Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pericardial Effusion

  • Author: William J Strimel, DO, FACP; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Jan 03, 2016
 

Practice Essentials

Pericardial effusion is the presence of an abnormal amount of fluid and/or an abnormal character to fluid in the pericardial space. It can be caused by a variety of local and systemic disorders, or it may be idiopathic. See the image below.

This echocardiogram shows a large amount of perica This echocardiogram shows a large amount of pericardial effusion (identified by the white arrows).

Signs and symptoms

Signs and symptoms of pericardial effusion include the following:

  • Chest pain, pressure, discomfort
  • Light-headedness, syncope
  • Palpitations
  • Cough
  • Dyspnea
  • Hoarseness
  • Anxiety and confusion
  • Hiccoughs

See Clinical Presentation for more detail.

Diagnosis

Examination findings in patients with pericardial effusion include the following:

  • Classic Beck triad of pericardial tamponade: Hypotension, muffled heart sounds, jugular venous distention
  • Pulsus paradoxus
  • Pericardial friction rub
  • Tachycardia
  • Hepatojugular reflux
  • Tachypnea
  • Decreased breath sounds
  • Ewart sign: Dullness to percussion beneath the angle of left scapula
  • Hepatosplenomegaly
  • Weakened peripheral pulses, edema, and cyanosis

Lab tests

The following laboratory studies may be performed in patients with suspected pericardial effusion:

  • Electrolyte levels
  • CBC count with differential
  • Cardiac biomarker levels (eg, troponin, CK-MB, LDH)
  • Tests for other markers of inflammation (eg, ESR, CRP)
  • TSH level
  • Blood cultures
  • RF levels
  • Immunoglobulin complex tests
  • ANA tests
  • Complement levels
  • Pericardial fluid analysis

Early in the course of acute pericarditis, the ECG typically displays diffuse ST elevation in association with PR depression; the ST elevation is usually present in all leads except for aVR, although in postmyocardial infarction pericarditis, the changes may be more localized.

Specific tests for infectious diseases or other conditions may also be warranted, based upon clinical suspicion, such as the following:

  • Viral cultures
  • Tuberculin skin testing or QuantiFERON-TB assay
  • Rickettsial antibodies
  • HIV serology
  • Adenosine deaminase levels
  • CEA levels
  • PCR

Imaging studies

Echocardiography is the imaging modality of choice for the diagnosis of pericardial effusion and includes the following techniques:

  • 2-D echocardiography
  • M-mode echocardiography: Adjunct to 2-D echocardiography
  • Doppler echocardiography
  • Transesophageal echocardiography
  • Intracardiac echocardiography

Other radiologic studies used in the evaluation of pericardial effusion include the following:

  • Chest radiography
  • Chest CT Scanning and MRI: May be superior to echocardiography in detecting loculated pericardial effusions

Procedures

Procedures that may be used in patients with pericardial effusion include the following:

  • Diagnostic and/or therapeutic pericardiocentesis
  • Diagnostic pericardioscopy
  • Placement of a pulmonary artery catheter

See Workup for more detail.

Management

Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with an NSAID. Prednisone may be administered for severe inflammatory pericardial effusions or when NSAID treatment has failed.

Autoimmune pericardial effusions may respond to treatment with anti-inflammatory medications. In general, selection of an agent depends on the severity of the patient's symptoms and the tolerability and adverse-effect profiles of the medications.

Pharmacotherapy for pericardial effusion includes use of the following agents, depending on the etiology:

  • NSAIDs (eg, indomethacin, ibuprofen, naproxen, diclofenac, ketoprofen, aspirin)
  • Corticosteroids (eg, prednisone, methylprednisolone, prednisolone)
  • Anti-inflammatory agents (eg, colchicine)
  • Antibiotics (eg, vancomycin, ceftriaxone, ciprofloxacin, isoniazid, rifampin, pyrazinamide, ethambutol)
  • Antineoplastic therapy (eg, systemic chemotherapy, radiation)
  • Sclerosing agents (eg, tetracycline, doxycycline, cisplatin, 5-fluorouracil)

Hemodynamic support for pericardial effusion includes the following:

  • Hemodynamic monitoring with a balloon flotation pulmonary artery catheter
  • IV fluid resuscitation

Surgical treatments for pericardial effusion include the following:

  • Pericardiostomy
  • Pericardotomy
  • Thoracotomy
  • Sternotomy
  • Pericardiocentesis

See Treatment and Medication for more detail.

