Pericardial Effusion (2022)




Key Points





  • Pericardial effusion is common and can be accurately detected by providers of different specialties using point-of-care ultrasound.



  • The clinical importance of a pericardial effusion can be synthesized from a combination of both clinical and ultrasound findings.



  • Emergency pericardiocentesis guided by ultrasound can be a lifesaving procedure.





Background


Pericardial effusions are defined as the presence of fluid in the pericardial space that exceeds the upper physiologic amount of 50mL and may be caused by malignancy, uremia, trauma, infection, and rheumatologic diseases. Although the incidence of pericardial effusions in the general population is not known, data suggest that up to 13.6% of patients with otherwise unexplained dyspnea presenting to emergency departments have pericardial effusions of varied clinical significance. Bedside ultrasound allows rapid, noninvasive diagnosis of pericardial effusion and acute pericardial tamponade. Physical exam findings, such as Beck’s triad (hypotension, jugular venous distention, and muffled heart sounds), although commonly emphasized, are not specific, and may be more reliable in trauma patients with a rapid accumulation of fluid. Few applications of emergency point-of-care ultrasound are more time critical and potentially lifesaving as cardiac ultrasound to detect pericardial tamponade. It is well documented that focused cardiac ultrasound can be learned by noncardiologists with different scopes of practice who can reliably diagnose pericardial effusions with >95% accuracy compared with comprehensive transthoracic echocardiography.




Image Interpretation


The pericardium is a dense, fibrous double-layered membrane that completely encircles the heart and a few centimeters of the aorta and pulmonary arteries. The dense parietal pericardial tissue is highly echogenic (bright white appearance on ultrasound) and is easily recognized both anteriorly and posteriorly as the sonographic border of the heart. The pericardial space is a blind sac contained within the visceral and parietal pericardium and usually contains a scant amount of pericardial fluid.


A normal heart contains approximately 10mL of serous fluid in the pericardial sac. This small amount of fluid is occult on ultrasound, and the parietal and visceral layers of pericardium are seen as one hyperechoic layer adjacent to the myocardium in most views Pericardial effusions are seen on ultrasound as an anechoic (black) band that encircles the heart and separates the bright white, highly reflective parietal pericardium from the heterogeneous gray myocardium. Although a very small amount of fluid can be normal, distinguishing the origin (physiologic vs. pericardial disease) is not readily possible. In high-risk clinical circumstances where trivial effusions may be harbingers of important, evolving pericardial disease (e.g., penetrating trauma, postcardiac procedure), even a very small effusion should be considered pathologic until proven otherwise.


Free-flowing pericardial fluid initially accumulates posteriorly and is identified in the most dependent area of the pericardial sac. In the subcostal view, an effusion is seen as an anechoic stripe between the right ventricular free wall and pericardium adjacent to the liver ( Figure 17.1 and Pericardial Effusion (1) ). In the parasternal long-axis and short-axis views, pericardial effusions are seen posterior to the left ventricle ( Figure 17.2 and Pericardial Effusion (2) ). As the volume of pericardial fluid increases, an effusion becomes circumferential ( Figure 17.3 ). After cardiac surgery or percutaneous procedures, or in patients with recurrent pericardial disease, pericardial fluid may be loculated and does not flow freely with changes in patient position. Recognition of a loculated pericardial effusion is important because hemodynamic compromise can occur with even a small amount of located fluid.




Pericardial Effusion (3)



A pericardial effusion is seen separating the pericardial layers between the liver and the right ventricular (RV) free wall in a subcostal 4-chamber view.

(Video) Pericarditis and Pericardial Effusion



Pericardial Effusion (4)



Posterior accumulation of a small pericardial effusion in the far field (arrows) in a parasternal long-axis view. Note pericardial effusions course in a plane anterior to the descending thoracic aorta (DTA). LV, left ventricle; LA, left atrium.




