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Radiología. 2010;52(5):414-424
ISSN: 0033-8338
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Radiological approach to cardiac tamponade
J.R. Fortuño Andrésa,*, A. Alguersuari Cabiscola, J. Falcó Fagesa,
E. Castañer Gonzálezb, P. Bermudez Bencerreya
a
Unitat de Radiologia Vascular i Intervencionista, Servei Diagnòstic per la Imatge, UDIAT-Centre Diagnòstic, Institut Universitari
Parc Taulí-UAB, Sabadell, Barcelona, Spain
b
Sección de Radiología Torácica, Servei Diagnòstic per la Imatge, UDIAT-Centre Diagnòstic, Institut Universitari Parc Taulí-UAB,
Sabadell, Barcelona, Spain
Received 21 January 2010; accepted 21 May 2010
KEYWORDS
Cardiac tamponade;
Pericardium;
Pericardiocentesis;
Percutaneous
drainage
Abstract
Cardiac tamponade is a life-threatening medical emergency. The radiologist’s role in the clinical
management of patients with cardiac tamponade is usually minor and nearly always limited to
the diagnostic process, and the condition is normally treated by other specialists. In this review,
we aim to provide readers with the essential information to enable a complete diagnostic and
therapeutic radiological approach. We emphasize US-guided percutaneous pericardial drainage;
when performed correctly, this technique improves patients’ symptoms immediately with
minimal discomfort and a very low rate of complications.
© 2010 SERAM. Published by Elsevier España, S.L. All rights reserved.
PALABRAS CLAVE
Taponamiento
cardiaco;
Pericardio;
Drenaje percutáneo
Abordaje radiológico del taponamiento cardiaco
Resumen
El taponamiento cardiaco es una urgencia médica que puede comprometer la vida del paciente.
Como radiólogos habitualmente tenemos una participación menor en el manejo clínico de esta
enfermedad, casi exclusivamente limitada al proceso diagnóstico, mientras que el tratamiento
lo realizan otros especialistas. Con esta revisión pretendemos dar las nociones básicas
imprescindibles para realizar un abordaje radiológico completo tanto diagnóstico como
terapéutico. Hacemos especial hincapié en la técnica de drenaje pericárdico percutáneo guiado
por ecografía, que realizada correctamente proporciona al paciente una mejora sintomática
instantánea con mínimas molestias y con muy baja tasa de complicaciones.
© 2010 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados.
*Corresponding author.
E-mail: [email protected] (J.R. Fortuño Andrés).
0033-8338/$ - see front matter © 2010 SERAM. Published by Elsevier España, S.L. All rights reserved.
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Radiological approach to cardiac tamponade
415
Cardiac tamponade is a medical emergency that may be
severe enough to threaten the life of the patient. 1
Understanding the pathophysiology of cardiac tamponade,
which is a condition that has been known for centuries, 2
brings out the necessity for a decisive therapeutic
intervention. As soon as the effects on the circulatory
system secondary to an increase of pericardial pressure
are diagnosed, urgent fluid drainage needs to be
performed in order to restore heart function
For effective diagnosis and treatment of cardiac
tamponade, we need appropriate clinical orientation,
understanding of the pathophysiology of the condition,
imaging techniques such as chest radiography and
ultrasound, and a percutaneous drainage system with
echographic guidance.
Surprisingly, although the diagnostic and therapeutic
tools are available and are profusely used in other clinical
scenarios, few radiologists are normally involved in the
management of this condition.
The aim of this update is to provide a comprehensible
approach of the pathophysiological and diagnostic
characteristics and treatment of cardiac tamponade,
with an emphasis on the pericardial drainage technique,
its outcomes and complications, and to consider other
possible alternatives. In our opinion, radiologists should
be aware not only of the radiologic signs of cardiac
tamponade, but also should be prepared for treating
this condition in an easy, rapid, safe and effective
manner.
