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Pericardial Effusion and Pericardiocentesis Review http://dx.doi.org/10.4070/kcj.2012.42.11.725 Print ISSN 1738-5520 • On-line ISSN 1738-5555 Korean Circulation Journal Pericardial Effusion and Pericardiocentesis: Role of Echocardiography Hae-Ok Jung, MD Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Pericardial effusion can develop from any pericardial disease, including pericarditis and several systemic disorders, such as malignancies, pulmonary tuberculosis, chronic renal failure, thyroid diseases, and autoimmune diseases. The causes of large pericardial effusion requiring invasive pericardiocentesis may vary according to the time, country, and hospital. Transthoracic echocardiography is the most important tool for diagnosis, grading, the pericardiocentesis procedure, and follow up of pericardial effusion. Cardiac tamponade is a kind of cardio- genic shock and medical emergency. Clinicians should understand the tamponade physiology, especially because it can develop without large pericardial effusion. In addition, clinicians should correlate the echocardiographic findings of tamponade, such as right ventricular collapse, right atrial collapse, and respiratory variation of mitral and tricuspid flow, with clinical signs of clinical tamponade, such as hypo- tension or pulsus paradoxus. Percutaneous pericardiocentesis has been the most useful procedure in many cases of large pericardial effu- sion, cardiac tamponade, or pericardial effusion of unknown etiology. The procedure should be performed with the guidance of echocardiog- raphy. (Korean Circ J 2012;42:725-734) KEY WORDS: Pericardial effusions; Echocardiography; Cardiac tamponade; Pericardiocentesis. Introduction ricardium. Pericardial fluid acts as a lubricant between the heart and the pericardium. Excess fluid or blood accumulation in this cavity is Normal pericardium is a double-walled sac that contains the heart called pericardial effusion.4)5) and the roots of the great vessels. The pericardium is composed of two different layers; an outer fibrous parietal pericardium and an in- Etiologies of Pericardial Effusion ner visceral pericardium.1) The inner visceral pericardium is a serous- type membrane and is located immediately outside of the myocar- Pericardial effusion can develop in patients with virtually any con- dium.2)3) The pericardium prevents sudden dilatation of the heart, dition that affects the pericardium, including acute pericarditis and especially the right chamber, and displacement of the heart and gr- a variety of systemic disorders.1)5) The clinical causes of pericardial ef- eat vessels, minimizes friction between the heart and surrounding fusion are very diverse and include malignancies of other organs, structures, and prevents the spread of infection or cancer from the pulmonary tuberculosis, chronic renal failure, thyroid disease, auto- lung or pleura. The pericardium also contributes to diastolic coupl- immune disease, and iatrogenic and idiopathic causes (Table 1).5-7) ing between the two ventricles.3)4) In between the parietal and vis- The development of a pericardial effusion may have important im- ceral pericardium, there is a pericardial cavity filled with 10-50 cc of plications for the prognosis (as in patients with intrathoracic ma- fluid, an ultrafiltrate of plasma that is produced by the visceral pe- lignancy) or diagnosis (as in myopericarditis or acute pericarditis), or both (as in dissection of the ascending aorta).6) When a pericardial Correspondence: Hae-Ok Jung, MD, Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of effusion is initially or incidentally detected, a major concern for cli- Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-040, Korea nicians may be its etiology. In a majority of cases, the etiology of the Tel: 82-2-2258-1302, Fax: 82-2-2258-1605 effusion can be presumed from the underlying condition of the pa- E-mail: [email protected] tient. Although the exact etiology of pericardial effusion can be iden- • The author has no financial conflicts of interest. tified by invasively-obtained pericardial fluid or tissue, an invasive This is an Open Access article distributed under the terms of the Creative procedure, like pericardiocentesis, is only indicated when the effu- Commons Attribution Non-Commercial License (http://creativecommons. sion is large or symptomatic, the effusion is accompanied by tam- org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work ponade, or the cause of the effusion is questionable. There is some is properly cited. discrepancy in the etiologies of pericardial effusion, requiring peri- Copyright © 2012 The Korean Society of Cardiology 725 726 Pericardial Effusion and Pericardiocentesis