Pericardial effusion, Cardiac Tamponade, and echo guided pericardiocentesis

KSC 2017 Echo5- Myocardial and Pericardial disease Pericardial effusion, Cardiac Tamponade, and echo guided pericardiocentesis Ji-Hyun Jung Division of Cardiology Sejong Hospital KSC 2017 The 61 th Annual Scientific Meeting of the Korean Society of Cardiology

The Korean Society of Cardiology COI Disclosure Name of First Author: Ji-Hyun Jung The authors have no financial conflicts of interest to disclose concerning the presentation KSC 2017 The 61 th Annual Scientific Meeting of the Korean Society of Cardiology

Anatomy of normal pericardium Visceral pericardium a single layer of mesothelial cells Parietal pericardium a fibrous structure that is <2 mm thick The 2 layers of the pericardium are separated by a potential space (15~35ml)

Anatomy of normal pericardium

Mechanical Functions of the pericardium Effects on chambers - Limits short-term cardiac distention - Facilitates cardiac chamber coupling and interaction - Maintains pressure-volume relation of the cardiac chambers and output from them - Maintains LV geometry Effects on whole heart - Lubricates, minimizes friction - Equalizes gravitation and inertial, hydrostatic forces - Mechanical barrier to infection Immunologic Vasomotor Fibrinolytic Modulation of myocyte structure and function and gene expression Vehicle for drug delivery and gene therapy

Pericardial effusion Abnormal accumulation of fluid in the pericardial space

Idiopathic Etiology of Pericardial disease - Acute idiopathic pericarditis* (probably viral or post-viral) - Chronic idiopathic effusion Infectious - Viral, Bacterial infection (Tuberculosis), Fungal Inflammatory - Associated connective tissue disease (RA, SLE, Others) Post-myocardial infarction (ASD, Free wall rupture, Dressler syndrome ) Associated with systemic disease (Uremia, Hypothyroidism, Cirrhosis, Amyloidosis) Malignancy (Direct tumor involvement, Effusion due to lymphatic obstruction) Miscellaneous - Posttrauma, Postsurgical, Radiation induced - Congestive heart failure, Severe PAH, RV Failure - Down syndrome - Pregnancy

Clinical presentation Asymptomatic Shortness of breath or difficulty breathing (dyspnea) Discomfort when breathing while lying down (orthopnea) Chest pain, usually behind the breastbone or on the left side of the chest Chest fullness

2015 ESC guideline Diagnosis of Pericardial effusion Transthoracic echocardiography is recommended in all patients with suspected pericardial effusion (I C) Chest X-ray is recommended in patients with a suspicion of pericardial effusion or pleuropulmonary involvement (I C) Assessment of markers of inflammation (i.e. CRP) are recommended in patients with pericardial effusion (I C) CT or CMR should be considered in suspected cases of loculated pericardial effusion, pericardial thickening and masses, as well as associated chest Abnormalities (IIa C) Echo-free space DDX) mediastinal fat, fibrosis, thymus, or other tissue

Amount of pericardial effusion 다른 reference 에서는어떻게정의하는지. seen only in systole <10 mm 10 20 mm >20 mm Klein et al. 2015 ASE guideline

Amount of pericardial effusion 다른 reference 에서는어떻게정의하는지. seen only in systole <10 mm 10 20 mm >20 mm

Differentiation of Pericardial from Pleural Effusion 1) Pericardial reflections surround the pulmonary veins and tend to limit the potential space behind the LA. 2) Descending thoracic aorta 3) Frequently identify the parietal pericardium 4) Note the nodular densities overlying on the visceral aspect of the pericardium

Pericardial effusion on CT Localization and quantitation of pericardial fluid Tissue characterization on the basis of computed tomographic attenuation (> 60 Hounsfield units suggest hemorrhage) Differentiation of pericardial thickening from fluid Feasibility of surgery vs percutaneous drainage of complex effusions 2015 ESC guideline

2015 ESC guideline Sx (Pericarditis) Treatment of pericardial effusion Amount, Hemodynamic significance Inflammatory marker Large idiopathic chronic effusions have a 30 35% risk of progression to cardiac tamponade

