Pericardial Effusion

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CHAPTER 68 Pericardial Effusion

Lynn S. Broderick

Pericardial effusion can occur from various causes, including infection, trauma, and systemic disease. Infectious causes of pericardial effusion are described in more detail in Chapter 69. This chapter focuses on pericardial effusion secondary to systemic disease.

DEFINITION

Pericardial effusion refers to the abnormal accumulation of fluid within the pericardial space. The pericardial fluid may be a transudate, may be an exudate, or may be hemorrhagic.

PREVALENCE AND EPIDEMIOLOGY

The prevalence of pericardial effusion depends on the underlying cause. Pericardial effusion detectable by echocardiography may be present in 50% of patients with rheumatoid arthritis. Pericardial effusion is also common in patients with systemic lupus erythematosus and scleroderma.

ETIOLOGY AND PATHOPHYSIOLOGY

Pericardial effusion is an abnormal accumulation of fluid within the pericardial space. In the absence of acute inflammation, clinical symptoms depend on the size of the effusion, the rate of accumulation, and the ability of the pericardium to expand. Cardiac tamponade occurs when the intrapericardial pressure is high enough to impede cardiac filling. The pericardial fluid may be a transudate, an exudate, or hemorrhagic. Pericardial effusion is common in some diseases, such as chronic renal disease and heart failure. Pericardial effusion can occur in any collagen vascular disease, but is particularly common in patients with lupus erythematosus and rheumatoid arthritis (Fig. 68-1).

image

image FIGURE 68-1 A 19-year-old man with systemic lupus erythematosus presented with increasingly severe left-sided chest pain, which worsened on inspiration and with movement. CT scan with intravenous contrast medium was performed to evaluate for possible pulmonary embolism. A, Bright blood axial MR image shows a large pericardial effusion (E) and a left pleural effusion (asterisk) causing passive atelectasis of the left lower lobe (L). B-D, Contrast-enhanced axial CT images at the level of the pulmonary artery (P) (B) and at the level of the aortic valve (A) (C), and a coronal reconstructed image (D) show a large pericardial effusion (E). Echocardiography (not shown) showed minimal collapse of the right ventricle during diastole. Pericardiocentesis was performed, and the patient’s symptoms resolved. LV, left ventricle.

Pericardial effusion can occur in patients with acute myocardial infarction, particularly if the infarction is large in size. It can also occur in a delayed manner after myocardial infarction or surgery (Dressler syndrome). Metastatic disease involving the pericardium results in pericardial effusion, often without detectable pericardial nodules or thickening. Pericardial disease is frequent in patients with rheumatoid arthritis, particularly in patients with active disease. Patients are typically asymptomatic, however. Rheumatoid pericardial disease may manifest as serous or serosanguineous fluid. Pericardial fluid can be present in patients with rheumatic fever, although this is an uncommon entity in the United States. In patients with pericardial effusion secondary to rheumatic fever, there is usually a classic presentation of acute pericarditis that occurs 1 week or so after the initial onset of fever.

MANIFESTATIONS OF DISEASE

Clinical Presentation

Pericardial effusion in the absence of acute pericarditis may be clinically silent, unless tamponade physiology is present. The clinical symptoms of cardiac tamponade are related to the resulting decrease in cardiac output and include hypotension and tachycardia. Jugular venous distention is present on physical examination. A decrease in systemic blood pressure by more than 10 mm Hg during inspiration is diagnostic of pulsus paradoxus. Pulsus paradoxus was originally described as the disappearance of the radial pulse during inspiration. Pulsus paradoxus is actually an exaggeration of the normal decrease in systemic blood pressure during inspiration.1

Imaging Indications and Algorithm

Asymptomatic pericardial effusion may be discovered incidentally. When pericardial effusion is suspected, echocardiography is the imaging modality of choice to document the effusion and to determine if there is evidence of tamponade.

Imaging Techniques and Findings

Radiography

Chest radiographs may show interval enlargement of the cardiac silhouette. Pericardial effusion should be suspected when cardiac enlargement occurs over a short period of time (Fig. 68-2). The classic “water flask” appearance of the cardiac silhouette in pericardial effusion can also be seen in patients with dilated cardiomyopathy. In patients with dilated cardiomyopathy, the hilar structures are displaced laterally as the heart enlarges. In patients with large pericardial effusion, the hila may become obscured because the pericardial reflections extend to cover the proximal portions of the great vessels.2 If there is sufficient subepicardial fat, and the fat is oriented such that it is visible on radiographs, widening of the pericardial line, indicative of pericardial effusion, can be detected on chest radiograph—the epicardial fat pad sign (see Fig. 68-2).3,4

image

image FIGURE 68-2 A 42-year-old man with acquired immunodeficiency syndrome (AIDS) who had been treated for cryptococcal infection in the past presented with fatigue. A, Baseline chest radiograph from June shows a normal cardiac silhouette. B, Posteroanterior chest radiograph obtained in October shows interval cardiac enlargement. C, Lateral chest radiograph obtained in October shows posterior displacement of the subepicardial fat (arrowheads), consistent with pericardial effusion. Pericardial effusion was confirmed by echocardiography. Cryptococcus was cultured from the pericardiocentesis sample.