A number of conditions can mimic pericardial effusion and must be distinguished from true effusions. First, an epicardial fat pad, fatty tissue interposed between the two layers of pericardium, may be misdiagnosed as a pericardial effusion because they both appear anechoic and occupy the potential pericardial space. Fat can be distinguished from a true effusion based on its more gray or isoechoic appearance, rather than the anechoic appearance of an effusion. Also, nonloculated effusions typically collect dependently (posteriorly, in a supine patient), and if an anechoic space is seen only anteriorly, then it is most likely an epicardial fat pad ( Figure 17.4 and Pericardial Effusion (6) ). Effusions containing pus, fibrin, thrombus, or cellular debris from malignancy may appear more echogenic and can be overlooked as myocardium or adjacent lung tissue ( Figure 17.5 ). Second, a pleural effusion can be mistaken for a pericardial effusion. In a parasternal long-axis view, both effusions are seen as anechoic areas posterior to the left atrium and left ventricle but can be distinguished based on their relationship to the descending thoracic aorta (DTA). A pericardial effusion traverses anterior to the DTA, whereas a left pleural effusion is seen posterior to the DTA ( Figures 17.6 and 17.7 and Pericardial Effusion (7) ). If the descending thoracic aorta is not well seen, an effusion should be confirmed from parasternal short-axis and subcostal views, or a dedicated left pleural view can also be obtained. Lastly, in certain views, providers must be vigilant not to mistake peritoneal fluid for pericardial fluid. Because the subcostal cardiac imaging plane crosses the upper abdomen, ascites may be misinterpreted as pericardial fluid in this view ( Figure 17.8 and Pericardial Effusion (8) ). The absence of circumferential fluid around the heart, and acquiring corroborating cardiac and abdominal ultrasound views, can eliminate this pitfall.




Pericardial Effusion (9)



An epicardial fat pad (arrows) is shown in a subcostal 4-chamber view. Echodensities can be appreciated in the fat layer as well as absence of a circumferential fluid collection. LV, left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium.

(Video) Pericarditis and pericardial effusions - causes, symptoms, diagnosis, treatment, pathology



Pericardial Effusion (10)



Pericardial blood clot is seen a subcostal 4-chamber view. Arrows point to some anechoic effusion that has yet to clot. Mixed echo densities are common in complex effusions. RV, right ventricle.




Pericardial Effusion (11)



Large left pleural effusion as seen from a parasternal long-axis view. There is no pericardial effusion. The anechoic space representing the pleural fluid is only seen deep to the descending thoracic aorta (DTA). RVOT, right ventricular outflow tract; LV, left ventricle; LA, left atrium.




Pericardial Effusion (12)

(Video) Cardiac Tamponade - pericardial effusion, causes, pathophysiology, investigations and treatment


Both a pericardial effusion and left pleural effusion are demonstrated in this parasternal long-axis view. The pericardial effusion is seen anterior to the descending thoracic aorta (DTA), while the pleural effusion is posterior to the DTA. LV, left ventricle; LA, left atrium.




Pericardial Effusion (13)



Subcostal 4-chamber view in a patient with ascites and no pericardial effusion. Because the ascites in this view is adjacent to the pericardium, it can be mistaken for a pericardial effusion. Attention to the falciform ligament (arrow) and the absence of circumferential collection around the heart can help avoid this pitfall. RV, right ventricle.





Pathologic Findings


Hemodynamic effects of fluid in the pericardial space depend both on the volume and rate of fluid accumulation, as well as the patient’s intravascular volume status. A slowly expanding pericardial effusion (e.g., malignant effusion) can become quite large (>2000mL) with little increase in pericardial pressure, whereas rapid accumulation of even a small volume of fluid (50–100mL) can lead to a marked increase in pericardial pressure (e.g., myocardial perforation during placement of a pacemaker lead) ( Figure 17.9 ). Other important factors that determine the hemodynamic consequences of pericardial effusion include pericardial fluid characteristics (serous vs. blood), anatomic distribution (eccentric vs. concentric), integrity of the pericardial layers (inflamed, neoplastic invasion, fibrous), volume status of the patient, and size and thickness of the underlying cardiac chambers.