Pressure
Introduction
Cardiac
tamponade
a
b
Limit of
pericardial strech
A
B
Volume
Figure 1 Pericardial pressure-volume curve. As the pericardial
effusion initially increases, the pericardial space accommodates
the volume of fluid without a significant increase in pericardial
pressure. When pericardial stretch limit and reserve volume
are exceeded, even small increments of volume cause
significant increase in the pericardial pressure. This fact leads
to a decrease in diastolic heart filling which results in decreased
stroke volume, and finally, reduced cardiac output. In rapid
pericardial effusion (curve a) the capacity of the pericardium
to stretch is lower, and therefore, the reserve volume is scarce
(A). Small volumes may provoke tamponade, unlike slow or
subacute effusion (curve b) where the pericardial capacity to
stretch allows a more progressive accommodation to the
expanding effusion, with a larger reserve volume (B).
Pathophysiology
Cardiac tamponade results from compression of the heart
chambers secondary to accumulation of fluid, gas, blood
or clots within the pericardial cavity. Understanding of
the pathophysiological features of cardiac tamponade is
essential to diagnosis and treatment. 3
The pericardium is a fibrous sac that contains the heart
and that is composed of two layers: the internal or
visceral, which is attached to the epicardium, and the
external or parietal that consists of collagen and elastin
fibers. Under normal conditions, the space between the
two lawyers contains15–20 ml of serous fluid and is
practically virtual in healthy people. Pericardial tissue
determines the mechanical characteristics of the
pericardium: at physiological cardiac volumes, the
pericardium exhibits a compliant behaviour. The capacity
of the pericardium to stretch increases progressively until
it becomes stiff in a relatively abrupt manner. These
characteristics determine the pressure-volume curve of
the pericardium (fig. 1). If the volume increases slowly,
the pericardium initially distends to a certain point
without elevation of pericardial pressure, and since this
pressure does not exceed cavity pressure, tamponade
does not occur. 4
As the pericardial content progressively accumulates,
the limit of the reserve volume is reached which is the
volume that will just distend the pericardium without
increasing pressure. Once this limit is exceeded, any
increment provokes pericardial pressure increments.
When this pressure exceeds intracardiac pressure,
cardiac chambers collapse compromising heart filling.
The rate of accumulation is the key to effective
compensatory mechanisms of adaptation 5 and is more
significant in establishing cardiac tamponade than a
definite amount of pericardial fluid. This explains why
patients with chronic effusion of gradual setting can
tolerate accumulations of fluid of up to 1.000–1.500 ml.
Hemodynamic compromise appears when the effusion
reduces the cardiac chambers and complicates the
ventricular filling, affecting cardiac output. Since right
hearts works at lower pressures, it is more susceptible
to increases of pericardial pressure; this is why the first
hemodynamic consequence of tamponade is impairment
of right chamber filling. Similarly, since the free
ventricular walls cannot distend and the total cardiac
work (blood volume) is constant, when the pericardial
pressure increases, the interdependence between
chambers also increases. Volume within a chamber
increases reciprocally when pressure in the adjacent
chamber decreases. This explains the effects of
respiratory phases during tamponade. Under normal
conditions, inspiration increases heart filling (mainly of
right chambers) when intrathoracic pressure decreases,
due to the gradient pressure between systemic veins
and right cardiac chambers. During tamponade,
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416
however, since the increase of intrapericardial pressure
limits the stretch capacity and filling of the right
ventricle, when inspiration fills the right heart, this can
only distend towards the left ventricle. This fact causes
the so-called paradoxical septal motion that limits the
filling of the left ventricle, which finally results in
stroke volume and cardiac output involvement. These
changes explain the clinical signs for the diagnosis of
cardiac tamponade:
1. Jugular venous distention secondary to venous pressure
increase due to impaired venous return to the right
heart.
2. Pulsus paradoxus defined as a fall in systolic blood
pressure of more than 10 mmHg during inspiration.