Next

Background

Pericardial effusion is the presence of an abnormal amount of and/or an abnormal character to fluid in the pericardial space. It can be caused by a variety of local and systemic disorders, or it may be idiopathic. (See Etiology.)

Pericardial effusions can be acute or chronic, and the time course of development has a great impact on the patient's symptoms. Treatment varies, and is directed at removal of the pericardial fluid and alleviation of the underlying cause, which usually is determined by a combination of fluid analysis and correlation with comorbid illnesses (see the image below). (See Presentation, Workup, Treatment, and Medication.)

This image is from a patient with malignant perica This image is from a patient with malignant pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette in the anteroposterior (AP) chest film.

Embryology

In the human embryo, the pericardial cavity develops from the intraembryonic celom during the fourth week. The pericardial cavity initially communicates with the pleural and peritoneal cavities, but during normal development these are separated by the eighth week.

The visceral and parietal pericardium are derived from the mesoderm, albeit from different parts of the embryo. The visceral pericardium develops from splanchnic mesoderm, as cells originating from the sinus venous spread out over the myocardium. The parietal pericardium derives from lateral mesoderm that covers and accompanies the developing pleuropericardial membrane, which will eventually separate the pleural and pericardial cavities. In healthy subjects, the pericardium covers the heart and great vessels, with the exception of only partially covering the left atrium.

Congenital absence of the pericardium can occur and can be either partial or complete. This condition is often clinically silent, but it can potentially lead to excessive cardiac motion (in the case of complete absence), causing vague chest pain or dyspnea, or, in the case of partial absence with significant defects, strangulation of heart muscle and possible death.[1]

Physiology

The pericardial space normally contains 15-50 mL of fluid, which serves as lubrication for the visceral and parietal layers of the pericardium. This fluid is thought to originate from the visceral pericardium and is essentially an ultrafiltrate of plasma. Total protein levels are generally low; however, the concentration of albumin is increased in pericardial fluid owing to its low molecular weight.

The pericardium and pericardial fluid provide important contributions to cardiac function, including the following:

  • The parietal pericardium contributes to resting diastolic pressure, and is responsible for most of this pressure in the right atrium and ventricle
  • Through their ability to evenly distribute force across the heart, the pericardial structures assist in ensuring uniform contraction of the myocardium

The normal pericardium can stretch to accommodate a small amount of fluid without a significant change in intrapericardial pressure, although once this pericardial reserve volume is surpassed, the pressure-volume curve becomes steep. With slow increases in volume, however, pericardial compliance can increase to lessen the increase in intrapericardial pressure.

Previous
Next

Pathophysiology

Clinical manifestations of pericardial effusion are highly dependent on the rate of accumulation of fluid in the pericardial sac. Rapid accumulation of pericardial fluid may cause elevated intrapericardial pressures with as little as 80 mL of fluid, while slowly progressing effusions can grow to 2 L without symptoms.

Understanding the properties of the pericardium can help to predict changes within the heart under physiologic stress.

By distributing forces across the heart, the pericardium plays a significant role in the physiologic concept of ventricular interdependence, whereby changes in pressure, volume, and function in one ventricle influence the function of the other.

The pericardium plays a pivotal role in cardiac changes during inspiration. Normally, as the right atrium and ventricle fill during inspiration, the pericardium limits the ability of the left-sided chambers to dilate. This contributes to the bowing of the atrial and ventricular septums to the left, which reduces left ventricular (LV) filling volumes and leads to a drop in cardiac output. As intrapericardial pressures rise, as occurs in the development of a pericardial effusion, this effect becomes pronounced, which can lead to a clinically significant fall in stroke volume and eventually progress to the development of pericardial tamponade.

The pericardium plays a beneficial role during hypervolemic states by limiting acute cardiac cavitary dilatation.

Previous
Next

Etiology

The cause of abnormal fluid production depends on the underlying etiology, but it is usually secondary to injury or insult to the pericardium (ie, pericarditis). Transudative fluids result from obstruction of fluid drainage, which occurs through lymphatic channels. Exudative fluids occur secondary to inflammatory, infectious, malignant, or autoimmune processes within the pericardium.