Pericardial Effusion (14)



Relationship of pressure within the pericardium versus pericardial fluid volume. Rapidly accumulating pericardial effusions cause a sudden rise in pericardial pressure leading to cardiac tamponade at smaller volumes, while slowly accumulating effusions cause a gradual rise in pericardial pressure leading to tamponade at much higher volumes. RV, right ventricle

(Video) Pericardial Effusion - Mayo Clinic



Pericardial Effusion (Small, Moderate, Large)


Several scales for quantifying the volume of a pericardial effusion have been described, but the assessment of these dimensions is subjective. Most commonly, the maximum fluid dimension measured in diastole allows for the following categorization ( Figure 17.10 ):



  • 1.

    Small: <1cm ( Pericardial Effusion (15) )


  • 2.

    Moderate: 1–2cm ( Pericardial Effusion (16) )


  • 3.

    Large: >2cm ( Pericardial Effusion (17) )




Pericardial Effusion (18)

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Tags: Point of Care Ultrasound

May 20, 2019 | Posted by drzezo in ULTRASONOGRAPHY | Comments Off on Pericardial Effusion

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FAQs

Pericardial Effusion? ›

Pericardial effusion (per-e-KAHR-dee-ul uh-FU-zhun) is the buildup of too much fluid in the double-layered, saclike structure around the heart (pericardium). The space between these layers typically contains a thin layer of fluid.

What is the most common cause of pericardial effusion? ›

Lung cancer is the most common cause of the malignant pericardial effusion. Trauma: Blunt, penetrating, and iatrogenic injury to the myocardium, aorta, or coronary vessels can lead to the accumulation of blood within the pericardial sac.

What is treatment for pericardial effusion? ›

Drainage procedures or surgery to treat pericardial effusion may include: Fluid drainage (pericardiocentesis). A health care provider uses a needle to enter the pericardial space and then inserts a small tube (catheter) to drain the fluid. Imaging techniques, typically echocardiography, are used to guide the work.

Is pericardial effusion serious? ›

Pericardial effusion is a buildup of fluid in the space around the heart. It can happen for a wide range of reasons, including infections, injuries or other medical conditions. If the buildup is severe or happens quickly, it can compress your heart and cause cardiac tamponade, a life-threatening medical emergency.

What happens when you have a pericardial effusion? ›

Pericardial effusion is the buildup of extra fluid in the space around the heart. If too much fluid builds up, it can put pressure on the heart. This can prevent it from pumping normally. A fibrous sac called the pericardium surrounds the heart.

Can pericardial effusion be cured? ›

Depending on the severity of the buildup, pericardial effusion may be treatable with medicines. If the health care team determines that it's necessary to drain the excess fluid, they may recommend a procedure called pericardiocentesis, which uses a needle and small catheter to drain the fluid.

How long can you live with pericardial effusion? ›

Survival rates are consistently poor in patients with malignancy who present with a pericardial effusion. In our series, patients had a median survival of 2.6 months. Patients with lung cancer had a median survival of 2.1 months while those with other types of cancer of 4.7 months.

What makes a pericardial effusion worse? ›

When inflammation of the sac causes a pericardial effusion, the main symptom is chest pain. It may get worse when you breathe deeply and better when you lean forward.

What drugs can cause pericardial effusion? ›

Causes of Pericardial Effusion

Certain prescription drugs, such as hydralazine, a medication for high blood pressure; isoniazid, a tuberculosis drug; and phenytoin, a medication for epileptic seizures. Chemotherapy drugs, such as doxorubicin and cyclophosphamide.

Is Mild pericardial effusion normal? ›

There is normally a small amount of fluid around the heart (small pericardial effusion). This is produced by the sac around the heart and is an important part of normal heart functioning.

How do you get a pericardial effusion? ›

Pericardial effusion can result from inflammation of the pericardium (pericarditis) after an illness or injury. In some settings, large effusions may be caused by certain cancers. A blockage of pericardial fluids or a collection of blood within the pericardium also can lead to this condition.

How long is recovery from pericardial effusion? ›

Recovery may take several weeks or months, depending on the severity and cause of the pericardial effusion. A possible complication of pericardial effusion is cardiac tamponade, which is a medical emergency requiring immediate intervention.

