Signs Of Tamponade Research Articles

Collapse of three cardiac chambers due to a pericardial effusion

We report a case of pericardial effusion with collapse of three cardiac chambers including the left atrium, a very specific sign of tamponade always urging for quick pericardiocentesis.

Low-Pressure Cardiac Tamponade

Low-pressure cardiac tamponade is a form of cardiac tamponade in which a comparatively low pericardial pressure results in cardiac compression because of low filling pressure. This syndrome is poorly characterized because only isolated cases have been reported. We conducted a study of its clinical and hemodynamic profiles. From 1986 through 2004, we evaluated all patients at our institution with combined pericardiocentesis and cardiac catheterization. We identified those patients who fulfilled catheterization-based criteria of low-pressure cardiac tamponade and compared their clinical and catheterization data with those of patients with classic tamponade. A total of 1429 patients with pericarditis were evaluated, 279 of whom underwent combined pericardiocentesis and catheterization. Criteria of low-pressure cardiac tamponade were met in 29, whereas 114 had criteria of classic cardiac tamponade. Patients with low-pressure tamponade less frequently had clinical signs of tamponade, but the rate of constitutional symptoms, use of diuretics, and echocardiographic findings of tamponade were similar in both groups. Patients with low-pressure tamponade showed a significant increase in cardiac output after pericardiocentesis, but they usually had less severe cardiac tamponade compared with patients with classic tamponade. Prognosis was related mainly to the underlying disease. Low-pressure cardiac tamponade was identified in 20% of patients with catheterization-based criteria of tamponade. Clinical recognition may be difficult because of the absence of typical physical findings of tamponade in most patients. Although some patients are critically ill, most show a stable clinical condition. However, these patients obtain a clear benefit from pericardiocentesis.

L’embolie pulmonaire au secours de la tamponnade cardiaque

The association of cardiac tamponade and pulmonary embolism has not previously been described. We report the case of a patient, who presented with such an association, due to an underlying pulmonary carcinoma. When a major pericardial effusion is associated with pulmonary hypertension, some echocardiographic signs of tamponade may appear, such as a moderate right ventricular collapse, or the absence of a paradoxical septum. The presence of pulmonary hypertension in this context of tamponade may have paradoxically saved the life of this patient.

Catheter pericardiocentesis for delayed tamponade after cardiac valve operation

Background. Late tamponade is a rare cause of morbidity and mortality after cardiac valve operation. We describe our recent experience with this entity. Methods. This is a single institution, procedure-matched, retrospective review of patients undergoing pericardiocentesis more than 7 days after cardiac operation, during a 7-year period. Results. Pericardiocentesis for delayed tamponade was performed in 43 of 9,612 patients. Although isolated valve operation accounted for 17% of all patients overall, 76% of patients undergoing pericardiocentesis (33 of 43) had undergone isolated valve operation. The average age in this group was 58 years, compared to an average of 68 years in all patients. Patients presented with tamponade an average of 18 days after operation. Positive predictors included elevated prothrombin time on presentation. Of the patient cohort 75% presented with dyspnea, 61% with inability to diurese, and 61% with hypotension. Echocardiography detected effusions in all patients, but specific echocardiographic signs of tamponade were present in only 30%. Of the patients, 97% were successfully treated by pericardiocentesis. All were safely restarted on warfarin. One patient required pericardial window. Conclusions. Delayed cardiac tamponade is more common after isolated valve operation, as opposed to coronary artery bypass grafting and valve/coronary artery bypass grafting. It tends to occur in the third postoperative week in younger patients who are aggressively anticoagulated. Pericardiocentesis with catheter placement is highly effective, and patients can be reanticoagulated safely. This series underestimates the incidence of late tamponade, as some patients may present to outside facilities. The diagnosis is aided by a high degree of suspicion.

