INTRODUCTIONPresence of abnormal amount and/or character

of fluid in the pericardial spaceCan be caused by

LOCAL/SYSTEMIC/IDIOPATHIC causesCan be ACUTE or CHRONIC (symptoms)Important implications for prognosis

(intrathoracic neoplasm), diagnosis (myopercarditis) or both (dissecting of ascentding aorta)

Treatment directed at removal of pericardial fluid and alleviation of the underlying cause

PHYSIOLOGYVolume of fluid: 15-50 ml.Essentially and ultrafiltrate of plasmaTotal protein generally low. Albumin conc.

HIGH.Contribution of pericardial fluid:

end-diastolic pressure (mostly RA,RV)ensure uniform contraction of the myocardium

Acute (80ml) vs. Chronic (up to 2lt).

ETIOLOGY As a component of any pericardial disorder

or 2ry to a systemic disorder:Acute idiopathic or viral pericaditis Infectious: Viral, Purulent pericarditis, Tuberculous, HIVPost MI/post cardiac surgeryMalignancy (lung, breast, hodgkin’s, mesothelioma)Mediastinal radiationAutoimmune diseaseDialysis, Ch. Renal failureHypothyroidism (myxedema), ovarian hyperstimulation synd.Drugs: procainamide, isoniazid, hydralazine, anticoagulants.

ETIOLOGYHEMORRHAGIC PERICARDIAL EFFUSION:Malignancy (26%)Trans-catheter interventions and/or pacemaker insertion

(18%)Post-pericardiotomy syndrome (13%)Complication of MI (free wall rupture, thrombolysis) (11%) Idiopathic (10%)Uremic (7%)Aortic dissection (4%)Trauma (3%)Other (8%)

CLINICAL- SYMPTOMSCVS: chest pain, pericardial pain (relieved by

sitting), light headedness, syncope, palpitations

RESP: cough, dyspnea, hoarsnessGI: hiccoughsNEUR: anxiety, confusion

CLINICAL- SIGNSCVS: BECK’s triad of tamponade

(hypotension, muffled heart sounds, jugular venous distension), pulsus paradoxus, pericardial friction rub, tachycardia, hepatojugular reflux.

RESP: tachypnea, decreased breath sounds, Ewart sign

GI: hepato-splenomegalyEXTREMITIES: weakened peripheral pulses,

edema, cyanosis.

DIAGNOSISSuspect when: All cases of acute pericarditisUnexplained persistent fever +\- source.

Purulent per.New radiographic cardiomegaly without

pul. Congestion.Isolated left pleural effusionHemodynamic deterioration after MI,

cardiac surgery, invasive cardiac procedures.

APPRAOCHClinically, ECG, X-RAY.Once pericardial effusion is suspected:Establish the presence of effusion :

clinically ECG, ECHO (sensitive, specific, hemodynamic significance

Assess the hemodynamic impactEstablish the cause

Establish the presence of effusionAccording to ACC/AHA/ASE 2003Clinically – insensitive and nonspecific.ECG- low voltage QRS complexes <5mm in

all limb leads, <10mm in V1-V6. (tamponade and inflammation); alternans in P and QRS complexes- pathognomonic.

ECHO: sensitive, specific, hemodynamic significance

CT, MRI

Assess hemodynamic impactRanges from no significance mild

compromisecardiac tamponadeFactors determining the degree of

hemodynamic compromise:1.Volume2.Rate of accumulation (acute vs. subacute)3.Pericardium is scarred or adherent

Establish the cause of effusionOften recognized by the clinical setting in which it

occurs (cancer, MI, hypothyroidism, renal failure)Chance of diagnosis rises as the effusion is larger.

(15/20% vs. 90%; why? Diag., aggressive approach)Clinical assess.: size; +/- tamponade; inflammatory

signs (chest pain, pericardial friction rub, fever diffused ST elev.)

Lab. Tests: CBC, chemistry+renal function, thyroid, anti dsDNA,complement, chst CT

Pericardiocentesis & biopsy : culture, cytology, PCR.protein,LDH,Glucose,RBC,WBC: do not distinguish exudate from transudate

TREATMENTCONSIDER: underlying disease,

hemodynamic significance, presence of tamponade.

Underlying disease: infectious, malignant, uremic peric. MI, collagen vascular disease.

Cardiac tamponade: volume resuscitation (RA pressure 10-12mmHg).

Pericardial fluid drainage: percutaneous/ pericadiectomy.

Summery Abnormal amount/character of pericardial fluidLOCAL/SYSTEMIC/IDIOPATHIC causesACUTE vs. CHRONICClinical – not specific. Tamponade.APPROACH: Clinically, ECG, X-RAY; Establish

the presence of effusion ; Assess the hemodynamic impact Establish the cause

TREATMENT: underlying disease, hemodynamic significance, presence of tamponade.