Collection of fluid in the pericardial sac is known as Pericardial effusion. All cases of pericarditis can lead to pericardial effusion. The symptoms in a case of pericardial effusion depends upon the quantity and rate of accumulation of fluid. Rapid accumulation of large quantity of pericardial fluid can cause life threatening cardiac tamponade. Small to low moderate effusion, especially occurring insidiously, can be asymptomatic. Rapidly accumulating pericardial effusion of more than 200 ml. can cause haemodynamic disturbance and can produce symptoms. Slowly accumulating fluid in pericardial space may not produce symptoms even upto 1.5 to 2 litres. If the pericardium is stiff due to any pathology then smaller quantity of fluid can cause symptoms.
Etiology
All causes of pericarditis can cause pericardial effusion.
7)Radiation.
8)Malignancy
•Primary – Mesothelioma.
•Secondary – From lungs, breast, lymphoma and leukaemia.
Etiology
All causes of pericarditis can cause pericardial effusion.
7)Radiation.
8)Malignancy
•Primary – Mesothelioma.
•Secondary – From lungs, breast, lymphoma and leukaemia.
Clinical Presentation
Asymptomatic: Slowly accumulating small to moderate pericardial effusion may not cause significant elevation of intra-pericardial pressure and hence are asymptomatic. Occasionally these patients complain of fatigue or exertional breathlessness.
Symptoms and Signs
Symptoms of large pericardial effusion are:
a) Feeling of dull ache or pressure in the centre part of chest.
b) Symptoms due to compressive effect of fluid filled pericardial sac on neighbouring
structures:
Asymptomatic: Slowly accumulating small to moderate pericardial effusion may not cause significant elevation of intra-pericardial pressure and hence are asymptomatic. Occasionally these patients complain of fatigue or exertional breathlessness.
Symptoms and Signs
Symptoms of large pericardial effusion are:
a) Feeling of dull ache or pressure in the centre part of chest.
b) Symptoms due to compressive effect of fluid filled pericardial sac on neighbouring
structures:
i)Dyspnoea – due to lung compression and collapse. Bronchial heart sounds and impaired resonance on percussion below the angle of the left scapula due to lung collapse in large pericardial effusion is known as Ewart’s sign.
ii) Dysphagia – due to oesophageal compression.
iii) Irritating cough – due to bronchial irritation and compression.
iv) Hiccough – due to phrenic nerve stretch and irritation.
v) Hoarseness – rarely can occur due to compression of left recurrent laryngial nerve.
c) Symptoms due to systemic venous congestion like facial puffiness, right hypochondrial pain, abdominal fullness and nausea can occur.
d) Massive and rapid pericardial effusion can cause cardiac tamponade which can cause haemodynamic collapse – fall in cardice output, hypotension and shock.
Clinical Signs of PE
Jugular venous pressure may be elevated in moderate PE. ‘X’ descent will be more prominent than ‘Y’ descent. No abnormal impulses over the precordium. On percussion, the dull note may extend beyond the palpated apex beat and also on to the right side of sternum. Heart sounds may be feeble and pericardial rub may be heard.
Investigations
1) Electrocardiogram (ECG): Low voltage complexes is the classical ECG finding. In massive PE with tamponade, electrical alternans, (sometimes total electrical alternans) can occur.
2) X-ray Chest: Uniform cardiomegaly with a smooth outline is characteristic of PE .The superior venacava is usually engorged. Pulmonary vessels will be less prominent. In large pericardial effusion, the cardio-phrenic angle will be acute.
3) 2 Dimensional Echocardiography (2DE): Transthoracic 2DE is the investigation of choice to confirm PE and cardiac tamponade. The salient 2DE features of PE are:
a)Echo free space indicating fluid collection in the pericardial sac.
b) Decreased movement of parietal pericardium.
c)In exudative pericardial effusion like tuberculous effusion, there will be fibrous strands attached to the visceral as well as parietal pericardium.
d) If the effusion is large, the heart will be swinging in the pericardial fluid. This swinging movement is thought to be the cause of electrical alternans.
In cardiac tamponade, there will be diastolic collapse of the right ventricle This is because of intrapericardial pressure being higher than the right ventricular diastolic pressure in cardiac tamponade. Doppler can detect respiratory variation of mitral and tricuspid flow patterns in cardiac tamponade. The mitral flow increases on expiration while tricuspid flow increases on inspiration
i) Small PE (approximately 100 ml.) – mostly seen in the posterior part of the heart and fluid space is less than 1 cm. in width.
ii) Moderate PE (100 – 500 ml.) – seen all around the heart – width 1.0cm.
iii) Large PE (>500 ml.) – more than 1 cm. in width all around.
iv) Tamponade – 2DE can show swinging movement of the heart, diastolic collapse of right ventricle and respiratory flow variation across the atrioventricular valves.
