Tamponade not effusion !!! echocardiography in cardiac tamponade and Pericardiocentesis

1. CARDIAC TAMPONADE
HARSHITHA,FIDHA,FIRAS
Bsc.CVT
MCHP , MAHE

2. PERICARDIAL FLUID
PERICARDIAL SAC
 Outer parietal pericardium
 Inner visceral pericardium
In btw pericardial fluid is present
NORMAL :15-50 mL

3. PERICARDIAL EFFUSION
PUTS PHYSICAL PRESSURE ONTO THE HEART
Symptoms:Chestpain
SOB
Malaise
Cause:
 Any process causing inflammation or injury
to pericardium
 Any process affecting lymphatic drainage
of fluid

4. CARDIAC TAMPONADE
 Increased intrapericardial pressure
reduces cardiac function
 COMPRESSION OF HEART by rapid
accumulation of fluid in pericardial sac

5. PERICARDIAL SAC WITHSTAND
 Slow,progressive,long term
effusion:upto 1500 mL
(without showing symptoms)
 Acute effusion:100-200mL blood
suddenly entering pericardium
(patient symptomatic)
NOTE:
Affects the cardiac hemodynamics by
creating equilibrium of diastolic
pressures in all 4C

6. MECHANISM

7. PHYSICAL EXAMINATION
• Tachycardia
• Pulsus paradoxus
• Becks triad
 Hypotension
 Elevated JVP
 Muffled HS
COMPLICATIONS
• HF
• Pulmonary edema
• Shock
• Death
Therefore cardiac tamponade is a
medical emergency
Treated with pericardiocentesis
CARDIAC ETIOLOGIES
• Dissection of aortic aneurysm
• End stage lung cancer
• Acute MI
• Cardiac surgery
• Pericarditis
ASYMPTOMATIC EFFUSIONS
Hypothyroidism
Uremia,
Collagen vascular diseases
(lupus,rheumatoid arthritis,scleoderma etc..)

8. ECG
ELECTRICAL ALTERNANS
SINUS TACHYCARDIA
LOW VOLTAGE

9. X RAY

10. ECHO

11. ECHO Findings:
• Pericardial effusion
• Diastolic right ventricular collapse
• Systolic right atrial collapse
• Plethoric IVC with minimal respiratory variation
• Exaggerated respiratory cycle changes in mitral and tricuspid valve
in-flow velocities as a surrogate for pulsus paradoxus

12. 1.Pericardial effusion
Heart swinging within pericardial sac
• size of the effusion does not necessarily predict pericardial
tamponade.
• More important in predicting tamponade are the rate of
rise of the effusion and the pericardial compliance

13. No diastolic collapse in a
chronic pericardial effusion
 Once the pericardium’s compliance reaches a certain threshold, even a small increase in
pericardial fluid can lead to tamponade.

14. 2.Right ventricular collapse
• The right ventricle (RV) collapses when the intrapericardial pressure
exceeds the intracardiac pressure.
• The severity of tamponade is correlated with the duration of the
chamber’s collapse
• The outflow region collapses first, followed by the basal segment
once tamponade progresses.
• diastolic collapse will less likely occur in conditions like acute or
chronic cor pulmonale, pulmonary hypertension, severe LV failure,
or other etiologies of RV hypertrophy. Positive-pressure ventilation
will exert this effect as well.

15. Distinct downward motion of the right ventricular free
wall (larger arrow) in early diastole.
As the mitral valve (MV) opens to indicate
diastole, the RV outflow tract (RVOT) anterior
wall can be seen collapsing downward.

16. PSAX
SYSTOLE DIASTOLE
Pulmonary
valve closed
RVOT collapse

17. M mode
End systole is noted by the large
downward-pointing arrow, after
which there is further collapse of
the right ventricular-free wall (small
arrow) in early diastole.
Mitral valve opening
indicates diastole

19. 3.Right atrial collapse
• The RA is at its lowest pressure during
systole, or more precisely, in late diastole
at the onset of atrial relaxation.
• Its pressure during systole is lower than
that of the RV in diastole, so systolic RA
collapse is therefore the earliest
echocardiographic sign of tamponade
• The sensitivity for tamponade is higher,
ranging from 50% in early tamponade to
100% with its progression
Systolic RA collapse in the SX
view

20. 4.Plethoric IVC
• Defined as dilation of the IVC
and hepatic veins with < 50%
reduction in diameter during
inspiration
• A plethoric IVC can be
visualized in the subcostal
plane .
• The diameter should be
measured about 2-3 cm from
the IVC-RA junction, usually
around the level of the hepatic
vein draining into the IVC

22. 5.DOPPLER Respiratory variation
• Pulsus paradox (Ventricular
interdependence)
• During inspiration, expect a
>25% decrease in MV in-flow
velocity, and a 40% increase in
TV in-flow velocity.

23. 1
2
E
I
I
E

25. Management
• Medications and IV to improve blood pressure
• Supplemental oxygen to reduce load
• Pericardiocentesis

26. Pericardiocentesis
• Pericardiocentesis, also called the pericardial tap, is an invasive
procedure performed to remove excessive pericardial fluid from the
pericardial sac.
• It is often performed in the setting of pericardial tamponade to
correct hypotension due to decreased stroke volume from extrinsic
compression of the chambers of the heart.
• Removal of 5-10ml may dramatically improve the stroke volume and
cardiac output by 25-50%.

27. Indications
• Pericarditis
• Trauma
• Cardiac Tamponade

28. Echocardiography
• The echocardiography-guided approach allows defining the position of the
effusion, the ideal entry site and needle trajectory for pericardiocentesis.
• There are two different approaches to echo guidance:
• The first is the echo-assisted method, in which the operator memorises the
optimal needle trajectory and advances the needle towards the pericardial
space without a continuous ultrasound visualisation.
• The second approach is the echo-guided method with a continuous
echocardiographic monitoring. It has also been proposed to use a needle
carrier mounted on the ultrasound transducer to advance the needle to
the pericardial space.

30. Approaches for pericardiocentesis
Place of
Puncture
Apical
Description
The needle insertion site is 1-2 cm lateral to the apex beat within the fifth, sixth or seventh
intercostal space. Advance the needle over the superior border of the rib to avoid
intercostal nerves and vessels.
Disadvantages
Risk of ventricular puncture due to the proximity to the left ventricle.
Increased risk for pneumothorax for the proximity to the left pleural space.
Advantages
The thicker left ventricle wall is more likely to self-seal after puncture.
Due to ultrasound not penetrating air, using echocardiographic guidance ensures avoidance
of the lung.
The path to reach the pericardium is shorter.

31. Place of Puncture Parasternal
Description
The needle insertion site is in the fifth left intercostal space close to the sternal margin. Advance
the needle perpendicular to the skin (at the level of the cardiac notch of the left lung).
Disadvantages
Risk of pneumothorax and puncture of the internal thoracic vessels (if the needle is inserted
more than 1 cm laterally).
Advantages
Echocardiographic guidance, also with phase array probe, provides a good visualisation of
pericardial structures.

32. Place of Puncture Subxiphoid
Description
The needle insertion site is between the xiphisternum and left costal margin. Once beneath the
cartilage cage, lower the needle to a 15-to-30-degree angle, with the abdominal wall directed
towards the left shoulder.
Disadvantages
A steeper angle may enter the peritoneal cavity, and a medial direction increases the risk of right
atrial puncture. In some cases, the left liver lobe may be transversed intentionally if an alternative
site is not available.
The path to reach the fluid is longer.
Advantages
Lower risk of pneumothorax.

33. Thank you