Cardiac tamponade

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S{{#meta: itemprop="medicalWebPageAudiences" content="patient"}}{{#meta: itemprop="medicalWebPageSpecialities" content="cardiology"}}{{#meta: itemprop="medicalWebPageInfoTypes" content="symptoms,diagnosis,treatment,causes,prognosis,complications"}} Classification Classic::Classification Atypical::Screening::

Overview

Cardiac tamponade Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Cardiac Tamponade from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
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Case #1
Cardiac tamponade On the Web
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American Roentgen Ray Society Images of Cardiac tamponade All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Cardiac tamponade
CDC on Cardiac tamponade
Cardiac tamponade in the news
Blogs on Cardiac tamponade
Directions to Hospitals Treating Type page name here
Risk calculators and risk factors for Cardiac tamponade

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]; Varun Kumar, M.B.B.S Ramyar Ghandriz MD[5]

Overview

Cardiac tamponade is a medical emergency condition in which fluid/blood accumulates in the pericardium (the sac in which the heart is enclosed). The elevated pericardial pressure puts significant pressure on the heart, causing a decrease in the diastolic filling of the ventricles, and hence in stroke volume. The end result is ineffective pumping of blood, shock, and potentially death. It is caused mainly by the accumulation of a large or uncontrolled pericardial effusion. The effusion can occur rapidly (as in the case of trauma or myocardial rupture), or over a more gradual period of time (as in cancer). The fluid involved is often blood, but pus is also found in some circumstances. Common causes of increased pericardial effusion include hypothyroidism, trauma (either penetrating trauma involving the pericardium or blunt chest trauma), pericarditis (inflammation of the pericardium), iatrogenic trauma (during an invasive procedure), and ventricular rupture. It should be differentiated from tension pneumothorax, hypovolemia and acute congestive heart failure. Patients with cardiac tamponade may present with sudden onset of chest pain, palpitations, breathlessness and lightheadedness. Physical examination may show the classic Beck's triad (hypotension, muffled heart sound, and elevated jugular venous distension), tachycardia, pulsus paradoxus, and pericardial rub depending on the type, and severity of tamponade. The electrocardiogram in cardiac tamponade usually demonstrates sinus tachycardia, and may sometimes show reduced QRS voltage and electrical alternans. Chest X ray will demonstrate pneumopericardium and cardiac silhouette changes. Echocardiography findings include pericardial effusion, diastolic compression of the RV, diastolic compression of the right atrium (RA), plethora of the inferior vena cava and paradoxical septal motion. Pericardiocentesis can provide a diagnostic sampling of pericardial fluid and can be used as a therapeutic maneuver to evacuate pericardial fluid and lower the pericardial pressure.

Historical Perspective

Cardiac tamponade is a very common emergent manifestation, which can be caused by traumatic injuries, since the emulation of the disease tracks back to centuries ago. Acknowledgment of existing pericardial is first done by hippocrates, which was continued by Galen to describing what is now known as pericardial effusion.

Classification

Cardiac tamponade is an emergency form of cardiac effusion. it is more over classified by the pathological causes. The management of emergent situation is not very differed by the basic cause.

Pathophysiology

Cardiac tamponade occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch. If the amount of fluid increases slowly (such as in hypothyroidism) the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If the fluid occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 ml can cause tamponade. However, if the volume of the fluid accumulation is too rapid and or large, then the hemodynamic compromise can occur with a rise in pericardial pressure. This in turn reduces stroke volume, and eventually, cardiac output. If fluid continues to accumulate, then with each successive diastole, less and less blood enters the ventricles, as the increasing pressure presses on the heart and forces the septum to bend into the left ventricle, leading to a decreased stroke volume.

Causes

Cardiac tamponade is caused by the accumulation of a large or uncontrolled pericardial effusion. The effusion can occur rapidly (as in the case of trauma or myocardial rupture), or over a more gradual period of time (as in cancer). The fluid involved is often blood, but pus is also found in some circumstances. Common causes of increased pericardial effusion include hypothyroidism, trauma (either penetrating trauma involving the pericardium or blunt chest trauma), pericarditis (inflammation of the pericardium), iatrogenic trauma (during an invasive procedure), and ventricular rupture.