In up to 60% of cases, pericardial effusion is related to a known or suspected underlying process. Therefore, the diagnostic approach should give strong consideration to coexisting medical conditions.

Idiopathic

In many cases, the underlying cause is not identified. However, this often relates to the lack of extensive diagnostic evaluation.

Infectious

Human immunodeficiency virus (HIV) infection can lead to pericardial effusion through several mechanisms, including the following:

  • Secondary bacterial infection
  • Opportunistic infection
  • Malignancy (Kaposi sarcoma, lymphoma)
  • "Capillary leak" syndrome, which is associated with effusions in other body cavities

The most common cause of infectious pericarditis and myocarditis is viral. Common etiologic organisms include coxsackievirus A and B, and hepatitis viruses. Other forms of infectious pericarditis include the following:

  • Pyogenic - Pneumococci, streptococci, staphylococci, Neisseria, Legionella species
  • Tuberculous
  • Fungal - Histoplasmosis, coccidioidomycosis, Candida
  • Syphilitic
  • Protozoal
  • Parasitic

Neoplastic

Neoplastic disease can involve the pericardium through the following mechanisms:

  • Direct extension from mediastinal structures or the cardiac chamber
  • Retrograde extension from the lymphatic system
  • Hematologic seeding

Malignancies with the highest prevalence of pericardial effusion include lung (37% of malignant effusions) and breast (22%) malignancies, as well as leukemia/lymphoma (17%). However, patients with malignant melanoma or mesothelioma also have a high prevalence of associated pericardial effusions.

Postoperative/postprocedural

Pericardial effusions are common after cardiac surgery. In 122 consecutive patients studied serially before and after cardiac surgery, effusions were present in 103 patients; most appeared by postoperative day 2, reached their maximum size by postoperative day 10, and usually resolved without sequelae within the first postoperative month.

In a retrospective survey of more than 4,500 postoperative patients, only 48 were found to have moderate or large effusions by echocardiography; of those, 36 met diagnostic criteria for tamponade. The use of preoperative anticoagulants, valve surgery, and female sex were associated with a higher prevalence of tamponade.[2]

Early chest tube removal following cardiac surgery, around midnight on the day of surgery, may be associated with an increased risk of postoperative pleural and/or pericardial effusions requiring invasive treatment.{ref 88} This may occur even if chest tube output during the last 4 hours is below 150 mL compared with removal of the tubes next morning.

Symptoms and physical findings of significant postoperative pericardial effusions are frequently nonspecific, and echocardiographic detection and echo-guided pericardiocentesis, when necessary, are safe and effective; prolonged catheter drainage reduces the recurrence rate.[3]

Pericardial effusions in cardiac transplant patients are associated with an increased prevalence of acute rejection.[4]

Other

Less common causes of pericardial effusion include the following:

  • Uremia
  • Myxedema
  • Severe pulmonary hypertension
  • Radiation therapy
  • Acute myocardial infarction - Including the complication of free wall rupture
  • Aortic dissection - Leading to hemorrhagic effusion from leakage into the pericardial sac
  • Trauma
  • Hyperlipidemia
  • Chylopericardium
  • Familial Mediterranean fever
  • Whipple disease
  • Hypersensitivity or autoimmune related - Systemic lupus erythematosus, [5] rheumatoid arthritis, ankylosing spondylitis, rheumatic fever, scleroderma, Wegener granulomatosis
  • Drug associated - Eg, procainamide, hydralazine, isoniazid, minoxidil, phenytoin, anticoagulants, methysergide
Previous
Next

Epidemiology

Occurrence in the United States

Few large studies have characterized the epidemiology of pericardial effusion; however, the available data consistently show that pericardial effusion is more prevalent than is clinically evident. A higher incidence of it is associated with certain diseases.

Small pericardial effusions are often asymptomatic, and pericardial effusion has been found in 3.4% of subjects in general autopsy studies.

A wide variety of malignant neoplasms and hematologic malignancies can lead to pericardial effusion. Data on the prevalence varies, with some studies showing the presence of pericardial effusion as high as 21% in such patients. A large study by Bussani et al showed cardiac metastases (9.1%) and pericardial metastases (6.3%) in cases of death from all causes in individuals with an underlying carcinoma at autopsy.[6] As previously mentioned, malignancies with the highest prevalence of pericardial effusion include lung (37% of malignant effusions) and breast (22%) malignancies, as well as leukemia/lymphoma (17%).

