TAMPONADE CARDIAQUE. Dr Cédrick Zaouter TUSAR 15 décembre 2015

Transcription

1 TAMPONADE CARDIAQUE Dr Cédrick Zaouter TUSAR 15 décembre 2015

2 OUTLINE History Incidence Definition Pathophysiology Aetiologies Investigations - Echocardiography Treatment of cardiac tamponade

3 Pericardial effusion & Cardiac Tamponade Claudius Galen ( AD) first description Richard Lowe (1669): Physiology Edmund Rose: cardiac tamponade

4 Incidence of postoperative pericardial effusions The reported incidence of postoperative pericardial effusions ranges between 1% and 77% References: 1.Tsang TS, Barnes ME, Hayes SN, et al.. Chest 1999;116: Ikäheimo MJ, Huikuri HV, Airaksinen KE, et al.. Am Heart J 1988;116(1 pt 1): Pepi M, Muratori M, Barbier P, et al. Br Heart J 1994;72: Malouf JF, Alam S, Gharzeddine W, Stefadouros MA.. Eur Heart J 1993;14: Cheung EW, Ho SA, Tang KK, Chau AK, Chiu CS, Cheung YF. Heart 2003;89: Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Ann Thorac Surg 2002;74:

5 Study design Incidence of postop pericardial effusions: 1% and 77% Small prospective studies: higher incidences reported > frequent echocardiographic examinations most effusions were clinically insignificant 77% Retrospective studies of clinically important pericardial effusions the reported incidence is 1% to 2% References: 1.Tsang TS, Barnes ME, Hayes SN, et al.. Chest 1999;116: Ikäheimo MJ, Huikuri HV, Airaksinen KE, et al.. Am Heart J 1988;116(1 pt 1): Pepi M, Muratori M, Barbier P, et al. Br Heart J 1994;72: Malouf JF, Alam S, Gharzeddine W, Stefadouros MA.. Eur Heart J 1993;14: Cheung EW, Ho SA, Tang KK, Chau AK, Chiu CS, Cheung YF. Heart 2003;89: Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Ann Thorac Surg 2002;74:

6 Definition Fluid in the pericardial sac, creating an increased pressure within the pericardial space that impairs the ability of the heart to fill and to pump Abnormally large volumes of fluid within the pericardial sac does not always necessitate the development of tamponade

7 ANATOMY OF THE PERICARDIUM Fusing where the great vessels exit 1. Mesothelium cells volume of ml 2. Buffer the heart from external impact 3. Reduce resistance during motion 4. Barrier against infection

8 Pericardial effusion does not mean cardiac tamponade 50 ml 2000 ml Volume exceeds limit of parietal pericardial stretch Pericardial reserve volume Pericardial effusion: anatomical diagnosis Cardiac tamponade: physiological diagnosis

9 In the absence of other pathology pericardiocentesis will normalize pressures and improve the cardiac output, confirming the diagnosis

10 Pericardium compliance reduced TUMOR

11 Pericardium compliance reduced NATURE OF THE FLUID Acute effusions > transudates blood. Chronic effusions: > fibrosed and more viscous

12 Aetiologies The most common diagnoses were: 1- Acute idiopathic pericarditis (20%) 2- Iatrogenic effusion(16%) 3- Malignancy (13%), 4- Chronic idiopathic effusion (9%), 5- Acute myocardial infarction (8%), 6- End-stage renal disease (6%) 7- Congestive heart failure (5%), 8- Collagen vascular disease (5%) 9- Tuberculosis & Bacterial infection (4%). Effusions are extremely common after cardiac surgery BUT large effusions causing tamponade are rare in this setting LeRoy C. JAMA, April 25, 2007 Vol 297, No. 16

13 Pathophysiology Stages of cardiac tamponade Early stages R side < L side Reduced venous return R sides are compressed CVP rises Impaired RV filling Under-loaded Ventricle Low contractility Low SV

14 Pathophysiology Stages of cardiac tamponade Late stages Pericardial pressure > L side Reduced CO Obstructive shock Cardiac arrest Increased fluid retention