This is mainly due to the paradoxical septal motion
during inspiration when venous return increases and
the rest of the cardiac walls cannot distend because
of the effusion. The septal shifting towards the left
ventricle reduces notably the stroke volume,
resulting in decreased systolic pressure during
inspiration. 4
3. Reflex tachycardia as a mechanism to compensate the
decrease in stroke volume secondary to poor filling of
the left ventricle. Finally, when these mechanisms can
no longer maintain an adequate cardiac output,
hypotension and shock occur.
Although both cavities work at 15–20 mmHg pressures, in
severe tamponade, normal filling pressures can result in
tamponade, this is the so-called low-pressure tamponade. 6
This happens in hypovolemia, in the context of pre-existing
pericardial effusion, when a small increase of pericardial
pressure results in collapse of the heart chambers due to
their low pressure and, therefore, clinical signs of
tamponade appear with normal jugular venous pressure. 7
Causes
Causes of cardiac effusion are summarized in table 1. The
causes most likely to lead to tamponade are bacterial and
mycobacterial infections, 8 HIV infection and neoplastic
and hemorrhagic diseases. However, although idiopathic
pericarditis is not likely to cause cardiac tamponade,
given its high incidence, pericarditis is the most common
cause. 9
J.R. Fortuño Andrés et al
Table 1 Etiology of pericardial effusion
Idiopathic
Infectious
1. Viral: Echococcus, Coxsackie virus, Adenovirus,
Cytomegalovirus, hepatitis B virus, infectious
mononucleosis, HIV
2. Bacterial: Pneumococcus, Staphylococcus,
Streptococcus, Mycoplasma, Lyme disease,
Haemophilus influenzae, N. meningitidis
3. Micobacterium: M. tuberculosis, M. avium
intracellulare
4. Fungal: histoplasmosis, Coccidioimycosis
5. Protozoal
Immune-inflammatory
1. Connective tissue diseases: Lupus erythematosus,
rheumatoid arthritis, scleroderma
2. Arteritis: Polyarterititis nodosa, temporal arteritis
3. Myocardial infarction
• Early
• Late (Dressler syndrome)
4. Post-traumatic/Postoperative
5. Drug-associated: Procainamide, hydralazine, isoniazid,
ciclosporin, etc.
Neoplastic
1. Primary: mesothelioma, sarcomas
2. Secondary: lung, breast, lynphomas, leukemias
Trauma: penetrating wound, after cardiopulmonary
resuscitation techniques
Iatrogenic
1. Early post-surgical
2. Endovascular procedures: coronary angioplasty,
defibrillators or pacemakers, placement of central
catheters
3. Post radiation
Congenital: cysts
Other:
1. Heart failure
2. Hypothyroidism
3. Amyloidosis
4. Aortic dissection
Clinical diagnosis
Although cardiac tamponade is a clinical diagnosis, most
signs and symptoms are not very specific when analyzed
individually. 10 Reflex tachycardia secondary to low cardiac
output is always present, as are the rest of the
sympathetic mechanisms triggered to maintain a sufficient
cardiac output. Hypotension is present in clinically
significant tamponade with serious hemodynamic
involvement; however, hypertensive patients might
maintain high blood pressure. Pulsus paradoxus is a
characteristic finding but it is nonspecific since other
conditions such as massive pulmonary thromboembolism
(PT) or severe bronchopulmonary disease 11 can also
provoke it. High jugular venous pressure is also present,
except in low-pressure tamponade. Electrocardiographic
findings are relatively sensitive, although not sufficiently
specific and result from acute pericarditis (diffuse ST
segment elevation, PR segment depression) or from the
pericardial effusion (low QRS voltages and electrical
alternans). 12
Differential diagnosis must include constrictive and
restrictive pericarditis, other causes of cardiogenic
shock and right heart failure secondary to massive PT.