70/M Chief Complaint) Diarrhea, vomiting (2WA) DOE (8WA) V/S) 120/80-80-16 PEx) Friction rub+ Lab) CBC 7180-12.6-390K, CRP 3.4

Chest PA

ECG

Echocardiography

Carol-F 처방후 2 주뒤 Echo f/u

Chest CT

Pericardial window operation Pericardium, biopsy Fibrinous pericarditis with chronic granulomatous inflammation and caseous necrosis Pericardial analysis Lymphodominant exudate (Poly 23%, Lymph 55%) ADA 33, LD 199, Protein 4.1 c/w TB pericarditis

Cardiac Tamponade and Pericardiocentesis

Pathophysiology of cardiac tamponade Intrapericardial Pressure equal end-diastolic pressures in RV or LV Decreased CO Roy CL, et al. JAMA. 2007;297:1810-1818.

Ralph Shabetai. Heart. 2004 Mar; 90(3):255-256. Cardiac tamponade life-threatening, slow or rapid compression of the heart due to the pericardial accumulation in the pericardial sac. Fatal!!! 1. amount of pericardial contents 2. rate of accumulation 속도에따른그래프 200cc >2000cc

Diagnosis of cardiac tamponade Chest PA ECG Enlarged cardiac silhouette (>250ml) Water bottle sign Low voltage Electrical alternans ST - T changes due to pericarditis

Diagnosis of cardiac tamponade Beck s triad Hypotension Soft or absent heart sounds Jugular venous distention (with a prominent x descent, absent y descent) Sternbach G. Claude Beck. J Emerg MEd. 1988 Sep 6(5):417-9.

Diagnosis of cardiac tamponade Clinical diagnosis is important! Beck s triad Tachycardia Hypotension Pulsus paradoxus A key diagnostic finding

Pulsus paradoxus BP drop (>10mmHg) during inspiration Expiration Inspiration Expiration Inspiration

Pulsus paradoxus in pericardial tamponade - A paradoxical pulse is the most helpful clinical test for cardiac tamponade (sensitivity of 98%, specificity of 83%) - Elevated jugular venous pressure (76%) and tachycardia (77%) have good sensitivity. - Hypotension and distant heart sounds are insensitive physical findings. JAMA 2007;297:1810-1818.

Pulsus paradoxus in pericardial tamponade N Engl J med 2003:349:684-90.

Echocardiographic findings in cardiac tamponade 2D and M-mode Diastolic RV collapse RA collapse/inversion Swinging heart Doppler Exaggerated respiratory variation in inflow velocity Exaggerated respiratory variation in inferior vena cava flow Phasic variation in RVOT/LVOT

Echocardiographic findings in cardiac tamponade Exaggerated respiratory variation in inflow velocity (E wave) : MV E-wave >30% : TV E-wave (earliest finding) Phasic variation in RVOT/LVOT Klein et al. 2015 ASE guideline

Echocardiographic findings in cardiac tamponade -Diastolic flow reversal after expiration -Velocities in tamponade are markedly reduced, reflecting reduced cardiac filling (normal 50 ->20~40cm/s) IVC plethora Klein et al. 2015 ASE guideline

Echocardiographic findings in cardiac tamponade RV, RA collapse at early diastolic phase (AV, PV closing) Duration of RA >1/3 of cardiac cycle Klein et al. 2015 ASE guideline Feigenbaum s Echocardiography, 7 th ed

Echocardiographic findings in cardiac tamponade RV, RA collapse (M-mode) Klein et al. 2015 ASE guideline Feigenbaum s Echocardiography, 7 th ed

Echocardiographic findings swinging of the heart

85/M Dyspnea 으로타병원에서치료받던중, CBC abnormality (lymphocytosis) 관찰되어 CLL 의심하내원함.