Patients with HIV, with or without acquired immunodeficiency syndrome (AIDS), are also found to have an increased prevalence of pericardial effusion.[7] Studies have shown the prevalence of pericardial effusion in these patients to range from 5-43%, depending on the inclusion criteria, with 13% having moderate to severe effusion. The incidence of pericardial effusion in patients infected with HIV has been estimated at 11%; however, it appears that highly active antiretroviral therapy (HAART) may have reduced the incidence of HIV-associated effusions.[8]

Race- and age-related demographics

No consistent difference among races is reported in the literature. AIDS patients with pericardial effusion are more likely to be white.

Pericardial effusion is observed in all age groups. The mean occurrence is in the fourth or fifth decades, although it is earlier than this in patients with HIV.[7]

Previous
Next

Prognosis

Most patients with acute pericarditis recover without sequelae. Predictors of a worse outcome include the following:

  • Fever greater than 38°C
  • Symptoms developing over several weeks in association with immunosuppressed state
  • Traumatic pericarditis
  • Pericarditis in a patient receiving oral anticoagulants
  • A large pericardial effusion (>20 mm echo-free space or evidence of tamponade)
  • Failure to respond to nonsteroidal anti-inflammatory drugs (NSAIDs)

In a series of 300 patients with acute pericarditis, 254 (85%) did not have any of the high-risk characteristics and had no serious complications. Of these low-risk patients, 221 (87%) were managed as outpatients and the other 13% were hospitalized when they did not respond to aspirin.

Patients with symptomatic pericardial effusions from HIV/AIDS or cancer have high short-term mortality rates.

Morbidity and mortality

The morbidity and mortality of pericardial effusion is dependent on etiology and comorbid conditions. Idiopathic effusions are well tolerated in most patients. As many as 50% of patients with large, chronic effusions (effusions lasting longer than 6 months) have been found to be asymptomatic during long-term follow-up.

Pericardial effusion is the primary or contributory cause of death in 86% of cancer patients with symptomatic effusions. The survival rate for patients with HIV and symptomatic pericardial effusion is 36% at 6 months and 19% at 1 year.

Pericardial tamponade

Pericardial tamponade, which is heralded by the equalization of diastolic filling pressures, can lead to severe hemodynamic compromise and death. It is treated with expansion of intravascular volume (small amounts of crystalloids or colloids may lead to improvement, especially in hypovolemic patients) and urgent pericardial drainage. Positive-pressure ventilation should be avoided, if possible, as this decreases venous return and cardiac output. Vasopressor agents are of little clinical benefit.

Previous
 
 
Contributor Information and Disclosures
Author

William J Strimel, DO, FACP Cardiologist, Lehigh Valley Heart Specialists

William J Strimel, DO, FACP is a member of the following medical societies: American College of Cardiology, American College of Physicians, Heart Rhythm Society

Disclosure: Nothing to disclose.

Coauthor(s)

Bilal Ayub, MD Chief Cardiology Fellow, Division of Cardiology, Department of Internal Medicine, Lehigh Valley Health Network

Bilal Ayub, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Echocardiography, National Lipid Association, American Society of Nuclear Cardiology

Disclosure: Nothing to disclose.

Tahmeed Contractor, MD Fellow, Division of Cardiology, Department of Internal Medicine, Lehigh Valley Health Network

Tahmeed Contractor, MD is a member of the following medical societies: American College of Cardiology, Indian Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Ramin Assadi, MD, Senior Fellow, Department of Cardiology, Loma Linda University School of Medicine

Ramin Assadi, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Abraham G Kocheril, MD, FACC, FACP, FHRS Professor of Medicine, University of Illinois College of Medicine

Abraham G Kocheril, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, Cardiac Electrophysiology Society, Central Society for Clinical Research, Heart Failure Society of America, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting

Justin D Pearlman, MD, PhD, ME, MA Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center

Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Ali A Sovari, MD, FACP, Clinical and Research Fellow in Cardiovascular Medicine, Section of Cardiology, University of Illinois College of Medicine; Staff Physician and Hospitalist, St John Regional Medical Center, Cogent Healthcare, Inc

Ali A Sovari, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Physiological Society, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Montaudon M, Roubertie F, Bire F, Laurent F. Congenital pericardial defect: report of two cases and literature review. Surg Radiol Anat. 2007 Apr. 29(3):195-200. [Medline].