Large pleural effusions producing signs of cardiac tamponade resolved by thoracentesis

W observed 2 patients with large pleural effusions and small to moderate pericardial effusions who had echocardiographic signs of cardiac tamponade that resolved completely after pleural tap. Because many diseases that produce pleural effusions also cause pericardial effusions, the occurrence of both a pericardial and a pleural effusion in the same patient is not uncommon. In this study, we wished to discover whether pleural effusions produced clinical and echocardiographic signs of cardiac tamponade, and if so, to assess the size of pleural effusion that could cause signs of tamponade. • • • Our study was approved by the institutional review board; all subjects signed an informed consent before the study began. Procedures were in accord with the guidelines set forth by our institution. Thirty-seven patients with pleural effusions and no clinical or echocardiographic evidence of organic heart disease comprised the study group. The etiologies of pleural effusions were: malignancy in 18 patients, chronic renal failure in 2 patients, human immunodeficiency virus related in 3 patients, pneumonia in 3 patients, tuberculosis in 2 patients, empyema in 2 patients, systemic lupus erythematosus in 2 patients, and unknown etiologies in 5 patients. The patients were divided into 2 groups. Group 1 consisted of 10 patients (7 men and 3 women, age range 33 to 88 years [mean 69]) with pleural effusions occupying less than a hemithorax on chest x-ray. Group 2 consisted of 27 patients (13 men and 14 women; age range 20 to 74 years [mean 49]) with effusions greater than a hemithorax. The sizes and distributions of pleural effusions in group 1 were as follows: 3 patients had right pleural effusions, 5 had left pleural effusions, and 2 patients had small bilateral effusions. Two subjects had small pericardial effusions. In group 2, 11 patients had left pleural effusions (Table 1). Eleven patients had effusions occupying 1 lung. Seven patients also had small pericardial effusions and 4 had moderate pericardial effusions. All patients underwent an evaluation of jugular venous pressure (JVP) and blood pressure measurement to assess the presence of pulsus paradoxus. The size of the pleural effusion was determined via posterior-anterior chest x-ray, then confirmed by lateral decubitus chest x-ray. A large pleural effusion is assumed when at least half a lung is involved. The same criteria are used when bilateral effusions are involved. Pulsus paradoxus, JVP, lung and cardiac auscultation, respiration rate, blood pressure, and the site and size of the pleural effusion were noted. Two-dimensional echocardiography was performed in all standard views. Apical 4-chamber, 2-dimensional echocardiograms and pulse-wave Doppler of the mitral inflow signals during quiet respiration were obtained by placing the sample volume at the tips of the mitral leaflets with a 2-MHz transducer. After echocardiograms were performed, patients were referred back to their primary care physicians to proceed with the indicated thoracentesis. The amount of fluid removed ranged from 900 to 1,500 ml (mean 1,267 ml) in 9 patients without chest tube placement. In the 11 patients who did have chest tubes placed, we cannot report exact volumes of fluid removed due to the unknown excess amount versus normal drainage of pleural fluids. Volumes removed were estimated to range from 2,000 to 4,000 ml (mean 3,050). Clinical examinations and echocardiograms were repeated within 24 hours after thoracentesis. Post-thoracentesis echocardiograms were analyzed for resolution of abnormalities noted in the previous study in 20 patients from group 2. Follow-up data were not available for 7 patients in group 2 due to death (n 2) or refusal to continue the study (n 5). The echocardiograms were reviewed. Right ventricular (RV) diastolic collapse was considered present if there was an inward motion of the right ventricle in diastole. The minimum and maximum velocities of E waves during quiet respiration were measured, and the percent change in velocity was determined. A change of 25% was considered abnormal respiratory variation in transmitral flow or flow velocity paradoxus. Group 1 patients had no clinical or echocardiographic signs of cardiac tamponade. In group 2, 8 subjects had elevated JVP ( 5 cm above the clavicle in the 45° position), 8 had pulsus paradoxus, 6 had RV From the Division of Cardiology, LAC & USC Medical Center, Los Angeles, California. Dr. Chandraratna’s address is: Long Beach VA Medical Center, Section of Cardiology (111C), 5901 E 7th Street, Long Beach, California 90822. E-mail: premindra.chandraratna @med.va.gov. Manuscript received June 6, 2001; revised manuscript received and accepted September 11, 2001. TABLE 1 Location and Size of Pleural Effusions in Group 2

Pericardial effusion associated with metastatic disease from an unknown primary tumor in a dog

A 6.5-year-old, spayed female Siberian husky presented with signs of cardiac tamponade and weakness. Pleural, pericardial, and abdominal effusion were identified with radiographs and ultrasound. Pericardiocentesis relieved signs of tamponade, and the dog was clinically improved. Pericardial effusion recurred, and pericardiectomy was performed. Histopathological examination of excised tissues failed to reveal evidence of infectious or neoplastic disease. After pericardiectomy, clinically apparent thoracic effusion persisted. The dog was euthanized, and postmortem histopathological examination revealed emboli of metastatic carcinoma cells in the epicardium. The location of intrathoracic disease in this dog made antemortem diagnosis difficult, if not impossible.