Can pericardial effusion disappear? ›

How is it treated? If there is only a small amount of extra fluid in your pericardium, you may not need treatment. The extra fluid may go away on its own. Treatment depends on the cause of the extra fluid, the amount of fluid, and your symptoms.

What virus causes pericardial effusion? ›

The most common cause of infectious pericarditis and myocarditis is viral. Common etiologic organisms include coxsackievirus A and B, and hepatitis viruses.

Can pericarditis be caused by stress? ›

Stress cardiomyopathy (CMP) has been described as a complication of post-myocardial infarction pericarditis (Dressler syndrome). Stress CMP can also be complicated by pericarditis. We describe the novel observation where idiopathic pericarditis is the primary disease, which precipitated stress CMP.

Is pericardial effusion an emergency? ›

While all significant pericardial effusions are of clinical importance, emergency drainage is needed only for patients with hemodynamic compromise. Cardiac tamponade with hemodynamic collapse is an absolute indication for emergency pericardial drainage via pericardiocentesis or surgical pericardiotomy.

Can you recover from fluid around the heart? ›

In chronic cases, it can last for more than 3 months. Some people with pericardial effusion may not show any symptoms, and doctors may discover the condition by chance — for example, if they notice fluid around the heart spaces in medical imaging that they have conducted for a different purpose.

Is pericardial effusion reversible? ›

Just as other symptoms of hypothyroidism, pericardial effusions can be reversed over time with thyroid hormone replacement [14].

Can you exercise with pericardial effusion? ›

Current guidelines recommend that return to physical exercise or sport is permissible if there is no longer evidence of active disease. This includes the absence of fever, absence of pericardial effusion, and normalization of inflammatory markers (ESR and or C-reactive protein).

Can you live a long life after pericarditis? ›

What is the survival rate of pericarditis? Without treatment, the survival rate of constrictive pericarditis is low. After a pericardiectomy, 78% of people can live five years and 57% live another 10 years.

Does alcohol cause pericardial effusion? ›

We conclude that in patients with mild acute alcohol-induced pancreatitis, pericardial effusion occurs frequently and that left ventricular function is unimpaired.

How much pericardial effusion is normal? ›

Normally there is between 10–50 ml of pericardial fluid.

Is pericardial effusion the same as congestive heart failure? ›

Theoretically, any malignancy can cause a pericardial effusion. Hypothyroidism and uremia are metabolic causes of a pericardial effusion and result from increased capillary permeability in these disease states. Increased hydrostatic pressure causing a pericardial effusion is present in congestive heart failure.

How do you sleep with pericarditis? ›

Sitting up and leaning forward tends to ease the pain, while lying down and breathing deep worsens it. Some people describe the pain as a dull ache or pressure in their chest. The chest pain may feel like a heart attack. If you experience chest pain, call 911 right away because you may be having a heart attack.

Is pericarditis linked to Covid? ›

COVID-19 may present with pericarditis without myocarditis or respiratory symptoms. This atypical presentation should be recognised for early isolation and limitation of the spread of the disease. Aspirin with colchicine is effective in the treatment of COVID-19 pericarditis.

Does pericarditis show up on ECG? ›

Pericarditis, or inflammation of the pericardium, has typical ECG findings. These findings occur in progressive stages, all of which are seen in about 50% of cases of pericarditis.

Does pericarditis damage the heart? ›

Prognosis of Pericarditis

When treated promptly, most people recover from acute pericarditis in two weeks to three months. It usually leaves no lasting damage to the heart or pericardium.

What drugs can cause pericardial effusion? ›

Causes of Pericardial Effusion

Certain prescription drugs, such as hydralazine, a medication for high blood pressure; isoniazid, a tuberculosis drug; and phenytoin, a medication for epileptic seizures. Chemotherapy drugs, such as doxorubicin and cyclophosphamide.

Is Mild pericardial effusion normal? ›

There is normally a small amount of fluid around the heart (small pericardial effusion). This is produced by the sac around the heart and is an important part of normal heart functioning.