  2. Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg. 2002 Oct. 74(4):1148-53. [Medline].

  3. Tsang TS, Barnes ME, Hayes SN, et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998. Chest. 1999 Aug. 116(2):322-31. [Medline].

  4. Ciliberto GR, Anjos MC, Gronda E, Bonacina E, Danzi G, Colombo P, et al. Significance of pericardial effusion after heart transplantation. Am J Cardiol. 1995 Aug 1. 76(4):297-300. [Medline].

  5. Rosenbaum E, Krebs E, Cohen M, et al. The spectrum of clinical manifestations, outcome and treatment of pericardial tamponade in patients with systemic lupus erythematosus: a retrospective study and literature review. Lupus. 2009 Jun. 18(7):608-12. [Medline].

  6. Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol. 2007 Jan. 60(1):27-34. [Medline].

  7. Meenakshisundaram R, Sweni S, Thirumalaikolundusubramanian P. Cardiac isoform of alpha 2 macroglobulin: a marker of cardiac involvement in pediatric HIV and AIDS. Pediatr Cardiol. 2009 Nov 14. [Medline].

  8. Lind A, Reinsch N, Neuhaus K, et al. Pericardial effusion of HIV-infected patients ? Results of a prospective multicenter cohort study in the era of antiretroviral therapy. Eur J Med Res. 2011 Nov 10. 16(11):480-3. [Medline]. [Full Text].

  9. Natanzon A, Kronzon I. Pericardial and pleural effusions in congestive heart failure-anatomical, pathophysiologic, and clinical considerations. Am J Med Sci. 2009 Sep. 338(3):211-6. [Medline].

  10. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004 Feb 28. 363(9410):717-27. [Medline].

  11. Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericarditis: high versus low doses: a nonrandomized observation. Circulation. 2008 Aug 5. 118(6):667-71. [Medline].

  12. Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985 Oct 1. 56(10):623-30. [Medline].

  13. Ben-Horin S, Bank I, Shinfeld A, Kachel E, Guetta V, Livneh A. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007 May 1. 99(9):1294-7. [Medline].

  14. Refaat MM, Katz WE. Neoplastic pericardial effusion. Clin Cardiol. 2011 Oct. 34(10):593-8. [Medline].

  15. Nugue O, Millaire A, Porte H, de Groote P, Guimier P, Wurtz A, et al. Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients. Circulation. 1996 Oct 1. 94(7):1635-41. [Medline].

  16. Hoit BD. Pericardial disease and pericardial tamponade. Crit Care Med. 2007 Aug. 35(8 Suppl):S355-64. [Medline].

  17. Karia DH, Xing YQ, Kuvin JT, Nesser HJ, Pandian NG. Recent role of imaging in the diagnosis of pericardial disease. Curr Cardiol Rep. 2002 Jan. 4(1):33-40. [Medline].

  18. Horowitz MS, Schultz CS, Stinson EB. Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation. 1974. 50:239-47.

  19. Faehnrich JA, Noone RB Jr, White WD, et al. Effects of positive-pressure ventilation, pericardial effusion, and cardiac tamponade on respiratory variation in transmitral flow velocities. J Cardiothorac Vasc Anesth. 2003 Feb. 17(1):45-50. [Medline].

  20. Taguchi R, Takasu J, Itani Y, Yamamoto R, Yokoyama K, Watanabe S, et al. Pericardial fat accumulation in men as a risk factor for coronary artery disease. Atherosclerosis. 2001 Jul. 157(1):203-9. [Medline].

  21. Iacobellis G, Leonetti F. Epicardial adipose tissue and insulin resistance in obese subjects. J Clin Endocrinol Metab. 2005 Nov. 90(11):6300-2. [Medline].

  22. Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007 Nov-Dec. 27(6):1595-610. [Medline].

  23. Watanabe A, Hara Y, Hamada M, et al. A case of effusive-constructive pericarditis: an efficacy of GD-DTPA enhanced magnetic resonance imaging to detect a pericardial thickening. Magn Reson Imaging. 1998 Apr. 16(3):347-50. [Medline].