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Radiological approach to cardiac tamponade
Clinical diagnosis is not difficult if the patient has been
previously diagnosed with pericardial effusion, has
undergone a recent medical procedure suggesting
iatrogenesis or there is an underlying pathology with a
high incidence of effusion. 13 More difficult to diagnosis
are the cases in which the background cannot help to
predict effusion and tamponade, as in these cases it is
essential a clinical suspicion based on the clinical data
supported by complementary tests, mainly ultrasound
imaging.
Imaging diagnosis
Chest radiography is considered normal if the effusion is
not quantitatively important. Although not a very common
fi nding, widening of the epicardial band can appear on
lateral projections (the epicardial fat pad sign). In slow
pericardial effusion, radiography demonstrates an
enlarged cardiac silhouette with the characteristic
water-bottle appearance (fig. 2). In these cases,
comparing previous radiographs with the new ones can be
most helpful in establishing diagnosis. In patients with
pneumopericardium, radiographs show the heart
s u r r o u n d e d b y a i r. T h e p r e s e n c e o f p e r i c a r d i a l
calcifications suggests chronic effusion or pericardial
constriction.
M mode and 2D Doppler Ultrasound is the imaging
technique of choice for diagnosis and follow-up of
pericardial effusion because of its high sensitivity, safety
and accessibility. 14 Ultrasound can determine the degree
of hemodynamic involvement of the effusion, which
appears as a hypo-anechoic band of variable thickness
417
between the two pericardial layers (fig. 3). Although the
fluid is initially located at a posterobasal level, it is
u n c ommon f or a n on -l oc u l ate d e f f u s ion to cause
tamponade unless the fluid surrounds the heart
completely.
Signs of cardiac tamponade are abundant (table 2), but
some of them —mainly transvalvular fl ow changes— are
diffi cult to assess by radiologists without experience in
echocardiography. Collapse of the right chambers during
the filling phase —first affecting the atrium and then the
ventricle—, distention of inferior vena cava (IVC), with
50 % diameter reduction during inspiration under normal
conditions, along with moderate or severe effusion and
within an appropriate clinical scenario, are reliable
parameters for diagnosis of tamponade. Echography can
Figure 3 Transthoracic ultrasound. Severe pericardial effusion
in both sacs involving right chambers. Image shows partial
collapse of right ventricle (asterisk).
Table 2 Echocardiographic signs of cardiac tamponade
2D echographic signs
1. Pericardial effusion: > 2 cm effusion is considered
severe. (↓ Sn and Sp)
2. Reduction and collapse of cardiac chambers
• Right chambers collapse (atrial first and then
ventricular): lack of these signs excludes cardiac
tamponade. (NPV 99 %, Sn and Sp 50–60 %)
• Left atrium compression: in more severe conditions.
(↑↑ Sp)
3. ICV dilation with little variation during breathing.
(↓ Sn and Sp)
4. Paradoxical septal motion
F i g u r e 2 C h e s t r a d i o g r a p h y. S e v e r e c a r d i o m e g a l y
(water-bottle heart) in a patient with chronic idiopathic
pericardial effusion showing signs of cardiac tamponade in the
context of disseminated lung cancer.
Doppler echographic signs
1. Transvalvular flow changes
2. Paradoxical Doppler flow in suprahepatic veins
(↓ Sn and SP)
Sp: specificity; Sn: sensitivity; NPV: negative predictive value.
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418
also provide information about the etiology of the
effusion, revealing the presence of fi brin, clots, tumor
mass, air or calcium.
Effusion located posteriorly, hematomas that are not
hypo or anechoic and localized tumors can go unnoticed.
Metastatic tumor infiltration of the pericardium can
masquerade as tamponade if there is no associated
effusion. In many of these cases, thoracic computed
tomography (CT) 15 is useful in the evaluation of pericardial
disease and also providing information about the
mediastinal and thoracic structures. 16 CT can also
differentiate tamponade from constrictive pericarditis,
since pericardial thickening can mimic fluid collections.