Differentiating cardiac tamponade from Other Diseases

The initial diagnosis of cardiac tamponade can be challenging, as there are a number of differential diagnoses, including tension pneumothorax, hypovolemia and acute congestive heart failure. The differential diagnosis of cardiac tamponade differs based on the type of cardiac tamponade (either acute or subacute).

Epidemiology and Demographics

The cardiac tamponade is most often attributed to the rupture of an acute myocardial infarction or an intrapericardial rupture of a dissecting ascending aortic aneurysm. In developed countries malignancy is the leading cause of cardiac tamponade secondary to pericardial effusion. The incidence of cardiac tamponade based on a giant sample size of about 216 million emergency admissions was about 115,638(0.05%). The incidence of cardiac tamponade increases with age; the mean age was around 61.9. Cardiac temponade mortality rate is significantly different due to its underlying cause.

Risk Factors

Most potent risk factors for cardiac tamponade include heart surgeries, cardiac myxomas, myocardial infarction and traumas.

Screening

Cardiac tamponade is more of a clinical diagnosis. If the patient clinical manifestation was raising suspicious toward tamponade, CT scan and echocardiogram are diagnostic gold standards for the disease.

Natural History, Complications, and Prognosis

Cardiac tamponade is a life-threatening condition requiring urgent intervention to remove the pericardial fluid. Complications include pulmonary edema, cardiac failure, cardiogenic shock and ultimately death.

Cardiac tamponade has a good prognosis if detected early and treated immediately. Short-term survival is mostly dependent on early diagnosis and relief of tamponade. Long-term survival depends upon the prognosis of the underlying cause, irrespective of the mode of treatment.

Diagnosis

Diagnostic Study of Choice

Cardiac tamponade is more of a clinical diagnosis, but still some diagnostic studies may be helpful.

History and Symptoms

Patients with cardiac tamponade may present with sudden onset of chest pain, palpitations, breathlessness and lightheadedness. Presentation vary with the cause and acuteness of development of tamponade. An acute cardiac tamponade follows trauma to the chest or rupture of the aorta or heart. A subacute cardiac tamponade occurs in the setting of a neoplasm or renal failure. A low pressure cardiac tamponade occurs in patients who are hypovolemic secondary to hemorrhage or over diuresis.

Physical Examination

Physical examination may vary depending on the type of cardiac tamponade. Physical examination may show the classic Beck's triad (hypotension, muffled heart sound, and elevated jugular venous distension), tachycardia, pulsus paradoxus, and pericardial rub depending on the type, and severity of tamponade. Initial diagnosis can be challenging, as there are a number of differential diagnoses, including tension pneumothorax, and acute heart failure.

Laboratory Findings

Non-specific markers of inflammation are generally elevated in pericarditis. This include the CBC, elevated C-reactive protein, ESR. The cardiac troponin is elevated if there is injury to the underlying myocardium, a condition termed myopericarditis. Diagnostic pericardiocentesis and biopsy help in identifying an underlying infectious or malignant process.

Electrocardiogram

The electrocardiogram in cardiac tamponade usually demonstrates sinus tachycardia, and may sometimes show reduced QRS voltage and electrical alternans.

X-ray

Cardiac tamponade is a clinical diagnosis, however chest X ray can be helpful sometimes. It will demonstrate pneumopericardium and cardiac silhouette changes.

Echocardiography and Ultrasound

The role of echocardiography in the evaluation of the patient with pericarditis is to characterize the presence, size, location and hemodynamic impact of a pericardial effusion. Tamponade is characterized by pericardial effusion, diastolic compression of the RV, diastolic compression of the right atrium (RA), plethora of the inferior vena cava and paradoxical septal motion.

CT scan

A CT scan is not commonly used for the diagnosis of cardiac tamponade as it is effectively diagnosed based on clinical features and echocardiography. Findings on CT include [Superior vena cava]] andInferior vena cava enlargement, Hepatic and renal vein enlargment, periportal edema, reflux of contrast material, collapse of the right atrium, Pericardial thickening.

MRI

Cardiovascular MRI is not commonly used for the diagnosis of cardiac tamponade as it is effectively diagnosed based on clinical features and echocardiography. Findings include Pericardial effusion, distension of the vena cavae and hepatic vein, collapse of the right sided cardiac chambers, interventricular septum shifts towards the left, paradoxical septal motion.

