Algorithm to select initial drainage procedure for pericardial effusion

PASP: pulmonary artery systolic pressure; GA: general anesthesia; JVP: jugular venous pressure; BP: blood pressure; ECG: electrocardiogram; RV: right ventricle; RA: right atrium; IVC: inferior vena cava.

* Clinical features that support cardiac tamponade:

• Symptoms: Chest pain, presyncope or syncope, dyspnea or tachypnea, orthopnea
• Physical exam: Hypotension, tachycardia, elevated JVP, absent lung crackles, diminished heart sounds, pericardial rub (rare), peripheral edema
• Pulsus paradoxus (decrease in systolic BP >10 mmHg on inspiration)
• ECG: Not sensitive or specific: Tachycardia, low voltage (maximum QRS amplitude <0.5 mV in the limb leads), electrical alternans, no features of acute myocardial ischemia
• Chest radiograph: Not sensitive or specific, may show enlarged cardiac silhouette, pleural effusions, clear lung parenchyma

¶ Echocardiogram findings that support cardiac tamponade:

• Pericardial effusion
• Swinging of heart in fluid
• Increased respiratory variation in mitral (>30%) or tricuspid (>60%) flow velocity
• Early diastolic collapse of RV, late diastolic collapse of RA (collapse of any chamber: sensitivity 90%; specificity 65%)
• IVC dilated less than a 50% reduction in the diameter during inspiration

Δ Non-cardiac tamponade indications for prompt fluid removal include:

• Suspected bacterial, tuberculous, or neoplastic pericarditis
• Large chronic (>3 months) idiopathic pericardial effusion
• Symptomatic moderate to large effusions not responsive to medical therapy

◊ Caution is required, as drainage of too much fluid may lead to loss of support of right ventricle and increased tricuspid regurgitation. However, in most cases the potential benefit of relieving tamponade will outweigh the risks of the procedure.

§ Patients undergoing pericardiocentesis commonly undergo subsequent surgical drainage with creation of a pericardial window to reduce the risk of pericardial fluid reaccumulation.