What is the treatment for cardiac tamponade (pericardial effusion)?

From the Guidelines

Cardiac tamponade requires immediate treatment through pericardiocentesis, which involves inserting a needle into the pericardial space to drain the accumulated fluid compressing the heart, as recommended by the European Society of Cardiology 1. This procedure should be performed urgently, ideally with ultrasound guidance, using an 18-gauge needle inserted just below the xiphoid process and directed toward the left shoulder. Once the needle enters the pericardial space, a catheter is advanced over the needle and connected to a drainage system. In emergency situations without ultrasound availability, blind pericardiocentesis may be necessary. Before the procedure, intravenous fluids should be administered to maintain blood pressure, and oxygen supplementation provided. If the patient is unstable, vasopressors like norepinephrine (starting at 0.1-0.5 mcg/kg/min) may be needed temporarily. Following drainage, the underlying cause must be addressed, which may require anti-inflammatory medications for pericarditis (such as colchicine 0.5-0.6 mg twice daily), antibiotics for infectious causes, or surgical intervention for trauma or malignancy. Some key points to consider in the treatment of cardiac tamponade include:

• The use of echocardiography as the first imaging technique to evaluate the size, location, and degree of hemodynamic impact of the pericardial effusion 1.
• The recommendation for urgent pericardiocentesis or cardiac surgery to treat cardiac tamponade 1.
• The importance of addressing the underlying cause of the tamponade, which may involve systemic antineoplastic treatment, pericardiocentesis, and intrapericardial instillation of cytostatic or sclerosing agents in cases of neoplastic pericardial effusion 1. Cardiac tamponade is life-threatening because fluid accumulation in the pericardial sac increases pressure around the heart, preventing proper filling and reducing cardiac output, which leads to hypotension, tachycardia, and potentially cardiac arrest if not treated promptly. The treatment approach may vary depending on the underlying cause, with options including pericardiocentesis, surgical pericardiotomy, and intrapericardial treatment tailored to the type of tumor in cases of malignant pericardial effusion 1. Overall, the goal of treatment is to relieve the compression on the heart, address the underlying cause, and prevent recurrence, with the choice of treatment guided by the severity of the tamponade, the underlying cause, and the patient's overall clinical condition 1.

From the Research

Diagnosis and Treatment of Cardiac Tamponade

• Cardiac tamponade is a life-threatening syndrome that requires urgent treatment by pericardiocentesis, which is an interventional technique to drain pericardial fluid by a percutaneous route 2.
• The diagnosis of cardiac tamponade is a clinical diagnosis based on a suggestive history and clinical presentation with worsening dyspnoea, distended jugular veins, muffled heart sounds and pulsus paradoxus, and should be confirmed by echocardiography 2, 3.
• Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad), dyspnoea, orthopnoea, weakness, fatigue, tachycardia and oliguria 3.

Pericardiocentesis Procedure

• The standard technique for pericardiocentesis is guided by echocardiography or fluoroscopy under local anaesthesia 2.
• Pericardiocentesis should be performed by experienced operators and carries a variable risk of complications, mainly cardiac chamber puncture, arrhythmias, coronary artery puncture or haemothorax, pneumothorax, pneumopericardium and hepatic injury 2.
• Percutaneous catheter pericardiocentesis is successful in 90-100% of cases and major complications are rare 4.

Alternative Treatment Options

• In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure 3.
• Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously 3.
• Transcardiac pericardiocentesis may be an important and potentially life-saving adjunctive technique after failure of conventional pericardiocentesis in rapidly deteriorating or extremely unstable patients 5.

Pre-Procedure Measures

• Intravascular volume expansion may be beneficial in patients with cardiac tamponade, with significant improvements in haemodynamic parameters seen with as little as 250 ml of intravenous normal saline 6.
• Rapid infusion of intravenous normal saline may improve cardiac haemodynamics in a significant proportion of tamponade patients, particularly those with a higher resting heart rate, a lower SBP at presentation, a higher initial intrapericardial pressure, and a lower cardiac index 6.