Pericardial Effusion

Aka: Pericardial Effusion

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II. Definition

  1. Fluid collection around heart within pericardial sac

III. Causes

  1. Benign Pericarditis
    1. See Pericarditis Causes
    2. Connective Tissue Disease (esp. Rheumatoid Arthritis)
  2. Malignant Pericarditis (common, occurs in 20-40% of cancer patients)
    1. Also occurs as a complication of combination Chemotherapy, Radiation Therapy
    2. Most common metastatic cancer causes
      1. Lung Cancer
      2. Breast Cancer
    3. Other cancer causes
      1. Esophageal Cancer
      2. Lymphoma
      3. Leukemia
      4. Melanoma
  3. Hemopericardium
    1. Heart surgery from post-operative Hemorrhage (common)
    2. Myocardial Infarction (free wall ventricular rupture)
    3. Aortic aneurysm
    4. Aortic Dissection
    5. Chest Trauma (especially penetrating Chest Injury)
    6. Anticoagulation
  4. Chylopericardium (milky Pericardial Effusion)
    1. Heart surgery from post-operative lymph collection
    2. Malignancy (lymphatic obstruction from heart)

IV. Symptoms: Symptoms

  1. Symptomatic threshold for Pericardial Effusion
    1. Acute (rapidly progressive): 200 ml
    2. Chronic: May not be significantly symptomatic until 1-2 Liters are present
  2. Common Symptoms
    1. Chest Pain
    2. Shortness of Breath (especially exertional Dyspnea)
    3. Palpitations

V. Signs

  1. See Cardiac Tamponade
  2. Pulsus Paradoxus
    1. Occurs in 77% of Cardiac Tamponade cases
  3. Beck Triad (more common in rapidly progressive Pericardial Effusions)
    1. Muffled heart sounds
    2. Hypotension
    3. Jugular Venous Distention

VI. Diagnostics: Electrocardiogram

  1. See Cardiac Tamponade
  2. Low amplitude wave forms
  3. Electrical alternans

VII. Imaging: Echocardiogram

  1. See Echocardiogram
  2. Features
    1. Pericardial Effusion will surround the heart and should be seen in multiple views
    2. Pericardial fluid moves in opposite direction as heart wall
    3. Cardiac Tamponade
      1. Right heart wall movement appears as a paradoxical rocking motion
      2. Right atrium collapse in systole (also occurs with Hypovolemic Shock)
      3. Right ventricular collapse in diastole
      4. May appear as a tiny man jumping on right ventricle like a trampoline (PLAX View)
  3. Differential diagnosis (look-alikes on Echocardiogram, confirm in multiple views)
    1. Descending aorta
    2. Pericardial fat pad (moves with heart wall)
      1. Clotted blood may have similar heterogeneous appearance as fat
      2. However clotted blood moves independently of heart wall
  4. Precautions
    1. Even a small Pericardial Effusion (0.5 cm) can cause tamponade
  5. References
    1. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
    2. Orman, Dawson and Mallin in Majoewsky (2013) EM:Rap 13(1): 4-6

VIII. Management

  1. Consult cardiothoracic surgery
  2. Emergent management for Cardiac Tamponade
    1. See Emergency Pericardiocentesis
  3. Chronic management
    1. Pericardial window
    2. Pericardiocentesis with indwelling pericardial catheter drainage
    3. Specific cause management (e.g. Chemotherapy)
    4. Consult oncology, Palliative Care when appropriate

IX. Prognosis

  1. Malignant Pericardial Effusion
    1. Median survival: 2-4 months

X. References

  1. Long, Long and Koyfman (2020) Crit Dec Emerg Med 34(11): 17-24
  2. Higdon (2018) Am Fam Physician 97(11):741-8 [PubMed]

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