  24. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003 Aug 14. 349(7):684-90. [Medline].

  25. Bruch C, Schmermund A, Dagres N, Bartel T, Caspari G, Sack S, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol. 2001 Jul. 38(1):219-26. [Medline].

  26. [Guideline] Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004 Apr. 25(7):587-610. [Medline].

  27. Meurin P, Tabet JY, Thabut G, Cristofini P, Farrokhi T, Fischbach M, et al. Nonsteroidal anti-inflammatory drug treatment for postoperative pericardial effusion: a multicenter randomized, double-blind trial. Ann Intern Med. 2010 Feb 2. 152(3):137-43. [Medline].

  28. Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation. 2005 Sep 27. 112(13):2012-6. [Medline].

  29. Imazio M, Cecchi E, Ierna S, Trinchero R. Investigation on Colchicine for Acute Pericarditis: a multicenter randomized placebo-controlled trial evaluating the clinical benefits of colchicine as adjunct to conventional therapy in the treatment and prevention of pericarditis; study design amd rationale. J Cardiovasc Med (Hagerstown). 2007 Aug. 8(8):613-7. [Medline].

  30. Maisch B, Ristic AD, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J. 2002 Oct. 23(19):1503-8. [Medline].

  31. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002 May. 77(5):429-36. [Medline].

  32. Klein SV, Afridi H, Agarwal D, Coughlin BF, Schielke LH. CT directed diagnostic and therapeutic pericardiocentesis: 8-year experience at a single institution. Emerg Radiol. 2005 Nov. 11(6):353-63. [Medline].

  33. Eichler K, Zangos S, Thalhammer A, et al. CT-guided pericardiocenteses: clinical profile, practice patterns and clinical outcome. Eur J Radiol. 2010 Jul. 75(1):28-31. [Medline].

  34. Palmer SL, Kelly PD, Schenkel FA, Barr ML. CT-guided tube pericardiostomy: a safe and effective technique in the management of postsurgical pericardial effusion. Am J Roentgenol. OCT 2009. 193:W314-20. [Medline].

  35. Motas C, Motas N, Rus O, Horvat T. Left paraxiphoidian approach for drainage of pericardial effusions. Interact Cardiovasc Thorac Surg. 2010 Jan. 10(1):4-5. [Medline]. [Full Text].

  36. Palma JH, Gaia DF, Guilhen JC, et al. Video-thoracoscopic pericardial drainage in the treatment of pericardial effusions. Rev Bras Cir Cardiovasc. 2009 Mar. 24(1):44-9. [Medline]. [Full Text].

  37. Allen KB, Faber LP, Warren WH. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg. 1999 Feb. 67(2):437-40. [Medline].

  38. Artom G, Koren-Morag N, Spodick DH, Brucato A, Guindo J, Bayes-de-Luna A, et al. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multi-centre all-case analysis. Eur Heart J. 2005 Apr. 26(7):723-7. [Medline].

  39. Barbaro G. Cardiovascular manifestations of HIV infection. Circulation. 2002 Sep 10. 106(11):1420-5. [Medline].

  40. Moore KL, Persaud TVN. Before We Are Born: Essentials of Embryology and Birth Defects. 4th ed. 1993.

  41. Bonnefoy E, Godon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000 May. 21(10):832-6. [Medline].

  42. Braunwald E. Cardiology: how did we get here, where are we today and where are we going?. Can J Cardiol. 2005 Oct. 21(12):1015-7. [Medline].

  43. Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia: WB Saunders Company; 1997. 1478-96.

  44. Cheitlin MD, Alpert JS, Armstrong WF. ACC/AHA Guidelines for the Clinical Application of Echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Developed in coll. Circulation. 1997 Mar 18. 95(6):1686-744. [Medline].

  45. Chen Y, Brennessel D, Walters J. Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature. Am Heart J. 1999 Mar. 137(3):516-21. [Medline].

  46. Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modalities, and management. Compr Ther. 1995 Jul. 21(7):378-85. [Medline].

  47. Eisenberg MJ, de Romeral LM, Heidenreich PA. The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG. A technology assessment. Chest. 1996 Aug. 110(2):318-24. [Medline].

  48. Fagan SM, Chan KL. Pericardiocentesis: blind no more! [editorial; comment]. Chest. 1999 Aug. 116(2):275-6. [Medline].