Ultrasonography

On echocardiography, uncomplicated pericardial fluid is hypoechoic and is found diffusely throughout the pericardial space. The size of the effusion is quantified as small when the space between the visceral and parietal pericardium measures less than 5 mm, moderate when the space measures between 5 mm and 2 cm, and large when the space measures more than 2 cm.5 Loculated fluid and intrapericardial stranding may be present. Echocardiographic findings of pericardial tamponade in the presence of a pericardial effusion include collapse of the right atrium during systole lasting more than a third of the systolic interval, collapse of the right ventricular free wall during diastole, and abnormal septal motion toward the left ventricle.

Computed Tomography

CT may be requested to evaluate further pericardial effusion identified on echocardiography if there is suspicion for loculation or associated pericardial thickening. Pericardial effusion is more frequently an incidental finding on CT examinations obtained for evaluation of other disease entities. When pericardial fluid is identified in patients with neoplasm, the pericardium should be carefully inspected to determine if there is nodular thickening that would indicate metastatic disease as the cause of the effusion. In patients with recent cardiac surgery or instrumentation, the density of the fluid should be evaluated to assess for possible hemopericardium. ECG gated sequences can be used to detect abnormal wall and septal motion indicative of pericardial tamponade. When ECG gating has not been used, compression of the cardiac chambers may be an indication of elevated intrapericardial pressure.

Magnetic Resonance Imaging

ECG gated MRI sequences can be used to detect abnormal wall and septal motion indicative of pericardial tamponade. MRI is better able to distinguish small pericardial effusion from pericardial thickening compared with CT. Pericardial effusion may be found incidentally on MRI.

DIFFERENTIAL DIAGNOSIS

Clinical Presentation

Pericardial effusion may be clinically silent. In the setting of cardiac tamponade, other causes of hypotension, shock, and elevated jugular venous distention, such as heart failure, pulmonary embolism, and myocardial infarction of the right ventricle, should also be considered.6

Imaging Findings

If the amount of pericardial fluid is very small, it may be difficult to distinguish pericardial effusion from pericardial thickening on CT scans.

TREATMENT OPTIONS

Medical

Treatment of patients with pericardial effusion is primarily directed at the underlying cause because the effusion is a manifestation of the systemic disease.

Surgical/Interventional

Emergent pericardiotomy is indicated in patients with evidence of pericardial tamponade. Pericardiotomy or pericardiectomy may be indicated in patients with metastatic pericardial disease. Surgical intervention may also be required for patients with unexpected postoperative hemopericardium.

INFORMATION FOR THE REFERRING PHYSICIAN

The imaging report should include an indication of the size of the pericardial effusion; whether there is pericardial thickening, nodularity, or loculation; and any finding associated with pericardial tamponade, if present.

KEY POINTS

image Congestive heart failure is the most common cause of small to moderate-sized pericardial effusion.
image Enlarging cardiac silhouette over a short time or in the postoperative setting should raise suspicion of the presence of pericardial fluid.

SUGGESTED READING

Spodick DH. Pericarditis in systemic diseases. Cardiol Clin. 1990;8:709-716.

REFERENCES

1 Spodick DH. Pulsus paradoxus. In: Spodick DH, editor. The Pericardium. New York: Marcel Dekker; 1997:191-199.

2 Baron MG. Pericardial effusion. Circulation. 1971;44:294-299.

3 Lane EJ, Carsky EW. Epicardial fat: lateral plain film analysis in normals and in pericardial effusion. Radiology. 1968;91:1-5.

4 Carsky EW, Mauceri RA, Azimi F. The epicardial fat pad sign. Radiology. 1980;137:303-308.

5 Otto CM. Pericardial disease: two-dimensional echocardiographic and Doppler findings. In: Otto CM, editor. Textbook of Clinical Echocardiography. Philadelphia: Saunders; 2000:213-228.

6 LeWinter MM, Kabbani S. Pericardial diseases. In: Zipes DP, Libby P, Bonow RO, et al, editors. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia: Saunders; 2005:1757-1780.

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