Can fluid around the heart go away on its own? ›

How is it treated? If there is only a small amount of extra fluid in your pericardium, you may not need treatment. The extra fluid may go away on its own. Treatment depends on the cause of the extra fluid, the amount of fluid, and your symptoms.

What can cause fluid around the heart? ›

What causes fluid around the heart?
  • Bacterial pericarditis. Staphylococcus, pneumococcus, streptococcus, and other kinds of bacteria can enter the fluid that surrounds the pericardium and cause bacterial pericarditis.
  • Viral pericarditis. ...
  • Idiopathic pericarditis.
Jan 7, 2019

What makes a pericardial effusion worse? ›

When inflammation of the sac causes a pericardial effusion, the main symptom is chest pain. It may get worse when you breathe deeply and better when you lean forward.

How long is recovery from pericardial effusion? ›

Recovery may take several weeks or months, depending on the severity and cause of the pericardial effusion. A possible complication of pericardial effusion is cardiac tamponade, which is a medical emergency requiring immediate intervention.

How do you get a pericardial effusion? ›

Pericardial effusion can result from inflammation of the pericardium (pericarditis) after an illness or injury. In some settings, large effusions may be caused by certain cancers. A blockage of pericardial fluids or a collection of blood within the pericardium also can lead to this condition.

Does pericardial effusion cause cough? ›

Constrictive pericarditis (called as the “heart of stone” in the bible) and pericardial effusion can present with cough. Tussive syncope has been well described in literature pertaining to constrictive pericarditis. However, it is extremely rare to have cough syncope in a case of pericardial effusion.

Can pericarditis be caused by stress? ›

Stress cardiomyopathy (CMP) has been described as a complication of post-myocardial infarction pericarditis (Dressler syndrome). Stress CMP can also be complicated by pericarditis. We describe the novel observation where idiopathic pericarditis is the primary disease, which precipitated stress CMP.

Is pericardial effusion the same as congestive heart failure? ›

Theoretically, any malignancy can cause a pericardial effusion. Hypothyroidism and uremia are metabolic causes of a pericardial effusion and result from increased capillary permeability in these disease states. Increased hydrostatic pressure causing a pericardial effusion is present in congestive heart failure.

It can happen for a wide range of reasons, including infections, injuries or other medical conditions.. Under normal circumstances, the pericardium has just enough fluid to cushion your heart, but not so much fluid that your heart can’t expand and fill up with blood with every heartbeat.. Cardiac tamponade happens when there’s too much fluid inside the pericardium, which means your heart has no room to expand and fill up with blood.. As the pericardium fills up, there's less space for your heart to expand.. Possible causes of pericardial effusion include:. Pericardial effusion can happen after heart surgery, radiation therapy for cancer or as a side effect of some medications.. Pericardial effusion is usually a significant condition, but it isn’t always a medical emergency.. When it happens because of injuries or heart and circulatory problems (or any reason that can cause an effusion to develop quickly), pericardial effusion needs quick treatment to avoid dangerous complications like cardiac tamponade.. If you don’t have symptoms, the most likely way a doctor will diagnose pericardial effusion is if they happen to see it on medical imaging for another reason.. In some cases, tests on the fluid taken out of your pericardium are also possible.. When a pericardial effusion is large or causes cardiac tamponade, it becomes a medical emergency that needs immediate treatment.. The cause of the effusion.. If you have an effusion that’s growing more quickly, that’s causing symptoms, or that’s happening because of more serious conditions (especially trauma or cancer), you will probably need treatment sooner rather than later.

Even if doctors cannot determine the cause of the pericardial effusion, they can still provide patients with a treatment plan.. Connection to Mesothelioma Pericardial effusion is a common symptom of malignant pericardial mesothelioma.. As a result of asbestos exposure , fibers may embed in the pericardium and cause inflammation.. Patients with severe pericardial effusions may experience other symptoms.. Pericardial Effusion Diagnosis To diagnose pericardial effusion, doctors will perform a physical exam and listen to a patient’s heart.. If a patient exhibits any pericardial effusion symptoms, doctors will perform additional testing to confirm the diagnosis.. If pericardial effusion is diagnosed, doctors may perform additional testing to determine the cause of the effusion.. For patients whose pericardial effusion is caused by mesothelioma, doctors will need to take a biopsy to definitively diagnose the cancer.. Common Treatments There are treatments available for individuals diagnosed with pericardial effusion.. Two common treatments are pericardiocentesis and pericardiectomy.. Pericardiocentesis is a minimally invasive procedure that removes the excess fluid from the pericardium.

