1	Cardiac Tamponade Yoram Agmon, MD Echocardiography Laboratory Department of Cardiology
2	Overview Hemodynamic spectrum Diagnosis Therapeutic approach Clinical scenarios
3	Hemodynamic Spectrum Not an “All-or-none” Phenomenon
4	Hemodynamic Spectrum Effect of Pericardiocentesis
5	Pathophysiology Pericardial Pressure Chamber compression Chamber size ¯ / collapse Limited cardiac volume ® interdependence Right heart « left heart (respiration) Atria « ventricles Pressure dissociation (respiration) Thorax / intracardiac Cardiac filling pressures
6	Chamber Compression Cavity Size ¯ Right ventricle Left ventricle Pseudo-hypertrophy
7	Chamber Compression Chamber Collapse
8	Chamber Compression RA Collapse
9	RA Collapse Timing / Duration / Respiratory Effects
10	RA Collapse
11	RV Collapse
12	RV Collapse
13	RV Collapse Hemodynamic Significance
14	RV Collapse
15	Chamber Collapse RA Wide physiological / echocardiographic spectrum By itself – not diagnostic of cardiac tamponade ! RV Advanced finding ~ Specific for cardiac tamponade
16	Localized Compression Post-surgery / trauma Variable / atypical hemodynamic expression a Specific chamber compressed Dx – imaging (>> D hemodynamics) TTE TEE, other (CT) High index of suspicion !
17	Chamber Interdependence Limited cardiac volume Right heart « left heart interdependence Respiration-dependent Atrio « ventricular interdependence Cycle-dependent
18	Ventricular Interdependence RV « LV (“Septal Bounce”)
19	Atrio-Ventricular Interdependence
20	Pressure Association / Dissociation Thorax « Intracardiac
21	Pressure Dissociation Thorax « Intracardiac
22	Respiratory D – LV Inflow
23	Respiratory D – LV Outflow Echocardiographic “Pulsus Paradoxus”
24	Elevated Central Venous Pressure Variable (pressure « “low-pressure tamponade”) Mechanisms Cardiac compression Fluid retention (CV adaptation to IPP ) Time-dependent Evaluation Physical examination Echocardiography IVC / hepatic veins size (plethora) Respiratory ICV changes
25	Elevated Central Venous Pressure
26	Diagnosis of Cardiac Tamponade Clinical Dx ? Echocardiographic Dx ?
27	Clinical Dx
28	Clinical / Echocardiographic Dx
29	Questionable Dx Questionable Dx ? Assume cardiac tamponade is present True clinical / physiological significance of pericardial fluid Frequently evident only following pericardiocentesis
30	Echo-Guided Pericardiocentesis Not Only via Subcostal Route !
31	Echo-Guided Pericardiocentesis Potential Entry Sites
32	Echo-Guided Pericardiocentesis Potential Entry Sites
33	Echocardiographic Report Amount of pericardial fluid Signs of cardiac compression Hemodynamic spectrum (¹ all-or-none) (mild-severe signs) Estimated central venous pressure Optimal site for puncture Expected ease / complexity of pericardiocentesis
34	Decision Making
35	Clinical Scenarios
36	Case #1 Typical Tamponade 60 yo – metastatic Ca of lung Progressive dyspnea (2-3 weeks) Physical exam Dyspnea ++; tachycardia; PP 20 mmHg TTE – large effusion (~ 1000 ml) Multiple signs of cardiac compression Elevated RAP (~ 15 mmHg) Technically easy approach (para-apical)
37	Case #1 – Decision Making
38	Case #2 Questionable Tamponade 60 yo – metastatic Ca of lung; “asthma” Progressive dyspnea (2-3 weeks) Physical exam Dyspnea ++; tachycardia; PP 20 mmHg TTE – moderate effusion (~ 300-400 ml) RA collapse; insp. D LV inflow / outflow Normal RAP Not so easy approach (sub-costal)
39	Case #2 – Decision Making
40	Case #3 64 yo female pt NSTE ACS Coronary angio – 3 vessel CAD PCI (multiple stents) to RCA (total occlusion) Anti-platelet drugs (+ IIb/IIIa inh.) Anti-coagulants Unsatisfactory result ® planned CABG (+1d) Routine TTE (CCU admission)
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42	- Small-moderate pericardial effusion (acute m/p) - Moderate signs of cardiac compression - Mildly elevated RA pressure (~10 mmHg)
43	Pericardial Fluid Accumulation Subacute (Chronic) vs Acute
44	Acute Tamponade Variable amount of pericardial fluid Commonly < large effusion Variable RAP High index of suspicion!
45	Case #4 “Not Only Tamponade…” 70 yo female pt Current admission – shock (acute onset) Surgical consultation (abdominal pain) CT – large pericardial effusion Emergency cardiology consultation TTE (limited exam) – moderate-large pericardial effusion (400-500 ml) with significant signs of cardiac compression
46	Case #4 (Cont.) On the way to the cath lab… Additional medical details (PMH): Hypertension (severe) Diabetes s/p CVA Recent hospitalization (-1 wk) Chest pain (resolved) Transient renal failure (ac. on chr.)
47	Case #4 (Cont.) Differential diagnosis ? Do we need any additional information prior to pericardiocentesis ?
48	Case #4 Post-Pericardiocentesis TEE
49	Tamponade & Aortic Dissection Is Pericardiocentesis Harmful ?
50	Tamponade & Aortic Dissection
51	Summary Non-invasive echocardiographic assessment of pericardial physiology Pathophysiologic spectrum Not an “all-or-none” phenomenon Role of echocardiography Beyond documentation of effusion Combined clinical + echo approach