Approach Considerations
Cardiac tamponade is a medical emergency that requires urgent drainage of the pericardial fluid. Preferably, patients should be monitored in an intensive care unit. All patients should receive the following:
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Oxygen
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Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary, to maintain adequate intravascular volume - Sagristà-Sauleda et al noted significant increase in cardiac output after volume expansion [24] (see the Cardiac Output calculator)
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Bed rest with leg elevation - This may help increase venous return
Positive-pressure mechanical ventilation should be avoided because it may decrease venous return and aggravate signs and symptoms of tamponade.
Inpatient care
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
Consultations associated with cardiac tamponade can include the following:
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Hemodynamically stable patients - Cardiologist
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Hemodynamically unstable patients - Cardiologist, cardiothoracic surgeon
Activity
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.
Follow-up
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, with or without echocardiographic guidance, 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 pericardiocentesis performed without echocardiographic guidance. 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 for drainage of the pericardial fluid.
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 subxiphoid approach, with resection of the xiphoid. However, a left paraxiphoid approach with preservation of the xiphoid has been described. [25]
Open thoracotomy and/or pericardiotomy [5] 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.
Pericardio-peritoneal shunt
In some patients with malignant recurrent pericardial effusions, the creation of a pericardio-peritoneal shunt helps to prevent recurrent tamponade.
Pericardiectomy
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. [26]
Using a right hemithoracic approach, the investigators employed a 15-mm trocar in the fourth right intercostal space of the anterior axillary and a 10-mm trocar in the seventh right intercostal space of the median axillary line.
Utilization of a 5-mm optic allowed two instruments, for the optic and for the endoscopic forceps, to be employed simultaneously using one 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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This anteroposterior-view chest radiograph shows a massive, bottle-shaped heart and conspicuous absence of pulmonary vascular congestion. Reproduced with permission from Chest, 1996: 109:825.
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A 12-lead electrocardiogram showing sinus tachycardia with electrical alternans. Reproduced with permission from Chest, 1996; 109:825.
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Early diastolic collapse of right ventricular free wall (subcostal view).
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Early diastolic collapse of right ventricular free wall (parasternal short-axis view at aortic valve).
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Late diastolic collapse of right atrium (subcostal view).
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Dilated inferior vena cava.
