Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade

Abstract

Pericardial effusion (PEff) is defined by an increase in the physiological amount of fluid within the pericardial space. It can appear following different medical conditions, mainly related to inflammation and cardiac surgery. Cardiac tamponade is a critical condition that occurs after sudden and/or excessive accumulation of fluid in the pericardial space that restricts appropriate filling of the cardiac chambers disturbing normal hemodynamics and ultimately causing hypotension and cardiac arrest. It is, therefore, a life-threatening condition that must be diagnosed as soon as possible for correct treatment and management. Echocardiographic evaluation of PEff is paramount for timely and appropriate diagnosis and management. A structured echocardiographic approach including two-dimensional, M-mode, and Doppler echocardiographic evaluation assessing (i) quantity and quality of pericardial fluid, (ii) collapse of cardiac chambers, (iii) respiratory variation of the ventricular diameters, (iv) inferior vena cava collapsibility, and (v) flow patterns in atrioventricular valves should give the bedside clinician the necessary information to appropriately manage PEff. Here, we review these key echocardiographic signs that will ensure an appropriate assessment of a patient with PEff and/or cardiac tamponade.

Keywords: cardiac tamponade; echocardiography; pericardial effusion; pericardium; ultrasound.

Figure 1

(A) Echocardiography in parasternal long axis. Arrow shows the posterior displacement of the apex and the lack of the typical round left ventricular apex. Cardiovascular magnetic resonance showing the clockwise rotation. Compared with the prone position (B), leftward posterior rotation of the heart is seen in when patient is in supine position (C).

Figure 2

Volume–pressure relationship in cardiac tamponade physiology. Rapid onset effusion leads faster to cardiac tamponade, comparing to a slow increase of the pericardial fluid that will allow the pericardium to stretch reaching the critical point with a higher volume of effusion.

Figure 3

Parasternal long axis (two-dimensional on the left and M-mode on the right) in a patient with pericardial effusion (PEff). Arrow shows echo-free signal from pericardial fluid. M-mode shows PEff only during systole.

Figure 4

Standard echocardiographic views to assess a pericardial effusion (*). (A) Parasternal short axis; (B) four-chamber view; and (C) subcostal view.

Figure 5

Ventricular interdependence. Diagram shows physiological hemodynamic changes in the cardiac chambers within the respiratory cycle.

Figure 6

Subcostal view showing fibrin strains in a large pericardial effusion.

Figure 7

On the left, subcostal view of a patient with significant pericardial effusion and evidence of right atrium (RA) collapse. On the right, M-mode through RA shows collapse duration over 1/3 of the systole.

Figure 8

Right ventricle (RV) collapse (left) in early diastole (end of T wave) in a patient with cardiac tamponade. On the right, collapse of both atria in another patient with signs of tamponade.

Figure 9

Loculated severe post surgical pericardial effusion around the left ventricle (LV). Fibrin strains are also seen within the fluid.

Figure 10

An exaggerated ventricular interdependence following significant pericardial effusion shows increased right ventricle (RV) diastolic diameter during inspiration with decreased diameter of the left ventricle (LV), with the opposite changes happening on expiration.

Figure 11

Typical image of inferior vena cava (IVC) plethora (left) in a patient with significant pericardial effusion. Collapse of IVC during inspiration is less than 50% (right).

Figure 12

Arrow shows paradoxical movement of the interventricular septum in early diastole suggesting elevated right ventricle filling pressures.

Figure 13

(A) Diagram showing mitral and tricuspid valves inflow patterns variability with the respiratory cycle in cardiac tamponade physiology. (B) Mitral peak E-wave of 119 cm/s (expiration) and 58 cm/s (inspiration), 48% drop in mitral E-wave velocity. (C) Doppler through tricuspid valve in the same patient shows an increase in peak E-wave (>40%) during inspiration.

Figure 14

Respiratory variability seen with Doppler analysis of the left ventricular outflow tract, demonstrating decrease of >10% following deep inspiration.

Figure 15

Pulsed-wave Doppler through hepatic veins shows reversal of the normal D wave on expiration (left). Diagram showing changes of normal pattern in cardiac tamponade (right).