  49. Feigenbaum, H. Echocardiography. 5th ed. Philadelphia: Lea & Febiger; 1994: 556-74.

  50. Flores RM, Jaklitsch MT, DeCamp MM Jr. Video-assisted thoracic surgery pericardial resection for effusive disease. Chest Surg Clin N Am. 1998 Nov. 8(4):835-51. [Medline].

  51. Guberman BA, Fowler NO, Engel PJ. Cardiac tamponade in medical patients. Circulation. 1981 Sep. 64(3):633-40. [Medline].

  52. Heidenreich PA, Eisenberg MJ, Kee LL. Pericardial effusion in AIDS. Incidence and survival. Circulation. 1995 Dec 1. 92(11):3229-34. [Medline].

  53. Ilan Y, Oren R, Ben-Chetrit E. Etiology, treatment, and prognosis of large pericardial effusions. A study of 34 patients. Chest. 1991 Oct. 100(4):985-7. [Medline].

  54. Imazio M, Demichelis B, Cecchi E, et al. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003 Dec 17. 42(12):2144-8. [Medline].

  55. Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004 Mar 17. 43(6):1042-6. [Medline].

  56. Kasper D, Branunwald E, Fauci A, et al. Harrison's Principles of Internal Medicine. 16th ed. McGraw-Hill Professional; 2005. 1414-1420.

  57. Kimberly RP. Treatment. Corticosteroids and anti-inflammatory drugs. Rheum Dis Clin North Am. 1988 Apr. 14(1):203-21. [Medline].

  58. Kocheril AG, Luttmann C, Sadaniantz A. Pneumococcal pericarditis successfully treated with catheter drainage and intravenous antibiotics. Cathet Cardiovasc Diagn. 1991 Dec. 24(4):286-7. [Medline].

  59. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004 Nov 18. 351(21):2195-202. [Medline].

  60. Little WC, Freeman GL. Pericardial disease. Circulation. 2006 Mar 28. 113(12):1622-32. [Medline].

  61. Maher EA, Shepherd FA, Todd TJ. Pericardial sclerosis as the primary management of malignant pericardial effusion and cardiac tamponade. J Thorac Cardiovasc Surg. 1996 Sep. 112(3):637-43. [Medline].

  62. Maisch B. Pericardial diseases, with a focus on etiology, pathogenesis, pathophysiology, new diagnostic imaging methods, and treatment. Curr Opin Cardiol. 1994 May. 9(3):379-88. [Medline].

  63. Maisch B, Ristic AD, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J. 2002 Oct. 23(19):1503-8. [Medline].

  64. Mangan CM. Malignant pericardial effusions: pathophysiology and clinical correlates. Oncol Nurs Forum. 1992 Sep. 19(8):1215-21. [Medline].

  65. Maruyama R, Yokoyama H, Seto T, Nagashima S, Kashiwabara K, Araki J, et al. Catheter drainage followed by the instillation of bleomycin to manage malignant pericardial effusion in non-small cell lung cancer: a multi-institutional phase II trial. J Thorac Oncol. 2007 Jan. 2(1):65-8. [Medline].

  66. Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation. 2005 Dec 6. 112(23):3608-16. [Medline].

  67. Mercé J, Sagristà-Sauleda J, Permanyer-Miralda G, Evangelista A, Soler-Soler J. Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: implications for the diagnosis of cardiac tamponade. Am Heart J. 1999 Oct. 138(4 Pt 1):759-64. [Medline].

  68. Meyers DG, Bagin RG, Levene JF. Electrocardiographic changes in pericardial effusion. Chest. 1993 Nov. 104(5):1422-6. [Medline].

  69. Meyers DG, Meyers RE, Prendergast TW. The usefulness of diagnostic tests on pericardial fluid. Chest. 1997 May. 111(5):1213-21. [Medline].

  70. Naqvi TZ, Huynh HK. A new window of opportunity in echocardiography. J Am Soc Echocardiogr. 2006 May. 19(5):569-77. [Medline].

  71. Nugue O, Millaire A, Porte H. Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients. Circulation. 1996 Oct 1. 94(7):1635-41. [Medline].

  72. Pankuweit S, Ristic AD, Seferovic PM, Maisch B. Bacterial pericarditis: diagnosis and management. Am J Cardiovasc Drugs. 2005. 5(2):103-12. [Medline].

