Cardiac Tamponade

Cardiac tamponade is a clinical syndrome caused by the accumulation of blood, fluid, pus, clots, or gas in the pericardial space, resulting in reduced ventricular filling and subsequent haemodynamic compromise. Cardiac tamponade is a medical emergency. The overall risk of death depends on the speed of diagnosis, the treatment provided, and the underlying cause of the tamponade.

• Cardiac tamponade related to trauma or HIV is more common in young adults.¹
• Tamponade due to malignancy and/or renal failure occurs more frequently in elderly individuals.

• Often associated with pericarditis:
  • Malignancy: commonest cause (especially breast cancer or lung cancer)
  • Acute myocardial infarction and post-infarction (including Dressler syndrome)
  • Infective: viral (including HIV), bacterial (e.g. tuberculosis), fungal
  • Connective tissue diseases: e.g. systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis
  • Radiation therapy
  • Myxoedema
  • Renal failure
  • Post-operative (cardiovascular surgery): haemorrhagic pericarditis
  • Idiopathic
• Drugs: e.g. hydralazine, procainamide, isoniazid, minoxidil
• Diagnostic procedures with cardiac perforation
• Trauma (incidence 2% in penetrating trauma, rare in blunt trauma) and surgery
• Aortic dissection

• Often accompanied by those of pericarditis.
• May present subacutely with anxiety, fatigue, altered mental status, or waxing/waning if intermittently decompressing.
• Dyspnoea, tachycardia, and tachypnoea. Cold and clammy extremities from hypoperfusion.
• Symptoms vary with the underlying cause and how acutely the tamponade has developed.

Signs

• Distended neck veins, tachycardia, tachypnoea and hepatomegaly
• Muffled heart sounds
• Pericardial friction rub, present in 50% but may be transient
• Acute tamponade leads to increased JVP - Beck triad: jugular venous distension, hypotension, and diminished heart sounds - rarely seen
• Pulsus paradoxus: exaggeration of the normal decrease in systemic blood pressure during inspiration
• JVP: the y descent is abolished due to an increase in intrapericardial pressure, preventing diastolic filling of the ventricles (cardiac tamponade causes an increase in both central venous pressure and pulmonary artery occlusion pressure).
• Cyanosis

• Aortic dissection
• Cardiogenic shock
• Constrictive pericarditis
• Pulmonary embolism
• Right ventricular infarction and other causes right ventricular failure
• Acute severe asthma
• Tension pneumothorax
• Large pleural effusion
• Tension pneumopericardium: usually seen in infants with mechanical ventilation but also may follow sternal bone marrow aspiration, penetrating chest wall injury, oesophageal rupture, and bronchopericardial fistula

• Creatine kinase and isoenzymes: elevated in myocardial infarction and cardiac trauma
• Renal function: diagnosis of uraemia
• Full blood count: infection
• Antinuclear antibody assay, ESR, and rheumatoid factor: assessment of possible connective tissue disease aetiology
• HIV testing: approximately 24% of all pericardial effusions are associated with HIV infection
• Testing for tuberculosis: important and not uncommon cause
• ECG: features may include sinus tachycardia, low-voltage QRS complexes, alternation of QRS complexes (usually in a 2:1 ratio), PR segment depression²
• Chest x-ray: cardiomegaly, water bottle-shaped heart, pericardial calcifications, or evidence of chest wall trauma
• Echocardiography: transthoracic echo is the test of choice³
• CT scanning, advantages being improved field of view, and ability to detect calcifications
• MRI
• Swan-Ganz cardiac catheterisation

Patients should be monitored in an intensive care unit. Pericardiocentesis (echo-guided being the procedure of choice) is the definitive treatment but may be hazardous and not relieve symptoms in cases of small effusions associated with constrictive pericarditis, e.g. malignancy, autoimmune conditions and viral infection.

• Oxygen
• Volume expansion to maintain adequate intravascular volume: with blood, plasma, dextran, or isotonic sodium chloride solution.
• Improve venous return: bed rest with leg elevation.
• Positive inotropic drugs: e.g. dobutamine.
• Positive-pressure mechanical ventilation should be avoided because it may decrease venous return.
• Further medical care includes:
  • Echocardiographically guided pericardiocentesis.: removal of pericardial fluid is the definitive therapy for tamponade.³
  • Emergency subxiphoid percutaneous drainage: is the safest method for emergency pericardiocentesis. Most safely performed under guidance by echocardiography. Without echocardiography guidance, may cause right ventricular puncture, which is not usually fatal but precipitates severe cardiac tamponade requiring surgical intervention.⁴
  • Percutaneous balloon pericardiotomy.
• Treatment of the underlying cause.

Surgical

• Pericardiodesis: for recurrent pericardial effusion or tamponade. Corticosteroids, tetracycline, or antineoplastic drugs can be instilled via intrapericardial catheter into the pericardial space.
• Pericardio-peritoneal shunt: may help prevent recurrent tamponade in patients with malignant pericardial effusions.
• Pericardiectomy: resection of the pericardium is rarely required.

• Untreated, it is rapidly fatal.
• Early diagnosis and treatment are crucial to reduce morbidity and mortality.