Current evaluation of cardiac stab wounds

Background. Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients.Methods. There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound).Results. Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies.Conclusions. Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).

Isolated primary chylopericardium: Treatment by thoracoscopic thoracic duct ligation and pericardial fenestration

Isolated chylopericardium is an uncommon entity. 1' 2 It may be congenital in origin or caused by surgical trauma, irradiation, caval obstruction, or primary or metastatic mediastinal tumors. 2' 3 The sequel common to all origins seems to be thoracic duct obstruction without development of collateral drainage. The exact cause of the disorder in the idiopathic cases is, however, unknown. 1 The diagnosis is confirmed by analysis of pericardial fluid obtained through pericardiocentesis. Current therapeutic options include dietary treatment, serial pericardiocentesis, pericardial-peritoneal shunts, pericardiectomy, and thoracic duct ligation. 1' 2. 4 We report the case of a patient with Recklinghausen disease and isolated chylopericardium successfully treated by video-assisted thoracoscopic surgical techniques. To our knowledge, this article reflects the first application of the preferred minimally invasive approach and is the first report of isolated chylopericardium associated with Recklinghausen disease. A 35-year-old man with a 20-year history of Recklinghausen disease reported recent cough and dyspnea. Chest radiographs showed an enlarged cardiomediastinal silhouette. The presence of pericardial effusion was confirmed echocardiographically. The diagnosis of Recklinghausen disease was initially made on the basis of multiple cafdau-lait skin spots and cutaneous neurofibromatosis located at the right foot and on the left side of the face. There was no evidence of intrathoracic lesions on either chest radiography or computed tomographic scan (Fig. 1). Echocardiographically guided pericardiocentesis produced 800 ml milky fluid, considered to be chyle because of a triglyceride level of 21.4 mmol/L and typical extracellular fat droplets seen on cytologic examination. The fluid reaccumulated within 14 days, resulting in clinical and echocardiographic signs of tamponade. Examination of the right thorax by video-assisted thoracoscopic surgical techniques (four trocar sleeves 7 to 10 mm in diameter inserted between the fifth and tenth intercostal space) revealed a normal pleural cavity without effusion or a w signs of intrathoracic neurofibromatotic manifestation. The pericardium appeared to be distended. After the right

How do the clinical findings in patients with pericardial effusions influence the success of aspiration?

To identify features associated with success or failure of aspiration of pericardial effusion. A retrospective analysis of 36 drainage procedures in 30 patients with pericardial effusion was performed using patient records and echocardiograms. Unsuccessful aspiration was associated with pericardial loculation but not with the seniority of the operator or the size and position of the effusion. Pericardiocentesis relieved symptoms of breathlessness in 21 of 26 patients who had a pericardial effusion suspected of causing dyspnoea. These 21 patients had few clinical or echocardiographic signs of classic tamponade. The paucity of abnormal physical or echocardiographic signs of tamponade in breathless patients with pericardial effusion does not exclude symptomatic benefit being derived from pericardiocentesis. Pericardial aspiration is safe in appropriate hands, although aspiration of loculated effusions may not be as successful as aspiration of non-loculated effusions.

1007-16 Quantitation of Apical Right Ventricular Collapse in Tamponade: A Diagnostic Improvement

Right ventricular (RV) collapse, a popular echocardiographic sign of tamponade is a subjective call with no precise criteria. RV collapse is usually diagnosed by early diastolic “dimpling” or local concavity of RV anterior wall in parasternal views. In 15 patients with pericardial effusion studied (A) during tamponade, and (B) after relief of tamponade, we noted that definite such “dimpling” could be seen in only five out of ten cases, while in six patients parasternal window was inadequate. In contrast, the apical four-chamber view could be obtained in all 15 patients. In this view we made several RV measurements including various transverse RV dimensions, RV area and ratios of these to the corresponding LV measurements. LV width/RV width ratio at the junction of the apical 1/4 to basal 3/4 of LV length showed the best separation between tamponade and post-tamponade values (p < 0.005). Using a cut-off value of LV width/RV width ≥3 as indicative of tamponade. This criterion showed no overlap between tamponade and post-tamponade values. Ratio of LV width to RV width ≥3, measured at the junction of apical 1/4 with basal 3/4 of LV, is a promising sign of tamponade, reflecting selectively greater collapse of near-apical region of RV in tamponade.