  73. Press OW, Livingston R. Management of malignant pericardial effusion and tamponade. JAMA. 1987 Feb 27. 257(8):1088-92. [Medline].

  74. Retter AS. Pericardial disease in the oncology patient. Heart Dis. 2002 Nov-Dec. 4(6):387-91. [Medline].

  75. Ruiz-García J, Jiménez-Valero S, Moreno R, Galeote G, Sánchez-Recalde A, Calvo L, et al. Percutaneous Balloon Pericardiotomy as the Initial and Definitive Treatment for Malignant Pericardial Effusion. Rev Esp Cardiol. 2012 Dec 21. [Medline].

  76. Sagrista-Sauleda J, Angel J, Permanyer-Miralda G. Long-term follow-up of idiopathic chronic pericardial effusion. N Engl J Med. 1999 Dec 30. 341(27):2054-9. [Medline].

  77. Shabetai R. Recurrent pericarditis: recent advances and remaining questions. Circulation. 2005 Sep 27. 112(13):1921-3. [Medline].

  78. Silva-Cardoso J, Moura B, Martins L. Pericardial involvement in human immunodeficiency virus infection. Chest. 1999 Feb. 115(2):418-22. [Medline].

  79. Spodick DH. Acute pericarditis: current concepts and practice. JAMA. 2003 Mar 5. 289(9):1150-3. [Medline].

  80. Spodick DH. Intrapericardial treatment of persistent autoreactive pericarditis/myopericarditis and pericardial effusion. Eur Heart J. 2002 Oct. 23(19):1481-2. [Medline].

  81. Spodick DH. The technique of pericardiocentesis. When to perform it and how to minimize complications. J Crit Illn. 1995 Nov. 10(11):807-12. [Medline].

  82. Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion. JAMA. 1994 Jul 6. 272(1):59-64. [Medline].

  83. Weisse AB, Desai RR, Rajihah G. Contrast echocardiography as an adjunct in hemorrhagic or complicated pericardiocentesis. Am Heart J. 1996 Apr. 131(4):822-5. [Medline].

  84. Weitzman LB, Tinker WP, Kronzon I, Cohen ML, Glassman E, Spencer FC. The incidence and natural history of pericardial effusion after cardiac surgery--an echocardiographic study. Circulation. 1984 Mar. 69(3):506-11. [Medline].

  85. Zhang P, Liegeois NJ, Wong C, et al. Altered cell differentiation and proliferation in mice lacking p57KIP2 indicates a role in Beckwith-Wiedemann syndrome. Nature. 1997 May 8. 387(6629):151-8. [Medline].

  86. Fenstad ER, Le RJ, Sinak LJ, et al. Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage. Chest. 2013 Nov. 144 (5):1530-8. [Medline].

  87. Celik S, Lestuzzi C, Cervesato E, et al. Systemic chemotherapy in combination with pericardial window has better outcomes in malignant pericardial effusions. J Thorac Cardiovasc Surg. 2014 Nov. 148 (5):2288-93. [Medline].

  88. Andreasen JJ, Sorensen GV, Abrahamsen ER, et al. Early chest tube removal following cardiac surgery is associated with pleural and/or pericardial effusions requiring invasive treatment. Eur J Cardiothorac Surg. 2016 Jan. 49 (1):288-92. [Medline].

  89. Izadi Amoli A, Bozorgi A, HajHossein et al. Efficacy of colchicine versus placebo for the treatment of pericardial effusion after open-heart surgery: A randomized, placebo-controlled trial. Am Heart J. 2015 Dec. 170 (6):1195-201. [Medline].

 
Previous
Next
 
This image is from a patient with malignant pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette in the anteroposterior (AP) chest film.
Echocardiogram (parasternal, long axis) of a patient with a moderate pericardial effusion.
This image is from a patient with malignant pericardial effusion. The effusion is seen as an echo-free region to the right of the left ventricle (LV).
This electrocardiogram (ECG) is from a patient with malignant pericardial effusion. The ECG shows diffuse low voltage, with a suggestion of electrical alternans in the precordial leads.
Subcostal view of an echocardiogram that shows a moderate to large amount of pericardial effusion.
This echocardiogram shows a large amount of pericardial effusion (identified by the white arrows).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.