A pericardial effusion refers to the accumulation of fluid in the pericardial sac surrounding the heart. The pericardial sac is composed of the thin visceral pericardium which consists of a single layer of cells adherent to the cardiac epicardium and the thicker and fibrous parietal pericardium composed of collagen and elastin which is adherent to the lungs, diaphragm, sternum, great vessels, and other mediastinal structures surrounding the heart. In a healthy individual, the pericardial sac contains between 15 mL and 50 mL of serous fluid.
The etiology of a pericardial effusion varies widely and can be divided into several categories:
Pericardial effusion is possible across all ages and populations. The predominant etiology of the effusion varies by demographic characteristics such as age, geography, and comorbidities. There is little data regarding the prevalence and incidence of pericardial effusions. In patients undergoing echocardiograms for other etiologies, the prevalence and incidence of pericardial effusion was 3 and 9% in a 6 year window in a large Italian hospital .
Pericardial effusion is due to the accumulation of fluid within the pericardial sac. This fluid may be transudative, exudative, or sanguineous and may contain infectious organisms or malignant cells. It may be due to infection, inflammation, or direct filling of the pericardial sac by blood from a defect in the myocardium (iatrogenic or traumatic injury or cardiac wall rupture) or backfilling from an ascending aortic dissection that dissects into the pericardium. Enough fluid may accumulate to cause cardiac tamponade via impaired venous blood return and decreased stroke volume. In the acute setting, only 100 ml to 150 mL of fluid is necessary to cause cardiac tamponade. In the chronic setting, the pericardial effusion may become one to two liters in size before it causes cardiac tamponade as long as the accumulation is gradual and the parietal pericardium has adequate time to stretch and accommodate the increased volume.
The clinical presentation of pericardial effusion is along a spectrum from a clinically irrelevant, incidental finding to life-threatening cardiac tamponade. This wide variation is due in large part to the variable rate of accumulation of the pericardial fluid. Acute accumulation may cause impaired cardiac filling and decreased cardiac output with as little as 100 mL of fluid while chronic, and slow accumulation may lead to significant effusions of one to two liters that produce no significant hemodynamic effects.
While both history and physical exam are critical components of the evaluation for pericardial effusion and cardiac tamponade, the standard of care now includes additional modalities such as echocardiography to confirm the diagnosis.
Treatment for pericardial effusion ranges from watchful waiting for emergent intervention and depends largely on the suspected etiology. Small effusions without evidence of hemodynamic compromise are watched with serial echocardiography if deemed necessary or determined to be small enough that no follow-up is necessary. Large effusions may receive a diagnostic pericardiocentesis to evaluate the etiology or drained to provide symptomatic relief if the patient has associated symptoms such as dyspnea, chest discomfort, pulmonary or lower extremity edema, or decreased exercise tolerance. Effusions that have accumulated rapidly enough or have grown to such a size as to cause hemodynamic instability or collapse are managed emergently at the bedside, the cardiac catheterization lab, or the operating room. Techniques for drainage include needle pericardiocentesis via subxiphoid or anterior thoracic approach with or without placement of a pericardial drain for serial evacuation, percutaneous balloon pericardiotomy, emergent thoracotomy and pericardiotomy, and surgical pericardial window via subxiphoid, anterior mini-thoracotomy, or video-assisted thoracoscopic surgery (VATS) approach. The type of intervention chosen is based on the etiology of the pericardial effusion, the clinical status of the patient at the time of the intervention, and the patient's expected clinical course.
Pericardial effusions are common. Unlike chronic effusions, acute effusions in symptomatic patients need emergent treatment. The management of pericardial effusions is by an interprofessional team that includes a cardiologist, radiologist, and a cardiac surgeon. While aspiration can help relieve symptoms and hemodynamic compromise in most patients, those occurring after a malignancy may require a pericardial window that can be done either open or via thoracoscopy. symptomatic pericardial effusions that are not properly treated carry a very high mortality.
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