CT imaging is particularly useful in the detection of
localized effusions or in areas inaccessible to ultrasound,
since CT can be used as guidance for drainage (fig. 4). CT
findings are distended IVC and SVC, periportal edema,
refl ux of contrast material into the azygos vein and IVC
and flattening of the left ventricular free wall during
diastole (fig. 5). However, none of these signs alone is
sufficiently specific.
J.R. Fortuño Andrés et al
Treatment
Treatment of choice for cardiac tamponade is drainage of
the pericardial content, preferably through percutaneous
access. Medical management with fluid therapy and
inotropic drugs is usually ineffective and should be used
only as adjuvant treatment. 17 Although the first pericardial
drainage was performed in 1810 by a surgeon in Napoleon’s
army, and the first pericardiocentesis was performed in
1840, the optimal approach to pericardial drainage
remains controversial. The ideal procedure should be easy
and rapid, with minimal morbidity and mortality, low rates
of recurrence and should ideally allow an etiologic
diagnosis of the effusion. 18 The two best-established
techniques are open surgical drainage and percutaneous
drainage. Potential advantages of the latter are its
promptness, accessibility and good tolerability, since
percutaneous drainage is a very little painful procedure
that can be performed without general anesthesia.
Advantages of subxiphoid pericardial drainage are direct
access to the pericardium with the possibility of obtaining
Figure 4 a) Chest radiography. Patient with lung cancer in the upper right lobe (arrow) that progressed into pericardial effusion
with cardiac tamponade in few months. b) The persistence of the symptoms after drainage is explained by the posterior location of
the collection, which prevented the placement of the catheter with echographic guidance. c) Enhanced CT of the chest shows an
organized pericardial collection. Access was done by fluoroscopy CT.
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Radiological approach to cardiac tamponade
419
Figure 5 Patient with type A aortic dissection (a and c) with hemopericardium. Please note some of the CT findings associated
with cardiac tamponade such as flattening of the free wall of the right ventricle (arrow in b) and contrast reflux into the IVC (a) due
to involvement of the right heart filling.
material in situ for etiologic diagnosis and the low rate of
recurrence. Few studies have compared both techniques;
however, two retrospective studies 18,19 confi rm the high
effectiveness of both techniques with higher rates of
recurrence in the percutaneous group. Surprisingly, one of
these studies showed that surgical biopsy does not improve
diagnostic accuracy of cytology. 18
Effectiveness of pericardiocentesis for the resolution of
the symptoms was > 95 % in the largest series. In the two
papers with the largest series that have been published
( 1 . 1 2 7 20 a n d 2 7 2 p a t i e n t s 21) a b o u t e c h o - g u i d e d
pericardiocentesis, the rate of major complications
was < 1,5 %, including heart chamber lacerations
necessitating surgery, ventricular tachycardia, intercostal
artery injury and pneumothorax. Minor complications,
those that required only clinical monitoring, were < 5 %
(fig. 6). If we compare these results with the results
reported for blind pericardiocentesis —rates of total
complications of 20 % and mortality rates as high as 6 % 22—
it can be deduced that the use of echographic guidance
improves signifi cantly the safety of the procedure. 23 In
the Tsang’s extensive series, the recurrence rate within
6 months was 27 % for patients who underwent simple
pericardiocentesis alone. This rate decreased to 14 % with
the use of a catheter for extended drainage, which has
become the mandatory approach in effusion causing
tamponade.
Although both techniques show high rates of success
for the resolution of the symptoms and surgical drainage
shows lower incidence, both guides 24 and opinion
a r t i c l e s 19,20 r e c o m m e n d p e r i c a r d i o c e n t e s i s a n d
echo-guided drainage as the initial treatment because it
is a less invasive technique and well tolerated by the
patient. Surgical drainage is recommended when the
fluid collection is not accessible by imaging techniques,
in recurrent effusion even undergoing an adequate
treatment or when the patient undergoes surgery to
solve an underlying condition, such as cardiac trauma.
