Department of Cardiac, Thoracic and Vascular Sciences University of Padua Cardiac Tamponade. Echocardiography in Diagnosis and Management

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1 Department of Cardiac, Thoracic and Vascular Sciences University of Padua Cardiac Tamponade. Echocardiography in Diagnosis and Management Luigi P. Badano, MD, FESC, FACC

2 Declaration of interest **Dr. Badano has received honoraries and research grants from: - GE Healthcare; - Sorin cardio S.p.A; - Actelion; - Edwards Lifesciences. *No off-label use of device

3 Accumulation of pericardial fluid under pressure leading to impaired cardiac filling Elevated intrapericardial pressure Impairement of systemic venous return Interventricular interdependence impaired filling of the LV during inspiration Can occur in pericardial effusion of any cause

4 Signs of haemodynamic impact of pericardial fluid Septal shift towards left with inspiration Marked respiratory variability of blood flows -Inspiratory increase of RV filling -Expiratory increase of LV filling -Opposite effects of RV/LV outflows Chamber wall collapse (diastolic RV, RA, LA, LV etc) Dilated IVC with blunted/absent respiratory variability Cardiac tamponade is a clinical syndrome! Ventricular interdependence

5 Small posterior pericardial effusion post-cardiac surgery Septal shift with inspiration

6 Small posterior pericardial effusion post-cardiac surgery Septal shift with inspiration

7 Signs of haemodynamic impact of pericardial fluid Tricuspid flow Mitral flow

8 Signs of haemodynamic impact of pericardial fluid LVOT flow

9 Signs of haemodynamic impact of pericardial fluid RV diastolic collapse occurs in early diastole when the ventricular volume is still low Pulmonary hypertension and RV hypertrophy can be associated with lack of RV collapse, despite the presence of cardiac tamponade

10 Signs of haemodynamic impact of pericardial fluid RA collapse, especially when it persists for more than 1/3 of the cardiac cycle, is highly sensitive for tamponade

11 Signs of haemodynamic impact of pericardial fluid LA collapse is among the most specific sign for cardiac tamponade

12 Signs of haemodynamic impact of pericardial fluid Variation of IVC diameter with respiration Normal (>50%) Abnormal

13 Haemodynamic impact: echo signs vs invasive haemodynamics RA collapse (45 pts) ,9 17,8 LA collapse (4 pts) 37,5 42,9 90,5 RV collapse (38 pts) Swinging heart (29 pts) 75 23,8 15, ,2 20,7 Leftward IVS motion (10 pts) VCI congestion (29 pts) , , (%) Sensitivity Specificity Positive predictive value Ristić et al. ACC 2001

14 Pericarditis Very large effusion with swinging heart

15 Amount of pericardial fluid Fluid quantity is not relevant for the diagnosis of tamponade

16 Amount of pericardial fluid Fluid quantity is not relevant for the diagnosis of tamponade Yet, moderate to large amounts should be signalled and more closely monitored

17 Regional cardiac tamponade Loculated pericardial effusion post-cardiac surgery (haematoma) Only selected chambers are compressed The typical signs of tamponade are usually absent, despite being hemodynamically significant

18 Guidelines on the Diagnosis and Management of Pericardial Diseases Indications for pericardiocentesis Class I indications Cardiac tamponade Effusions >20 mm in echocardiography (diastole) Suspected purulent or tuberculous pericardial effusion Class IIa indications Effusions mm in echocardiography in diastole for diagnostic purposes other than purulent pericarditis or tuberculosis (pericardial fluid and tissue analyses, pericardioscopy, and epicardial/pericardial biopsy) Suspected neoplastic pericardial effusion Maisch et al. Eur Heart J 2004

19 Guidelines on the Diagnosis and Management of Pericardial Diseases Indications for pericardiocentesis Class IIb indications Effusions <10 mm in echocardiography in diastole for diagnostic purposes other than purulent, neoplastic or tuberculous pericarditis Contraindications (Class III) Aortic dissection Relative contraindications include uncorrected coagulopathy, anticoagulant therapy, thrombocytopenia <50000/mm3, small, posterior and loculated effusions. If the diagnosis can be made otherwise or the effusions are small and resolving under anti-inflammatory treatment. Maisch et al. Eur Heart J 2004

20 Pericardiocentesis Selection of the optimal entry site 1. The location where the probe is the closest to PE and where PE is the largest 2. Avoid vital structures: liver, myocardium, lung 3. Avoid arteria mammaria interna (puncture 3-5 cm from the parasternal border) and intercostal blood vessels (puncture at the inferior margin of each rib)

21 Pericardiocentesis The procedure Courtesy of Prof. Aleksandar Lazarevic Banja Luka University School of Medicine

22 Pericardiocentesis Confirmation of needle and wire position Needle position Wire position

23 Pericardiocentesis Confirmation of needle position by contrast injection Agitated saline solution Echo-contrast monitored by 2D echo (4-Ch) Courtesy of Prof. Aleksandar Lazarevic Banja Luka University School of Medicine

24 Pericardiocentesis Results Before Intermediate After

25 Pericardiocentesis Results: major complications Author n Contrast study Death during puncture Right ventricular puncture Arrhythmia Callahan, no 0 (0%) 2 (1.7%) Not reported Guberman, no 1 (1.8%) 6 (11.7%) Not reported Chandraratna, Yes 0 (0%) 3 (18.7%) Not reported Susini, Yes 0 (0%) 2 (6.9%) 2 (6.9%) Krikorian, 123 No 5 (4.1%) 11 (8.9%) 1 (0.8%) Vayre, Yes 6 (5.4%) 11 (10%) 6 (5.4%) Tsang, Yes 1 16 (1.4%) 3 Kil, Yes 1 Not reported Not reported

26 Conclusions Echocardiography is the primary diagnostic tool for assessing the spatial distribution and functional significance of pericardial effusions In patients with cardiac tamponade, echocardiography remains the first and often only diagnostic method needed to make a definitive diagnosis and guide appropriate treatment