Problems and pitfalls in the echocardiographic assessment of pericardial effusion.

The echocardiographic diagnosis of pericardial effusions is usually based on visualization of a sonolucent circumcardiac space of varying width. However, potential fallacies in interpretation can arise if sonolucent spaces adjacent to the heart (pleural effusions, ascites, pericardial cysts) are mistaken for pericardial effusions. Loculated pericardial effusions, especially if unusual in location or configuration, can cause diagnostic difficulty on occasion. The differential diagnosis of various "solid" echoes within a pericardial effusion is of clinical relevance, yet not widely discussed. Inflammatory tissue, neoplastic involvement, pus, caseous material, and extravasated blood all have characteristic echocardiographic morphologies. All of the various reported echocardiographic signs of tamponade do not have the same significance, so that caution is necessary not to over- or under-read tamponade. Chamber collapse can be absent in real tamponade in specific situations. On the other hand, "regional" tamponade can occur if loculated pericardial effusions are sufficiently large and high tension; echocardiographic appearances are "atypical" but diagnostically valuable if correctly interpreted. These and certain other unusual variants of tamponade deserve to be better known among echocardiographers not only because of their intrinsic interest, but also to avoid potential pitfalls in the echocardiographic assessment of patients with suspected disease.

PERICARDIAL TAMPONADE SECONDARY TO PERFORATION BY CENTRAL VENOUS CATHETERS IN ORTHOPAEDIC PATIENTS

Pericardial tamponade from an indwelling central venous catheter developed in four orthopaedic patients. Two of these patients died acutely, and the other two sustained severe anoxic brain injury. The early signs of tamponade include tachycardia, hypotension, and increased central venous pressure. The outcome most often is fatal. When a central venous catheter has been placed incorrectly or has migrated, it can perforate the heart and produce pericardial tamponade. To avoid this complication, the tip of the catheter must be placed within the superior vena cava rather than the right atrium, and the position of the catheter must be ascertained with a radiograph of the chest. Prompt recognition and treatment of pericardial tamponade are imperative if a disastrous outcome is to be prevented.

Pericardial tamponade secondary to perforation by central venous catheters in orthopaedic patients.

Pericardial tamponade from an indwelling central venous catheter developed in four orthopaedic patients. Two of these patients died acutely, and the other two sustained severe anoxic brain injury. The early signs of tamponade include tachycardia, hypotension, and increased central venous pressure. The outcome most often is fatal. When a central venous catheter has been placed incorrectly or has migrated, it can perforate the heart and produce pericardial tamponade. To avoid this complication, the tip of the catheter must be placed within the superior vena cava rather than the right atrium, and the position of the catheter must be ascertained with a radiograph of the chest. Prompt recognition and treatment of pericardial tamponade are imperative if a disastrous outcome is to be prevented.

Color Flow Doppler Observations on Mitral Valve Flow in Tamponade

We studied the M-mode and two-dimensional imaging of color Doppler mitral flow in eight patients with pericardial effusion and tamponade, and in ten control subjects. Pulsed-Doppler recordings of mitral flow were also obtained in all. Marked phasic changes (presumably respiratory) were consistently recorded in all patients with tamponade with respect to brightness, hue, width (duration), and length of the M-mode Doppler color stream; in these patients, phasic changes were noted in width, length, and color of the mitral flow stream on the two-dimensionalechocardiographic recording, with reciprocal changes in tricuspid flow. In the normal subjects, only minimal fluctuations in these color Doppler characteristics were present. Phasic differences in flow velocity of mitral flow by pulsed Doppler were found between the tamponade and the control groups. Large phasic fluctuations in various characteristics of color Doppler mitral flow on M-mode and two-dimensional imaging may constitute yet another echocardiographic sign of tamponade. (ECHOCARDIOGRAPHY, Volume 8, September 1991)

Cholesterol crystals and IgE-containing immune complexes in rheumatoid pericarditis

A 72-year-old rheumatoid arthritis patient is described presenting with acute dyspnoea and peripheral oedema. A pericardial effusion with signs of tamponade was diagnosed. Examination of the pericardial fluid revealed the presence of cholesterol crystals and IgE-containing immune complexes. The significance of these findings in the differential diagnosis of pericardial disease is discussed.