Even in the increasingly common cases of tamponade
secondary to endoluminal procedures, pericardiocentesis
with echo-guided drainage remains the treatment of
choice making surgery unnecessary in most cases. 25
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420
J.R. Fortuño Andrés et al
Figure 7 a) 3D CT reconstruction of the chest depicting the
subxiphoid and intercostal access used for pericardiocentesis
and pericardial catheter placement. b) MIP CT of the chest in
sagittal projection showing subxiphoid access. c) Sagittal MIP
reconstruction of the chest in a patient with a pericardial
drainage catheter.
Figure 6 Caval-pericardial fistula as a complication of
drainage catheter placement. Antero-posterior (a) and lateral
(b) projections show opacification of IVC, right atrium and
ventricle and pulmonary artery after injection of contrast agent
via the catheter. The fistula self-resolved after removal of the
catheter.
How to perform pericardial drainage
Percutaneous pericardial drainage is better performed
under real-time echographic guidance. Use of CT-guided
drainage is reserved for fluid collections that are not
visible at echography or when echographic access is not
possible. Fluoroscopic guidance is rarely used alone, but as
a complement of echography. The patient lies supine in
moderate anti-Trendelemburg position, which facilitates
fluid to collect inferiorly in the pericardial sac and improves
comfort in patients with shortness of breath. Vital signs
monitoring (heart rate, blood pressure, oxygen saturation
and continuous electrocardiographic monitoring) is
mandatory and will provide us with full information about
the hemodynamic status of the patient during the
procedure. Even though the selection of the transducer
depends on the availability, on the radiologist’s experience
and patient’s morphotype, in our opinion, 4–5 MHz
transducers are the most recommended since they have
the perfect balance between depth, needed to visualize
the pericardial space, and image resolution, essential for
visualizing the needle trajectory. Subxiphoid approach is
the most common, but intercostal approach is also used in
some cases (fig. 7). Echography helps us to determine the
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Radiological approach to cardiac tamponade
best site for percutaneous puncture that allows reaching
the pericardial area with the largest fluid accumulation
without involving adjacent anatomical structures. Although
percutaneous drainage can be performed by direct trocar
insertion or the Seldinger micropunture technique, the
latter is the safest and most recommended technique.
Using one or the other depends on several factors, mainly
the user experience, and in those cases with severe fluid
accumulation and easy access, drainage can be performed
using a 6 F catheter. In the case of small fluid collections or
difficult access, a 20–22 G thin-wall needle is preferred. An
exchange system with a 0.01899 guidewire, a coaxial
introducer, a 0.03599 guide and a pigtail catheter are also
used. Whatever the procedure and once the site of access
is chosen, an echo-guided system is recommended in order
to follow the needle and catheter trajectory to the fluid
collection (fig. 8).
After the usual sterilization procedures and local
anesthesia administration, the percutaneous approach is
performed. In most cases, following the needle until it
reaches the sac is enough to be sure that we have reached
the pericardium, which is verified by fluid flowing out. In
neoplastic tamponade where the fluid is generally
sanguineous, it can be difficult to determine whether it is
pericardial effusion or blood coming from a potential
cardiac perforation that could go unnoticed 26 (fig. 9).
421
Close observation of the fluid and absence of blood
clotting characteristic of sero-hematic fluid will clear up
any doubts. Electrocardiographic monitoring with an
attachment to the needle can also help since direct
myocardial stimulation with the needle and the visible
Figure 9 Pericardial drainage and extraction of sanguineous
fluid in a patient with advanced breast cancer.
Figure 8 a) Equipment for direct trocar insertion (from right to left): 6 F pigtail catheter, scalpel, syringe with saline, local
anesthesia. b) Echo-guided pericardial drainage performed using a coaxial technique with thin-wall needle. c) Final insertion.
