of symptoms can occasionally be gradual rather than sudden.

<span class="mw-page-title-main">Pericardiocentesis</span> Procedure where fluid is aspirated from the pericardium

Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium.

Dressler syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium. It consists of fever, pleuritic pain, pericarditis and/or pericardial effusion.

<span class="mw-page-title-main">Pericardial fluid</span>

Pericardial fluid is the serous fluid secreted by the serous layer of the pericardium into the pericardial cavity. The pericardium consists of two layers, an outer fibrous layer and the inner serous layer. This serous layer has two membranes which enclose the pericardial cavity into which is secreted the pericardial fluid. The fluid is similar to the cerebrospinal fluid of the brain which also serves to cushion and allow some movement of the organ.

<span class="mw-page-title-main">Acute pericarditis</span> Medical condition

Acute pericarditis is a type of pericarditis usually lasting less than 6 weeks. It is the most common condition affecting the pericardium.

Pericardiectomy is the surgical removal of part or most of the pericardium. This operation is most commonly used to relieve constrictive pericarditis, or to remove a pericardium that is calcified and fibrous. It may also be used for severe or recurrent cases of pericardial effusion. Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat.

<span class="mw-page-title-main">Primary tumors of the heart</span> Medical condition

Primary tumors of the heart are extremely rare tumors that arise from the normal tissues that make up the heart. The incidence of primary cardiac tumors has been found to be approximately 0.02%. This is in contrast to secondary tumors of the heart, which are typically either metastatic from another part of the body, or infiltrate the heart via direct extension from the surrounding tissues. Metastatic tumors to the heart are about 20 times more common than primary cardiac tumors.

The following outline is provided as an overview of and topical guide to cardiology, the branch of medicine dealing with disorders of the human heart. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in cardiology are called cardiologists.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

<span class="mw-page-title-main">Hemopericardium</span> Medical condition

Hemopericardium refers to blood in the pericardial sac of the heart. It is clinically similar to a pericardial effusion, and, depending on the volume and rapidity with which it develops, may cause cardiac tamponade.

Tuberculous pericarditis is a form of pericarditis. It is a condition in which the pericardium surrounding the heart is infected by the bacterial species Mycobacterium tuberculosis. Tuberculous pericarditis accounts for a significant percentage of presentations of tuberculosis worldwide. The condition has four stages of disease which manifests with clinical presentations ranging from acute pericarditis to overt heart failure. Tuberculous pericarditis is an under-diagnosed condition. Diagnosis often requires a range of diagnostic tools, including pericardiocentesis, biochemical tests, and imaging. Treatment of this disease is similar to treatment of pulmonary tuberculosis. Alternative treatment options to reduce cardiac complications are also available.

The Hs and Ts is a mnemonic used to aid in remembering the possible reversible causes of cardiac arrest. A variety of disease processes can lead to a cardiac arrest; however, they usually boil down to one or more of the "Hs and Ts".

A pericardial window is a cardiac surgical procedure to create a fistula – or "window" – from the pericardial space to the pleural cavity. The purpose of the window is to allow a pericardial effusion or cardiac tamponade to drain from the space surrounding the heart into the chest cavity.

<span class="mw-page-title-main">Postpericardiotomy syndrome</span> Medical condition

Postpericardiotomy syndrome (PPS) is a medical syndrome referring to an immune phenomenon that occurs days to months after surgical incision of the pericardium. PPS can also be caused after a trauma, a puncture of the cardiac or pleural structures, after percutaneous coronary intervention, or due to pacemaker or pacemaker wire placement.

<span class="mw-page-title-main">Pericardial cyst</span>

A pericardial cyst is an uncommon benign dilatation of the pericardial sac surrounding the heart. It can lead to symptoms by compressing nearby structures, but is usually asymptomatic. Pericardial cysts can be congenital or acquired, and they are typically diagnosed with radiologic imaging. Management of pericardial cysts can include follow-up imaging, percutaneous aspiration, or surgical resection.

<span class="mw-page-title-main">Purulent pericarditis</span> Inflammation of the sac surrounding the heart due to bacterial infection.

Purulent pericarditis refers to localized inflammation in the setting of infection of the pericardial sac surrounding the heart. In contrast to other causes of pericarditis which may have a viral etiology, purulent pericarditis refers specifically to bacterial or fungal infection of the pericardial sac. Clinical etiologies of purulent pericarditis may include recent surgery, adjacent infection, trauma, or even primary infection. The onset of purulent pericarditis is usually acute, with most individuals presenting to a medical facility approximately 3 days following the onset of symptoms.

References

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  2. 1 2 3 4 5 6 7 8 9 10 11 12 Willner, Daniel A.; Goyal, Amandeep; Grigorova, Yulia; Kiel, John (2020), "Pericardial Effusion", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   28613741 , retrieved 2020-11-12
  3. 1 2 3 Vogiatzidis, Konstantinos; Zarogiannis, Sotirios G.; Aidonidis, Isaac; Solenov, Evgeniy I.; Molyvdas, Paschalis-Adam; Gourgoulianis, Konstantinos I.; Hatzoglou, Chrissi (18 March 2015). "Physiology of pericardial fluid production and drainage". Frontiers in Physiology. 6: 62. doi: 10.3389/fphys.2015.00062 . ISSN   1664-042X. PMC   4364155 . PMID   25852564.
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  7. ↑ Pericardial effusion:What are the symptoms?, Dr. Martha Grogan M.D.
  8. 1 2 Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015;314(14):1498–1506. doi:10.1001/jama.2015.12763
  9. ↑ Imazio, Massimo; Gaita, Fiorenzo; LeWinter, Martin (2015-10-13). "Evaluation and Treatment of Pericarditis: A Systematic Review". JAMA. 314 (14): 1498–1506. doi:10.1001/jama.2015.12763. hdl: 2318/1576078 . ISSN   0098-7484. PMID   26461998.
  10. ↑ Hallewell RA, Sherratt DJ (1976). "Isolation and characterization of Co1E2 plasmid mutants unable to kill colicin-sensitive cells". Mol Gen Genet. 146 (3): 239–45. doi:10.1007/bf00701246. PMID   794689. S2CID   24915129.
  11. 1 2 Ünal, Emre; Karcaaltincaba, Musturay; Akpinar, Erhan; Ariyurek, Orhan Macit (December 2019). "The imaging appearances of various pericardial disorders". Insights into Imaging. 10 (1): 42. doi: 10.1186/s13244-019-0728-4 . ISSN   1869-4101. PMC   6441059 . PMID   30927107.
  12. ↑ Chang, S (Jul–Sep 2014). "Brief Images: Massive pericardial effusion". Images in Paediatric Cardiology. 16 (3): 1–3. PMC   4521324 . PMID   26236369.
  13. 1 2 Kopcinovic, Lara Milevoj; Culej, Jelena (15 February 2014). "Pleural, peritoneal and pericardial effusions - a biochemical approach". Biochemia Medica. 24 (1): 123–137. doi:10.11613/BM.2014.014. ISSN   1330-0962. PMC   3936968 . PMID   24627721.
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