Other Imaging Findings

There are no other imaging findings associated with cardiac tamponade.

Other Diagnostic Studies

There are no other diagnostic studies associated with cardiac tampnoade.

Treatment

Medical Therapy

If the patient is symptomatic, and if there are signs of cardiac tamponade, urgent pericardiocentesis should be performed. Additional supportive therapy includes the administration of oxygen, fluid repletion, echocardiographic monitoring, treatment of underlying pathology, reversal of anticoagulation and monitoring.

Surgery

Percutaneous pericardiocentesis is a procedure where fluid is aspirated from the pericardium (the sac enveloping the heart) using a needle via a percutaneous approach. Pericardiocentesis can provide a diagnostic sampling of pericardial fluid and can be used as a therapeutic maneuver to evacuate pericardial fluid and lower the pericardial pressure.

Primary Prevention

There are no established measures for the primary prevention of cardiac tamponade.

Secondary Prevention

There are no established measures for the secondary prevention of cardiac tamponade.

References

Template:WikiDoc Sources

Pathophysiology

Cardiac tamponade Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Cardiac Tamponade from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Case Studies
Case #1
Cardiac tamponade On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Google Images
American Roentgen Ray Society Images of Cardiac tamponade All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Cardiac tamponade
CDC on Cardiac tamponade
Cardiac tamponade in the news
Blogs on Cardiac tamponade
Directions to Hospitals Treating Type page name here
Risk calculators and risk factors for Cardiac tamponade

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [6]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [7]; Varun Kumar, M.B.B.S. Ramyar Ghandriz MD[8]

Overview

Cardiac tamponade occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch. If the amount of fluid increases slowly (such as in hypothyroidism) the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If the fluid occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 ml can cause tamponade. However, if the volume of the fluid accumulation is too rapid and or large, then the hemodynamic compromise can occur with a rise in pericardial pressure. This in turn reduces stroke volume, and eventually, cardiac output. If fluid continues to accumulate, then with each successive diastole, less and less blood enters the ventricles, as the increasing pressure presses on the heart and forces the septum to bend into the left ventricle, leading to a decreased stroke volume.

Pathophysiology

Anatomy and Physiology of Pericardium

Layers of the Pericardium

• The pericardium is made up of two layers
  • Fibrous pericardium
    • Hard protective external layer
    • Attached to sternum anteriorly by sterno-pericardial ligaments and fused with the central tendon of the diaphragm and great vessels to allow mobility of the pericardial sac against sudden cardiac overfilling
  • Serous pericardium
    • Smooth internal layer made up of 2 components:
      • Parietal: reflects onto fibrous pericardium
      • Visceral: reflects onto heart and great vessels and forms the epicardium, the external layer of the heart wall
• Pericardial cavity: Potential space between parietal and visceral layers. It contains a serous fluid film that occupies the cavity and functions as lubricant against friction by all chest movements.

Pericardial Sinuses

• There are two small chambers or sinuses located where the visceral and parietal pericardia are continuous with one another within the pericardial cavity.

• Transverse sinus:
  • Located posterior to the pulmonary trunk and ascending aorta at the level between the superior vena cava and aortic arch
  • Formed after dorsal mesocardium rupture embryonically
  • Functional role is to allow the unhindered expansion of great arteries posteriorly during cardiac systole
  • Utilized surgically to pass surgical clamps or place ligatures around great arteries.
• Oblique sinus:
  • A blind recess (cul-de-sac) posterior to the left atrium between superior vena cava, right and left pulmonary veins inferior to the transverse sinus
  • Formed embryonically by the incorporation of the pulmonary vein tributaries into the left atrium
  • Functional role believed to be the expansion of the left atrium upon the normal collapse of the thorax

• 
• 

Pathogenesis

• The outer pericardium is made of fibrous tissue which does not easily stretch, and so once fluid begins to enter the pericardial space, pressure starts to increase. This causes obstructive shock to develop, and if left untreated, cardiac arrest may occur (in which case the presenting rhythm is likely to be Pulseless electrical activity). .