Some of these include:. Autoimmune conditions (such as with rheumatoid arthritis and lupus) Cancers (both those that spread to the pericardium from other regions of the body such as lung cancer, breast cancer, sarcomas, and lymphomas, and those that begin in the pericardium, such as pericardial mesothelioma ) Current or previous radiation therapy to the chest for lung cancer, breast cancer, esophageal cancer, lymphomas, and others Chemotherapy Kidney failure Hypothyroidism (usually when severe) Inflammation (including pericarditis ) Chest surgery (including surgery for heart disease or lung cancer) Heart attacks Medications. Some of the medications that may cause pericardial effusions include:. With heart failure, medications to treat the conditions, such as diuretics, may be used.. For people who have pericardial effusions due to benign causes (such as an infection) the prognosis with this procedure is good.. A pericardial effusion may be mild and temporary with conditions such as some viral infections, but can be serious and a poor prognostic sign for people living with cancer.. The treatment and prognosis of cancers, even lung cancer, is improving, and much of what you may have heard or read about metastatic cancer and pericardial effusions may not only be very disheartening, but inaccurate.

The pericardium is not that mandatory for normal cardiac function - however, affected pericardium presenting clinically as chronic or acute/recurrent pericarditis, pericardial constriction, cardiac tamponade, and pericardial effusion can be life-threatening and can be challenging to manage.. Dogs with pericardial diseases including first-degree relatives (littermates and parents) should not be bred so as to avoid passing the condition on to the next generation.. Acute Pericarditis: Acute type is the most frequent among the pericardial syndromes with multifactorial aetiology.. Recurrent Pericarditis: One of the most troublesome complications after an episode of acute pericarditis is recurrent pericarditis in which pericarditis relapses after discontinuation of treatment.. Constrictive Pericarditis: Pericardial constriction can be defined as a syndrome due to the compression of the heart caused by inelastic, thickened, and fused pericardial membranes that limit ventricular filling during diastole.. Pericardial Effusion: The increased fluid accumulation within the pericardial sac forms a pericardial effusion, which may be purulent, serous, or hemorrhagic, depending on etiology.. When the pericardial effusion is large or the rate of accumulation is too rapid, this fluid accumulation may become hemodynamically significant, as the fluid can extrinsically constrict the cardiac chambers restricting diastolic filling and causing cardiac tamponade syndrome.. Luckily, pericardial diseases are rare in dogs and the mortality rate is less than 2%.. Constrictive pericarditis is extremely rare after acute or idiopathic pericardial diseases, occurring in less than1% of cases.. In up to 30% of acute pericardial dogs, recurrent pericarditis can occur and this is spot on in cases that are not treated with colchicines.. The most feared acute complication following pericardial disease is cardiac tamponade and it is more frequently encountered in association with infectious causes of pericarditis and malignancy.. Dietary management of pericardial diseases in dogs.. The prognosis for pericardial disease in dogs depends on its severity and how early it was treated.. The survival rate for dogs that undergo surgical repair for idiopathic pericardial diseases is good.

Videos

1. PERICARDIAL EFFUSION
(5MinuteSchool)
2. How To Look For a Pericardial Effusion In an Echocardiogram
(GE Healthcare)
3. PERICARDIAL EFFUSION vs CARDIAC TAMPONADE - EXPLAINED IN 5 MINUTES (Beck's Triad, Causes, Diagnosis)
(5MinuteSchool)
4. Echocardiography Essentials: Detecting pericardial effusions
(Medmastery)
5. Pericarditis: Symptoms, Pathophysiology, Causes, Diagnosis and Treatments, Animation
(Alila Medical Media)
6. Differentiating pleural vs pericardial effusion by anatomy on echo
(Jason T Nomura)

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