Table 1. Major etiologies of pericardial effusion cardiocentesis between countries or centers. A review of many ar- Infections ticles from throughout the world shows that the relative frequency 1. Mycobacterium tuberculosis of different etiologies is mainly affected by the decade, local epide- 2. Bacterial - Staphylococcus, Streptococcus, pneumococcus, miology, hospital volume, and the diagnostic protocol.6)7) The etiolo- Hemophilus, Neisseria, Chlamydia, etc. gy of pericardial effusion in Korea and other countries is summariz- 3. Viral - Coxsackie virus, echovirus, adenovirus, CMV, HIV, etc. ed in Table 2.8-15) In Korea, lung cancer and pulmonary tuberculosis are Malignancies predominant causes of large pericardial effusion.8-10) Sagristà-Sau- 1. Metastatic - lung cancer, breast cancer, lymphoma, leukemia, stomach leda et al.13) reported that when an etiology is not apparent, the cli- cancer, melanoma, etc. nical indices, including the size of the effusion, the presence of in- 2. Primary - angiosarcoma, rhabdomyosacoma, mesothelioma, etc. flammatory signs, and cardiac tamponade, may be useful in sug- Iatrogenic gesting a possible etiologic category. For example, severe effusions 1. Percutaneous coronary intervention without inflammatory signs or tamponade were significantly asso- 2. Pacemaker, ICD, or CRT insertion ciated with chronic idiopathic pericardial effusion. In contrast, cardiac 3. Post-cardiac surgery or CPR tamponade without inflammatory signs was significantly associated Connective tissue diseases with malignant effusions. Systemic lupus erythematosus, rheumatoid arthritis, scleroderma, Behcet’s disease, etc. Transthoracic Echocardiography for Pericardial Metabolic diseases Effusion 1. Hypothyroidism 2. Chronic renal failure M-mode and 2-dimensional Doppler echocardiography is the Other situations most effective technique, and is the gold standard for the diagnosis 1. Blunt chest trauma or penetrating chest wall injury of pericardial effusion, because it is sensitive, specific, noninvasive, 2. Aortic dissection and easily made available at the bedside.16) Pericardial effusion can 3. Pericarditis and/or myocarditis 4. Post myocardial infarction be detected as an “echo-free space” on 2-dimensional echocardiog- 1-5) Idiopathic – when an identifiable cause of pericardial effusion is not found. raphy (Fig. 1). Small collections of pericardial fluid, which can be CMV: cytomegalovirus, HIV: human immunodeficiency virus, ICD: implant- physiologic (25 to 50 mL), may be visible during ventricular systole. able cardiac defibrillator, CRT: cardiac resynchronization therapy, CPR: car- When the amount of effusion is more than 50 mL, an echo-free sp- diopulmonary resuscitation ace persists throughout the cardiac cycle. When a pericardial effu- Table 2. Summary of the frequency of etiologies with large volumes of pericardial effusion requiring pericardiocentesis reported in Korea and other countries Sagristà- Kil Cho Kim Tsang Kabucku Levy Reuter Sauleda et al.8) et al.9) et al.10) et al.11) et al.12) et al.14) et al.15) et al.13) Study period 1995-2007 1998-2003 2001-2006 1993-2000 1998-2002 1990-1996 1998-2002 1995-2001 Number of patients 116 181 64 441 50 322 204 233 Location of hospital Seoul, Korea Seoul, Korea Daegu, Korea USA Turkey Spain France South Africa Etiologies (%) Malignancy 52.6 45 29.7 25 30 13 15 9.4 Tuberculosis or other 18.1 16 40.6 69.6 7 2 16 infections (mainly Tbc) (mainly Tbc) (mainly Tbc) (34.8% HIV +) Iatrogenic 6.0 19 42 16 0 Idiopathic 3.4 6 18.8 8 20 29 48 MI related - 4 - 2 Thyroid D 2.6 - 7.8 - 2 Collagen VD 5.2 1 - 4 8 5 10 5.2 Uremia 6.9 - - 22 6 2 5.2 Others 5.2 9 3.1 12 15 0 8.6 Collagen VD: Collagen vascular diseases, HIV: human immunodeficiency virus, MI: myocardial infarction, Tbc: tuberculosis, thyroid D: thyroid diseases http://dx.doi.org/10.4070/kcj.2012.42.11.725 www.e-kcj.org Hae-Ok Jung 727 Fig. 1. Representative images of echo-free space on 2-dimensional echocardiography. sion is detected by echocardiography, the next step is to assess the size of the effusion, its location, hemodynamic importance, and as- sociated diseases.4)17) A pericardial effusion is not always uniformly V3 V3 distributed around the heart. Initially, small effusions are evident V2 V2 V1 V4 V1 over the posterobasal left ventricle; however, as the fluid volume in- V4 creases, it gradually spreads anteriorly, laterally, and behind the left V5 V5 atrium. Ultimately, the separation becomes circumferential and ap- V6 V6 pears as “swinging heart”, which is a sign of a large pericardial effu- sion and possibly cardiac tamponade.4) Despite the fact that there is a large amount, the pericardial effusion does not surround the
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