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422
Figure 10 Pericardiography. Contrast agent diffusion within
the pericardial sac.
effects on cardiac rhythm can suggest an inadvertent
cardiac puncture. Administration of a small amount of
saline mixed with air, visible on US, can also help to
confirm needle position. And last, if we combine an
echographic and fluoroscopic approach, we can inject
contrast agent and visualize its effusion within the
pericardial space (fig. 10) under pericardiography or
introduce a thin guidewire and see how it navigates. Once
we have ascertained that the needle is intrapericardial,
the fluid is aspirated and sent for biochemical,
bacteriologic and cytological analyses. The thin guidewire,
coaxial system and thick guidewire are then introduced
and the catheter placed. There is no agreement on the
ideal catheter size, but it seems to be agreed the use of
6 F and 10 F catheters for hemorrhagic or purulent
tamponade, which might plug the catheter.
Follow-up must be essentially clinic, assessing the
improvement of the symptoms and the absence of fl ow
from the catheter, using US examination only in patients
with unsatisfactory outcome and when deciding to remove
the catheter definitively. Sometimes the symptoms persist
due to very dense or encapsulated effusions that are not
accessible to drainage. In these cases the catheter may
need to be repositioned under fl uoroscopy guidance, to
be replaced for a thicker one or even introduction of a
second catheter may be needed. The catheter will be
removed based on the absence of symptoms and fluid at
echography and absence of flow of fluids through the
catheter itself.
Neoplastic cardiac tamponade
Cardiac tamponade associated with malignancies is
characterized by a high recurrence rate that can reach up
to 40 % if treated with percutaneous drainage alone. 27 The
J.R. Fortuño Andrés et al
most common neoplasias causing pericardial invasion are
breast cancer, lung cancer, lymphoma, leukemia and
melanoma, and secondary involvement is 40 times more
frequent than primary involvement. Therapeutic aim for
this kind of tamponade is the resolution of the symptoms
and prevention of recurrences. Since tumoral invasion of
the pericardium suggests bad prognosis —with an average
survival of 6.1 months 28 and < 25 % one year after
diagnosis 29 —, it is necessary to carefully assess the
therapeutic management, and it seems logical to perform
the less invasive and more comfortable procedure for the
patiente. 30 Echo-guided pericardial drainage must be
used to attain a prompt clinical improvement and, if
short-term vital prognosis is not ominous, to instil
sclerosing or cytotoxic agents such as thiotepa, 31
tetracicline, 32 doxycycline, bleomycin, 33 cisplatin, 34,35
carboplatin 36 or mitomycin C. Administration of these
drugs via the catheter causes, besides local cytostatic
effect, sclerosis of the pericardial blades as a result of
the inflammatory reaction preventing recurrence of the
effusion. Although not frequent, local pain, arrhythmia,
fistula 37 and very rarely constrictive pericarditis can
occur. However, it is an effective, safe and minimally
invasive procedure. 38,39 Although there are not prospective
studies that compare this technique with other more
invasive procedures 40 such as subxiphoid pericardial
w i n d o w, p l e u r o p e r i c a r d i a l w i n d o w o r b a l l o o n
pericardiotomy, 41-44 it seems reasonable to perform an
elective access using a less invasive technique with the
lowest morbidity. In case of failure of pericardial
drainage, and depending on the patient’s life expectancy,
more complex procedures should be performed. 45-47
Conclusions
Cardiac tamponade is a potentially life-threatening
condition. The radiologist should be aware of the clinical,
pathophysiological and radiologic signs of this entity in
order to establish a diagnosis. Our role, however, should
not be exclusively diagnostic and, in this sense, we should
be able to treat tamponade effectively and safely
performing echo-guided pericardial drainage. When
performed under the best technical conditions,
echo-guided drainage provides the patient with immediate
symptomatic relief with minimal discomfort and a very
low rate of complications.
Conflict of interest
The authors have no financial relationship to disclose.
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