Cardiac Tamponade Treatment & Management
- Author: Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS; Chief Editor: Richard A Lange, MD, MBA more...
Cardiac tamponade is a medical emergency. Preferably, patients should be monitored in an intensive care unit. All patients should receive the following:
Bed rest with leg elevation - This may help increase venous return
Inotropic drugs (eg, dobutamine) - These can be useful because they increase cardiac output without increasing systemic vascular resistance
Positive-pressure mechanical ventilation should be avoided because it may decrease venous return and aggravate signs and symptoms of tamponade.
After pericardiocentesis, leave the intrapericardial catheter in place after securing it to the skin using sterile procedure and attaching it to a closed drainage system via a 3-way stopcock. Periodically check for reaccumulation of fluid, and drain as needed.
The catheter can be left in place for 1-2 days and can be used for pericardiocentesis. Serial fluid cell counts can be useful for helping to discover an impending bacterial catheter infection, which could be catastrophic. If the white blood cell (WBC) count rises significantly, the pericardial catheter must be removed immediately.
A Swan-Ganz catheter can be left in place for continuous monitoring of hemodynamics and to assess the effect of reaccumulation of pericardial fluid. A repeat echocardiogram and a repeat chest radiograph should be performed within 24 hours.
Consultations associated with cardiac tamponade can include the following:
Hemodynamically stable patients - Cardiologist
Hemodynamically unstable patients - Cardiologist, cardiothoracic surgeon
Initially, the patient should be on bed rest with leg elevation to increase the venous return. Once the signs and symptoms of tamponade resolve, activity can be increased as tolerated.
A follow-up echocardiogram and chest radiograph should be performed at a monthly follow-up examination to check for recurrent fluid accumulation.
Pericardiocentesis and Pericardiotomy
Removal of pericardial fluid is the definitive therapy for tamponade and can be done using the following 3 methods.
Emergency subxiphoid percutaneous drainage
This is a life-saving bedside procedure. The subxiphoid approach is extrapleural; hence, it is the safest for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder. When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%.
Echocardiographically guided pericardiocentesis
This is often carried out in the cardiac catheterization laboratory. The procedure is usually performed from the left intercostal space. First, mark the site of entry based on the area of maximal fluid accumulation closest to the transducer. Then, measure the distance from the skin to the pericardial space. The angle of the transducer should be the trajectory of the needle during the procedure. Avoid the inferior rib margin while advancing the needle to prevent neurovascular injury. Leave a 16-gauge catheter in place for continuous drainage.
Percutaneous balloon pericardiotomy
This can be performed using an approach similar to that for echo-guided pericardiocentesis, with the balloon being used to create a pericardial window.
Surgical Care in Hemodynamically Unstable Patients
For a hemodynamically unstable patient or one with recurrent tamponade, provide care as described below.
Surgical creation of a pericardial window
This involves the surgical opening of a communication between the pericardial space and the intrapleural space. This is usually a subxiphoidian approach, with resection of the xiphoid. However, a left paraxiphoidian approach with preservation of the xiphoid has been described.
Open thoracotomy and/or pericardiotomy may be required in some cases, and these should be performed by an experienced surgeon.
Recurrent cardiac tamponade or pericardial effusion
Sclerosing the pericardium
This is a therapeutic option for patients with recurrent pericardial effusion or tamponade. Through the intrapericardial catheter, corticosteroids, tetracycline, or antineoplastic drugs (eg, anthracyclines, bleomycin) can be instilled into the pericardial space.
In some patients with malignant recurrent pericardial effusions, the creation of a pericardio-peritoneal shunt helps to prevent recurrent tamponade.
Resection of the pericardium (pericardiectomy) through a median sternotomy or left thoracotomy is rarely required to prevent recurrent pericardial effusion and tamponade.
Video-Assisted Thorascopic Procedure
In a study of 15 patients with cardiac tamponade, Monaco et al found that a modified, video-assisted thoracoscopic procedure seemed to be a feasible treatment for the condition.
Using a right hemithoracic approach, the investigators employed a 15mm trocar on the fourth right intercostal space on the anterior axillary and a 10mm trocar on the seventh right intercostal space on the median axillary line.
Utilization of a 5mm optic allowed 2 instruments, for the optic and for the endoscopic forceps, to be employed simultaneously using 1 trocar; this left the second trocar available for dissecting scissors. All patients underwent a pericardial resection equal to that achievable via an anterolateral thoracotomy.
The pericardial effusion was effectively drained in all patients, with no intraoperative mortality or perioperative morbidity encountered.
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