• Ordinarily, drainage from the pericardium occurs via the thoracic duct and the right lymphatic duct into the right pleural space. In the absence of disease, the normal pericardium contains only 20-50 cc of serous fluid due to ultrafiltration from the blood. Up to about 75 cc can accumulate acutely in the pericardium without hemodynamic compromise. Much greater amounts of fluid can accumulate chronically over a prolonged period of time as the pericardial sac stretches slowly to accommodate the fluid without hemodynamic compromise. However, if the volume of the fluid accumulation is too rapid and or large, then the hemodynamic compromise can occur with a rise in pericardial pressure. This in turn reduces stroke volume, and eventually, cardiac output.

• If fluid continues to accumulate, then with each successive diastole, less and less blood enters the ventricles, as the increasing pressure presses on the heart and forces the septum to bend into the left ventricle, leading to a decreased stroke volume.

Below is a video demonstrating hemorrhagic effusion leading to cardiac tamponade. {{#ev:youtube|QwgfuDegC5Y}}

Gross Pathology

• 

  HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, an excellent example with valve and obviously ruptured heart wall.

• 

  HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, natural color view from within left ventricle caged plastic ball with steel complete struts

• 

  HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, natural color portion of caged plastic ball prosthesis shown with close-up of ruptured left ventricular wall

• 

  HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, natural color close-up view of torn myocardium and bottom of hetero or homograft valve

• 

  HEART: Infarct; Acute, Ruptured: Gross, natural color horizontal section ventricle anterior infarct not easily appreciated with thinning of myocardium

• 

  HEART: Rupture after myocardial infarction.

References

Causes

Cardiac tamponade Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Cardiac Tamponade from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Case Studies
Case #1
Cardiac tamponade On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Google Images
American Roentgen Ray Society Images of Cardiac tamponade All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Cardiac tamponade
CDC on Cardiac tamponade
Cardiac tamponade in the news
Blogs on Cardiac tamponade
Directions to Hospitals Treating Type page name here
Risk calculators and risk factors for Cardiac tamponade

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [9]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [10]; Varun Kumar, M.B.B.S.

Overview

Cardiac tamponade is caused by the accumulation of a large or uncontrolled pericardial effusion. The effusion can occur rapidly (as in the case of trauma or myocardial rupture), or over a more gradual period of time (as in cancer). The fluid involved is often blood, but pus is also found in some circumstances. Common causes of increased pericardial effusion include hypothyroidism, trauma (either penetrating trauma involving the pericardium or blunt chest trauma), pericarditis (inflammation of the pericardium), iatrogenic trauma (during an invasive procedure), and ventricular rupture.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Any cause of pericardial effusion capable of compromising the hemodynamic status of a patient is potentially life threatening.

Common Causes

The most common cause of cardiac tamponade include the following

• Ascending aortic dissection
• Collagen vascular diseases
• Iatrogenic - central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy
• Idiopathic
• Malignancy - breast cancer, Kaposi's sarcoma, lung cancer, lymphomas
• Penetrating trauma
• Pericarditis

Bacteria - pneumococcus, streptococcus, staphylococcus

Fungus - blastomyces, cryptococcus, histoplasma, pneumocystis carinii

Tuberculous

Virus - coxsackie virus, echovirus, CMV

• Post myocardial infarction treatment - heparin, thrombolytics
• Radiation
• Uremia