15 Suspicion: Clinical Features Dyspnea Tachycardia Hypotension poor discriminating Beck s triad EJVP Reduced heart sounds poor discriminating Hypotension Pulsus paradoxus > 10mmHg Ventricular interdependence

16 Suspicion: Clinical Features PAST MEDICAL HISTORY PM lead insertion Chest pain infarction/ pericarditis Renal failure > Ureamic P.Eff Tubercolosis > Inflammatory P.Eff Symptoms of pericardial effusion are nonspecific Few patients have the classic presentation of tamponade Many patients with pericardial effusion report minimal problems

17 Investigations Simple investigations ECG - Variation of QRS: electrical alternans CXR - Cardiomegaly

18 Investigations Simple investigations ECG The pooled sensitivity of low QRS voltage was only 42% CI: 32%-53% 2 studies reported that electrical alternans, sensitivity of 16% to 21%. Atrial arrhythmias are infrequent in cardiac tamponade ATOTW 283 Cardiac Tamponade March 2013 P. Odor A. Bailey; St. George s Hospital, London, UK

19 Investigations Advanced investigation: Echocardiography TTE demonstrates tamponade by RA collapse sensitivity of % and specificity %. TEE better views of the posterior aspects of the pericardium > essential: retroatrial ATOTW 283 Cardiac Tamponade March 2013 P. Odor A. Bailey; St. George s Hospital, London, UK

20 Quantification of Pericardial Effusions by Echocardiography and Computed Tomography Echocardiographically R2: 0,74 Small underestimation CT R2 : ml David Leibowitz et al Amer J of Cardiol 2011; 107:331

21 Investigations Echocardiography TTE The European Society of Cardiology RECOMMENDS A) 2D - Imaging: A. Collapse B) DOPPLER B. Septal-shift C. IVC dilatation

22 Investigations Echocardiography TTE The European Society of Cardiology RECOMMENDS A) 2D - Imaging: A. Collapse of 1- RA in systole 1-1 Partial: pretamponade= early stage Apical 4-chambers / Subcostal 1-2 Complete: Atrial transmural pressure is negligible = tamponade Apical 4-chambers / Subcostal 2- Anterior RV free wall in diastole Subcostal view / parasternal short axis view

23 Partial RA collapse: pretamponade = early stage

24 Partial RA collapse: pretamponade = early stage

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26 Cardiac tamponade

27 Investigations Echocardiography TTE The European Society of Cardiology RECOMMENDS 2D - Imaging: A. Collapse of RA, RV, LA & LV Apical 4-chambers / Subcostal B. Septal shift-ventricular interdependency Apical 4-chambers view

28 Pulsus paradoxus Ventricular interdependence

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30 Investigations Echocardiography TTE The European Society of Cardiology RECOMMENDS 2D - Imaging: A. Collapse of RA, RV, LA & LV Apical 4-chambers / Subcostal B. Septal shift-ventricular interdependency Apical four-chambers view C. IVC dilatation, without respiratory variation Subcostal view

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33 Echocardiography TTE Investigations The European Society of Cardiology RECOMMENDS 2-Pulse wave Doppler A. An inspiratory rise of the right flows of more than 40 50% B. An inspiratory decrease of the left flows above 25 40% C. An inverted E/A ratio at the tricuspid and the mitral level > relaxation impairment of both ventricles The intrathoracic pressure regimen is inverted during mechanical ventilation and study of flows using Doppler is totally inaccurate.

34 Tricuspid flow Rise of the right flows of more than 40 50%

35 Mitral flow Reduction of the left flows above than 25-40%

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37 Pattern of diastole in the sub hepatic veins

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39 Differential diagnosis Pleural effusion

40 Differential diagnosis Pleural effusion

41 Pitfalls Hypovolemia RVH Wrapped Epicardial effusion Especially after cardiac surgery

42 Treatment Large pericardial effusions require drainage in most cases Open drainage or pericardiocentesis Location and character of the effusion Physician preference and experience Echocardiography-guided pericardiocentesis is safe. 1. Tsang TS, Barnes ME, Hayes SN, et al.. Chest 1999;116: Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Mayo Clin Proc 2002;77: Susini G, Pepi M, Sisillo E, et al.. J Cardio- thorac Vasc Anesth 1993;7:

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45 Merci