Cardiac tamponade echocardiography and ultrasound

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyamvada Singh, M.D. [2] Ramyar Ghandriz MD[3]

Overview

The role of echocardiography in the evaluation of the patient with pericarditis is to chracterize the presence, size, location and hemodynamic impact of a pericardial effusion. Tamponade is characterized by pericardial effusion, diastolic compression of the RV, diastolic compression of the right atrium (RA), plethora of the inferior vena cava and paradoxical septal motion.

Echocardiography/Ultrasound

Echocardiography

• As part of their recommendations for echocardiography, the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Society of Echocardiography gave strong recommendations for echocardiography in pericardial diseases.
• Two dimensional echocardiography and Doppler echocardiography should be done in all suspected cases of cardiac tamponade and pericardial effusion.
• Follow up echocardiography for assessment of impending cardiac tamponade is very helpful for determining patient's outcome.
• Echocardiogram helps in determination of pericardial disease's hemodynamic parameters and the difference of pressure in cardiac chambers..

Findings

• Presence of moderate and large pericardial effusion.
• Swinging of the heart within the effusion
• Reversal of right atrial and right ventricular diastolic transmural pressures.
• Cardiac chamber collapse is a common finding in cardiac tamponade.
• The right atrium and right ventricle are the most likely to collapse when intrapericardial pressure exceeds intracardiac pressure within any particular chamber.
• Right atrial collapse
  • Right atrial pressure is minimal during diastole, however, pericardial pressure is maximal in diastole. Due to this fact, the first signs of collapse could be seen during right atrial diastole.
  • A right atrial collapse that persists for > 1/3rd of the cardiac cycle is a good indicator of impending tamponade.
  • Transient right atrial collapse can also occur normally.
• Diastolic collapse of the right ventricle is a very specific indicator for cardiac tamponade.
• Diastolic left atrial collapse is a very specific indicator for cardiac tamponade.
• Left ventricle collapse is uncommon due to the thickness of the ventricular wall.
• The respiratory variation of inflow and outflow across the mitral and tricuspid valves is increased.
  • Normal respiratory variation in inflow and outflow across the mitral and tricuspid valves ranges between 20 - 25 percent.
  • Mitral valve flow > 35 percent
  • Tricuspid valve flow is 80 to 100 percent.

Pericardial Effusion and Cardiac Tamponade

In pericardial effusion, large hypoechoic regions are seen surrounding the heart with the presence of oscillatory motion of the heart.

The echocardiogram below demonstrates the swinging motion of the heart in cardiac tamponade. {{#ev:youtube|U4xQ3-VRiNg}}

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Echocardiography of the heart with loculated pericardial effusion compressing the left ventricle. {{#ev:youtube|unnmmlCyyZM}}

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Cardiac tamponade {{#ev:youtube|YWVI6rRTIzU}}

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Cardiac tamponade {{#ev:youtube|_az8_V6bHE8}}

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Left ventricular free wall rupture with cardiac tamponade {{#ev:youtube|g9TdKcFRiLo}}

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Collapse of the right ventricle in a patient with cardiac tamponade {{#ev:youtube|dwJkJr00v5c}}

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A very large pericardial effusion due to malignancy as seen on cardiac ultrasound. Closed arrow: The heart, open arrow: The effusion

2015 ESC Guidelines on the Diagnosis and Treatment of Cardiac tamponade (DO NOT EDIT)

Recommendations for the diagnosis and management of cardiac tamponade

Class I

1. In a patient with clinical suspicion of cardiac tamponade echocardiography is recommended as the first imaging technique to evaluate the size, location and the degree of hemodynamic impact on the pericardial effusion(Level of Evidence: C)