Causes by Organ System

Cardiovascular	Acute myocardial infarction, aortic dissection, dissecting aortic aneurysm, Dressler's syndrome, Kawasaki disease, myocardial rupture, pericarditis, ventricular aneurysm
Chemical / poisoning
Dermatologic	Behcet syndrome
Drug Side Effect	Anticoagulants, bleomycin, Ceritinib, Cyclophosphamide, dantrolene, daunorubicin, doxorubicin, hydralazine, isoniazid, minoxidil, penicillin, phenylbutazone, phenytoin, procainamide
Ear Nose Throat	Temporal arteritis
Endocrine	Hypothyroidism
Environmental	No underlying causes
Gastroenterologic	Acute pancreatitis, inflammatory bowel disease, Whipple's disease
Genetic
Hematologic	Leukemia, lymphoma
Iatrogenic	Cardiac catheterization, cardiopulmonary resuscitation, cathether ablation for arrhythmias, coronary artery bypass grafting, dialysis, percutaneous coronary intervention, postpericardiotomy syndrome, radiation, TAVI, thoracic surgery, valvuloplasty
Infectious Disease	Actinomycosis, adenovirus, amebiasis, aspergillus, blastomycosis, brucellosis, candida, coccidiomycosis, coxsackie B Virus, cytomegalovirus, Ebstein-Barr virus, echinococcus, echovirus, haemophilus influenza, hepatitis B, histoplasmosis, influenza, legionella, Lyme disease, meningococci, mumps, mycobacterium tuberculosis, mycoplasma pnuemonia, neisseria, nocardia, pneumococci, pneumonia, rheumatic fever, salmonella, staphylococcus, streptococci, syphilis, toxoplasmosis, varicella
Musculoskeletal / Ortho
Neurologic	No underlying causes
Nutritional / Metabolic
Obstetric/Gynecologic	Ovarian hyperstimulation syndrome
Oncologic	Breast cancer, fibroma, Kaposi's sarcoma, leukemia, lung cancer, lymphoma, melanoma, mesothelioma, ovarian cancer, sarcoma
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	Bronchogenic cyst, lung cancer, pneumonia, sarcoidosis
Renal / Electrolyte	Renal failure
Rheum / Immune / Allergy	Acute rheumatic fever, amyloidosis, Behcet syndrome, collagen vascular disease, Dressler's syndrome, inflammatory bowel disease, Kawasaki disease, mixed connective tissue disease, polyarteritis nodosa, rheumatoid arthritis, sarcoidosis, scleroderma, systemic lupus erythematosus, temporal arteritis, Wegener's granulomatosis
Sexual	Neisseria gonorrhoeae, syphilis
Trauma	Blunt or penetrating chest trauma
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Idiopathic

Causes in Alphabetical Order

• Actinomycosis
• Acute myocardial infarction
• Acute pancreatitis
• Adenovirus
• Amebiasis
• Amyloidosis
• Anticoagulants
• Aortic dissection
• Aspergillus
• Behcet syndrome
• Blastomycosis
• Blunt or penetrating chest trauma
• Breast cancer
• Bronchogenic cyst
• Candida
• Cardiac catheterization
• Coccidiomycosis
• Collagen vascular disease
• Coronary artery bypass grafting
• Coxsackie B Virus
• Cyclophosphamide
• Cytomegalovirus
• Dantrolene
• Daunorubicin
• Dissecting aortic aneurysm
• Doxorubicin
• Dressler's syndrome
• Ebstein-Barr virus
• Echinococcus
• Echovirus
• Fibroma

• Haemophilus influenza
• Hepatitis B
• Histoplasmosis
• Hydralazine
• Hypothyroidism
• Idiopathic
• Inflammatory bowel disease
• Influenza
• Isoniazid
• Kaposi's sarcoma
• Kawasaki disease
• Legionella
• Leukemia
• Lung cancer
• Lupus
• Lyme disease
• Lymphoma
• Melanoma
• Meningococci
• Mesothelioma
• Minoxidil
• Mixed connective tissue disease
• Mumps
• Mycobacterium tuberculosis
• Mycoplasma pnuemonia
• Neisseria
• Nocardia
• Ovarian hyperstimulation syndrome
• Penicillin
• Percutaneous interventional procedures

• Pericarditis
• Phenylbutazone
• Phenytoin
• Pneumococci
• Pneumonia
• Polyarteritis nodosa
• Postirradiation
• Postpericardiotomy syndrome
• Procainamide
• Renal failure
• Rheumatic fever
• Rheumatoid arthritis
• Salmonella
• Sarcoidosis
• Sarcoma
• Scleroderma
• Staphylococcus
• Streptococci
• Syphilis
• Systemic lupus erythematosus
• TAVI
• Temporal arteritis
• Thoracic surgery
• Toxoplasmosis
• Valvuloplasty
• Varicella
• Ventricular aneurysm
• Wegener's granulomatosis
• Whipple's disease

References

Natural History, Complications & Prognosis

Natural History

Cardiac tamponade natural history

Diagnosis

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Treatment

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