Echocardiography in low pressure cardiac tamponade

Right ventricular (RV) diastolic collapse and right atrial (RA) collapse are 2 useful 2-dimensional echocardiographic signs of cardiac tamponade. 1–4 According to investigation of the hemodynamics of tamponade in animals under conditions of varying intravascular volume, the presence of RV diastolic collapse and RA collapse implies that the effusion has importantly compromised cardiac filling and output, and that these signs occur in tamponade even when intravascular volume is contracted. 3 Most clinical studies documenting the value of the echocardiographic signs of tamponade have been performed in cases of straightforward tamponade where other hemodynamic or clinical signs were also present. The importance of RV diastolic collapse and RA collapse in the detection of complicated tamponade in patients, such as that seen in a setting of hypovolemia, is not known. Recognition of tamponade is often difficult when it occurs in a state of intravascular volume depletion. 5,6 In this report we present a case of low pressure cardiac tamponade where the diagnosis of tamponade was made by the presence of RV diastolic collapse and RA collapse, despite normal right-sided pressures.

Large pericardial effusion after cardiac surgery: role of echocardiography in diagnosis and management.

We performed M-mode and two-dimensional (2-D) echocardiograms prospectively in 140 patients an average of eight days after open heart surgery. Large pericardial effusions occurred in 13 patients; three had complete circumcardiac pericardial effusion, four had local anterior adhesions, five had extensive anterior adhesions (posterior loculated effusion), and one had a large loculated pericardial effusion contiguous to the right atrium. In five patients with tamponade, the effusion was drained, with immediate reversal of symptoms and signs of tamponade. In the other eight patients, who had no deterioration in cardiovascular status, the effusion was not drained; instead, these patients were treated medically with indomethacin and observed with serial echocardiograms, and the effusions eventually disappeared. The most consistent echocardiographic differences between the five patients with and the eight patients without tamponade were that patients with tamponade had larger posterior pericardial effusions, more severe left atrial compression, and more indentation of the right atrial wall. Echocardiography plays an essential role in diagnosis and management of large pericardial effusions after open heart surgery. Patients with large pericardial effusions who are clinically stable need only medical management, including serial echocardiograms, but drainage is indicated if the cardiovascular or respiratory status worsens. Certain echocardiographic findings indicate a high probability of tamponade.

Diagnostic pericardial window. A safe alternative to exploratory thoracotomy for suspected heart injuries.

During a five-year period, 104 patients underwent a pericardial window procedure to diagnose possible cardiac injury. Eighty-eight procedures were performed by a subxiphoid approach, and 16 were transdiaphragmatic in combination with an exploratory laparotomy. There were 51 patients with stab wounds, 45 with gunshot wounds, and eight with blunt trauma. All penetrating wounds were near the heart. In seven patients the window disclosed cardiac damage with no clinical signs of tamponade or shock. Fifty-one patients had signs of tamponade; however, only 12 of them had a cardiac injury diagnosed by pericardial window. Nineteen patients had cardiac injuries. One examination had false-negative results and one study had false-positive results. Cardiac wounds repaired included the right ventricle (eight), left ventricle (three), right atrium (five), and cardiac vein or pericardial wounds (three). Complications were negligible and consisted of minor wound infections (two) and postpericardiotomy syndromes (two). The pericardial window provides a rapid and safe means of diagnosing cardiac injuries in patients with equivocal signs of heart injury while sparing the patient without a heart wound a major operation.

A Case of Spontaneous Incomplete Non-Traumatic Rupture of the Ascending Aorta with Acute Aortic Insufficiency

Spontaneous incomplete non traumatic rupture of the ascending aorta is rare but life-threatening; it may well remain unnoticed until emergency surgery becomes necessary. Its possibility should be considered in all patients presenting signs of tamponade, chest pain or aortic regurgitation, and it must be diagnosed by appropriate procedures.

Dynamic effects of pericardial effusion without tamponade. Respiratory responses in the absence of pulsus paradoxus.

Fourteen patients with pericardial effusions without clinical signs of tamponade (pulsus paradoxus or other cardiac and circulatory abnormalities) showed inspiratory reductions in echocardiographic left ventricular internal diastolic diameter which correlated directly with the exaggerated respiratory changes in systolic time intervals (both pre-ejection period and left ventricular ejection time). Excessive pericardial fluid affects left ventricular function even in the absence of clinical manifestations.