ECG

Chest PA

Echocardiography

Chest PA

Treatment of cardiac tamponade EM) Pericardiocentesis Medical treatment Hypotensive patients with hypovolemia : A low volume (250-500 ml) of normal saline to improve haemodynamic parameters Infusion of higher volumes may increase wedge pressure and intrapericardial pressure, and reduce cardiac output

Indication of Pericardiocentesis (PCC) Hemodynamically unstable patients emergent procedure!! Patients without hemodynamic compromise Symptomatic moderate to large effusion non-responsive to medical therapy Small effusion when tuberculous, bacterial or neoplastic pericarditis is suspected Chronic large effusion (>20mm in diastole) Diagnostic purpose without large effusion Low diagnostic power & High procedural risk Viral pericarditis self-limiting

Contraindication of PCC No absolute contraindications Relative contraindications Aortic dissection Post-infarction rupture of the free wall If hemodynamically unstable, very small amounts of the hemopericardium can be attempted To maintain blood pressure at around 90 mmhg Uncorrected coagulopathy, anticoagulant therapy, thrombocytopaenia (PLT <50,000/mm³)

Puncture site 1. Apical approach 1-2 cm lateral to the apex beat within the fifth, sixth or seventh intercostal space. Advance the needle over the superior border of the rib Risk of ventricular puncture/ pneumothorax The thicker left ventricle wall is more likely to self-seal after puncture The path to reach the pericardium is shorter Caterina CC. Cardiology Practice ESC, 2017 Nov;15

Puncture site 2. Subxiphoid the fifth left intercostal space, close to the sternal margin Risk of pneumothorax and puncture of the internal thoracic vessels 3. Subxiphoid approach Between the xiphisternum and left costal margin 15 to 30 angle (deeper angle may enter peritoneal cavity) Low risk of pneumothorax Caterina CC. Cardiology Practice ESC, 2017 Nov;15

PCC set dilator Needle (or epidural needle) 1% lidocaine (contrast agent) scalpel J shaped guide wires

Fluoroscopy-guided technique First imaging system Subxiphoid approach a needle containing a contrast medium Directed toward the left shoulder (30 ) Check the guidewire position in at least two angiographic projections SW Han, Korean Circ J. 2010 Oct;40(10):479-488

Echo-guided technique Safe and simple technique Semi-reclining position (angle of 30 ) and slightly rotated leftwards The extracardiac position of the tip or injecting 5 ml of agitated saline infusion real-time echo-monitored procedure Caterina CC. Cardiology Practice ESC, 2017 Nov;15

Surgical drainage Recurrent tamponade, when it is necessary to remove loculated effusions and/or when it is necessary to obtain tissue for diagnosis

After PCC Check Chest PA!! Pericardial drainage Immediately after PCC: remove enough fluid to normalize the CVP and BP (not >1 L) repeated every 4 to 6 hours Maintenance : 24 to 72 hours is sufficient Removal drainage < 25~30ml/day The recurrence rate after the initial procedure 27~55%

After PCC

Complications Minor complication (0.4-20%) Transient vasovagal hypotension, bradycardia Arrhythmia (SVT) Pneumothorax Pleuropericardial fistulas Major complication (0.3-3.9%) Death Injury of the cardiac chambers, coronary arteries or intercostal vessels Puncture of the abdominal viscera or peritoneal cavity Pneumothorax requiring chest tube placement Pneumopericardium Ventricular arrhythmias Pericardial decompression syndrome After a successful pericardial drainage, from a few hours to days later mechanism : unknown explanation is an acute left ventricular overload due to an increased right-sided preload associated with a persistent catecholaminergic peripheral vasoconstriction. prevention: remove enough fluid to normalize the central venous and systemic blood pressure (not >1 L) and to complete the removal in the subsequent few hours

Pneumothorax after PCC

Conclusion All patients with pericardial effusion or tamponade should undergo TTE to assess for the extent of effusion and hemodynamic compromise. CT and/or CMR should be done for those patients with complex effusion with subacute tamponade with the need for drainage. CT and/or CMR should be done for those with suspected hemopericardium or pericardial clot and to assess the source of effusion as in malignancy or inflammation.

Conclusion All patients with clinically suspected cardiac tamponade should undergo TTE with Doppler echocardiography as the initial imaging test, which can provide a definite diagnosis in most patients. Cardiac tamponade is a medical emergency. Pericardiocentesis is a life saving procedure in cardiac tamponade.

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