Cardiac Tamponade Cardiac Tamponade Dr. Mohammad AlGhamdi Dr. Mohammad AlGhamdi Consultant cardiologist Consultant cardiologist King AbdulAziz Cardiac Center King AbdulAziz Cardiac Center National Guard- Riyadh National Guard- Riyadh
Cardiac TamponadeCardiac Tamponade
Dr. Mohammad AlGhamdiDr. Mohammad AlGhamdiConsultant cardiologistConsultant cardiologist
King AbdulAziz Cardiac CenterKing AbdulAziz Cardiac Center
National Guard- RiyadhNational Guard- Riyadh
Cardiac TamponadeCardiac Tamponade
Life threateningLife threatening
Cardiac compression Cardiac compression syndromesyndrome
Due to pericardial Due to pericardial fluid accumulationfluid accumulation
Predisposing conditionsPredisposing conditions
60% of cases have known underlying conditions
Neoplasm-related conditions
Pericarditis (viral, uremic, TB, SLE,…)
Trauma (medical & non-medical)
Unrelated to effusion size,
but to the rate of accumulation
one-third of asymptomatic large chronic effusions
develop unexpected cardiac tamponade
Tamponade pathophysiologyTamponade pathophysiology
Low cardiac output state due to reduced cardiac filling.
Echo/Doppler findings attributed to hemodynamic abnormalities.
Pericardial pressure equal to or exceeds intracardiac pressure.
Pathological process
HemodynamicHemodynamic ClinicalClinical EchoEcho
External mechanical compression.
MechanicalMechanical
Clinical approachClinical approach
Hemodynamic instability
Clinical picture Basic investigations Imaging studies
pericardial effusion+
SOB
Tachycardia
Low BP
High JVP
Diminished HS
Pulsus paradoxus
Clear lungs
ECG
CXR
Trans-thoracic echo
TEE, CT scan, MRI
Limitations of clinical assessmentLimitations of clinical assessment
DyspneaTachycardia
Elevated JVPPulsus Paradoxus
Cardiomegaly on CXR
Diminished HSHypotension
Low voltage EKGSensitivity <50%
Sensitivity = 70%
PRESENTPRESENTAsthma/COPDAsthma/COPD
P. EmbolismP. Embolism
CHFCHF
Mitral StenosisMitral Stenosis
Hypovolemia Hypovolemia
AscitesAscites
ObesityObesity
ABSENTABSENTHypotensionHypotension
P. adhesionsP. adhesions
ARAR
ASDASD
RVHRVH
Pulsus P
aradoxus
Basic investigations
Low voltageLow voltage Electrical alternansElectrical alternans
Enlarged cardiac Enlarged cardiac silhouettesilhouette
CT or MRICT or MRI
Effusions measured by CT/MRI tend to be larger than in echocardiography
Echocardiographic Echocardiographic findingsfindings
Just remember thatJust remember that… …
Tamponade is a Tamponade is a clinical descriptionclinical description
not an echo diagnosis not an echo diagnosis
Echo findings would Echo findings would support or refute support or refute clinical suspicionclinical suspicion
√ X
Detecting Pericardial EffusionDetecting Pericardial Effusion
Echo-free space Echo-free space surrounding the surrounding the heartheart
Variable degrees Variable degrees of severityof severity
Differential diagnosis of pericardial Differential diagnosis of pericardial echo-free space echo-free space
CommonCommon Left pleural effusion Left pleural effusion Loculated Loculated
Pericardial effusionPericardial effusion Intrapericardial Intrapericardial
hematomahematoma Epicardial fat padsEpicardial fat pads
RareRare Pericardial cystPericardial cyst Desc. aortic Desc. aortic
aneurysmaneurysm LV pseudoaneurysmLV pseudoaneurysm Hiatus herniaHiatus hernia Massive LAE Massive LAE
Important landmarksImportant landmarks
Pericardial effusion Pericardial effusion is seen anterior to is seen anterior to the descending the descending aorta in PLA viewaorta in PLA view
Left pleural effusion Left pleural effusion is posterior to the is posterior to the descending aortadescending aorta
Tamponade by 2-D echoTamponade by 2-D echo
Pericardial effusionPericardial effusion
Heart swinging (chronic)Heart swinging (chronic)
Late RA diastolic collapseLate RA diastolic collapse
Early RV diastolic collapse Early RV diastolic collapse
Dilated IVC with reduced Dilated IVC with reduced collapsibility collapsibility
RA collapseRA collapse
RA Inversion (collapse)RA Inversion (collapse) Begins in late diastole and Begins in late diastole and
continues into systole continues into systole
Sensitive but not specific for Sensitive but not specific for clinical tamponadeclinical tamponade Increased specificity if lasting Increased specificity if lasting
>1/3 of systole>1/3 of systole
Brief inversion can occur without Brief inversion can occur without clinical tamponadeclinical tamponade
RV collapseRV collapse Occurs in early diastoleOccurs in early diastole
Duration of collapse is Duration of collapse is proportional to the severityproportional to the severity
Indicates impending or Indicates impending or existing clinical tamponadeexisting clinical tamponade
Limitations of RV collapseLimitations of RV collapse May be affected by:May be affected by:
Intravascular volumeIntravascular volume• Low pressure tamponadeLow pressure tamponade
RV Pressure/volume loadRV Pressure/volume load• RVH and PHTNRVH and PHTN• ASD, TR, PI ASD, TR, PI
RV complianceRV compliance• Ischemia, Trauma, Ischemia, Trauma,
Pericardial adhesionsPericardial adhesions
Doppler findingsDoppler findings
Tamponade by Doppler flowTamponade by Doppler flow
Exaggerated respiratory variationsExaggerated respiratory variations Inspiration:Inspiration:
• Tricuspid flow increasesTricuspid flow increases• Mitral flow decreasesMitral flow decreases
Expiration:Expiration:• Tricuspid flow decreasesTricuspid flow decreases• Mitral flow increasesMitral flow increases
Mitral peak flow velocity variations of >25%Mitral peak flow velocity variations of >25%
Tricuspid peak flow velocity variations of >45%Tricuspid peak flow velocity variations of >45%
Doppler timingDoppler timing
120-75÷120= 38%80-40÷80= 50%
Hepatic vein flowHepatic vein flow
Mitral inflow
HV flow
Echo-guided perecardiocentesisEcho-guided perecardiocentesis
Confirm presence and Confirm presence and hemodynamic effect of hemodynamic effect of pericardial effusionpericardial effusion
Check the window of Check the window of maximum fluid collection maximum fluid collection (apical or subcostal)(apical or subcostal)
Measure the depth from Measure the depth from transducer (skin) to transducer (skin) to effusioneffusion
Echo-guided perecardiocentesisEcho-guided perecardiocentesis
Guide the operator for the Guide the operator for the needle directionneedle direction
Confirm the presence of Confirm the presence of catheter in pericardial spacecatheter in pericardial space
Check mechanical and Check mechanical and hemodynamic improvement hemodynamic improvement after drainageafter drainage
Assess the residual Assess the residual pericardial effusionpericardial effusion
Surgical drainage for post op Surgical drainage for post op collection/hematomacollection/hematoma
Echo cases of Echo cases of tamponadetamponade
To followTo follow.… .…