Conditions Mimicking Pericardial Effusion
In 2DE few conditions can mimic PE. a) Pericardial fat—Mostly localized anteriorly. Absence of fat in the posterior part helps to
differentiate from PE.
b) Pericardial cysts can mimic loculated PE—Pericardial cysts are often found in the right cardiophrenic angle which is an important distinguishing feature.
c) Pleural effusion of the left side occasionally can cause confusion in the diagnosis of PE. In the parasternal long axis view, the PE stops at the left atrioventricular junction while pleural effusion does not have such demarcation. The pleural fluid is detected posterior to and beyond the cardiac images.
d) Computerised axial tomography and Magnetic resonance imaging—There investigations are not usually required for the diagnosis of PE.
ii) Dysphagia – due to oesophageal compression.
iii) Irritating cough – due to bronchial irritation and compression.
iv) Hiccough – due to phrenic nerve stretch and irritation.
v) Hoarseness – rarely can occur due to compression of left recurrent laryngial nerve.
c) Symptoms due to systemic venous congestion like facial puffiness, right hypochondrial pain, abdominal fullness and nausea can occur.
d) Massive and rapid pericardial effusion can cause cardiac tamponade which can cause haemodynamic collapse – fall in cardice output, hypotension and shock.
Clinical Signs of PE
Jugular venous pressure may be elevated in moderate PE. ‘X’ descent will be more prominent than ‘Y’ descent. No abnormal impulses over the precordium. On percussion, the dull note may extend beyond the palpated apex beat and also on to the right side of sternum. Heart sounds may be feeble and pericardial rub may be heard.
Investigations
1) Electrocardiogram (ECG): Low voltage complexes is the classical ECG finding. In massive PE with tamponade, electrical alternans, (sometimes total electrical alternans) can occur.
2) X-ray Chest: Uniform cardiomegaly with a smooth outline is characteristic of PE .The superior venacava is usually engorged. Pulmonary vessels will be less prominent. In large pericardial effusion, the cardio-phrenic angle will be acute.
3) 2 Dimensional Echocardiography (2DE): Transthoracic 2DE is the investigation of choice to confirm PE and cardiac tamponade. The salient 2DE features of PE are:
a)Echo free space indicating fluid collection in the pericardial sac.
b) Decreased movement of parietal pericardium.
c)In exudative pericardial effusion like tuberculous effusion, there will be fibrous strands attached to the visceral as well as parietal pericardium.
d) If the effusion is large, the heart will be swinging in the pericardial fluid. This swinging movement is thought to be the cause of electrical alternans.
In cardiac tamponade, there will be diastolic collapse of the right ventricle This is because of intrapericardial pressure being higher than the right ventricular diastolic pressure in cardiac tamponade. Doppler can detect respiratory variation of mitral and tricuspid flow patterns in cardiac tamponade. The mitral flow increases on expiration while tricuspid flow increases on inspiration
i) Small PE (approximately 100 ml.) – mostly seen in the posterior part of the heart and fluid space is less than 1 cm. in width.
ii) Moderate PE (100 – 500 ml.) – seen all around the heart – width 1.0cm.
iii) Large PE (>500 ml.) – more than 1 cm. in width all around.
iv) Tamponade – 2DE can show swinging movement of the heart, diastolic collapse of right ventricle and respiratory flow variation across the atrioventricular valves.
Conditions Mimicking Pericardial Effusion
In 2DE few conditions can mimic PE. a) Pericardial fat—Mostly localized anteriorly. Absence of fat in the posterior part helps to
differentiate from PE.
b) Pericardial cysts can mimic loculated PE—Pericardial cysts are often found in the right cardiophrenic angle which is an important distinguishing feature.
c) Pleural effusion of the left side occasionally can cause confusion in the diagnosis of PE. In the parasternal long axis view, the PE stops at the left atrioventricular junction while pleural effusion does not have such demarcation. The pleural fluid is detected posterior to and beyond the cardiac images.
d) Computerised axial tomography and Magnetic resonance imaging—There investigations are not usually required for the diagnosis of PE.
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