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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5189_Библиотеки_им_академика_М_И_Перельмана.pdf
316
G. Allen and M. Antkowiak
Echocardiographic Evaluation
ofPericardial Tamponade
Detection ofPericardial Eusion
The rst step in the echocardiographic assessment of the patient with suspected cardiac tamponade is demonstrating the presence of
pericardial effusion. Echocardiography remains
the modality of choice for detecting the presence
of pericardial effusion because its now wide
availability at the bedside allows for rapid, noninvasive assessment [5]. Two-dimensional mode
(2D mode) transthoracic echocardiography
(TTE) is highly sensitive and specic for the
detection of pericardial effusion. In many
patients, TTE can detect effusions as small as
50ml. Subxiphoid view is typically used in emergent cases for rapid assessment of the presence of
pericardial effusion, but additional assessment in
parasternal and apical views allows for a more
accurate estimation of effusion size [5]. The parasternal long axis (PLAX) view should penetrate
deep enough to visualize the descending aorta.
Unlike pleural uid, which will track up to but
never over the descending aorta, free-owing
pericardial uid will typically track between the
descending aorta and the left atrium (Fig. 24.4
and Supplementary Videos 24.3 and 24.4). TTE
also allows for the characterization of pericardial
effusion, differentiating simple, free-owing
effusions from loculated or localized effusions,
or those containing thrombus or other proteinaceous material [5]. It is imperative that clinicians be aware that the presence of a pericardial
effusion, even when large in volume, does not
imply a diagnosis of cardiac tamponade in the
absence of additional supportive clinical and
echocardiographic criteria. Echocardiography
allows clinicians to visualize the pathophysiologic effects of increased pericardial pressure
and, in many cases, correlate these with clinical
exam ndings.
Cardiac Chamber Collapse
Following the identication and characterization of pericardial effusion, additional
assessments can be made utilizing 2D echocardiography that can alert clinicians to the development of cardiac tamponade physiology. As
rising pericardial pressure exceeds intracardiac
pressure, cardiac chamber collapse results. This
can typically be assessed in apical and parasternal long views at various points in the car-
Fig. 24.4 Still shot of
parasternal long axis
(PLAX) view,
penetrating beyond the
depth of the descending
aorta (Ao),
demonstrating both a
large pleural effusion
(PLE), which terminates
at the descending aorta,
and a large pericardial
effusion, which can be
seen tracking (horizontal
arrow) up and in
between the descending
aorta (Ao) and left
atrium (see
Supplementary Videos
24.3 and 24.4 for
corresponding
echocardiogram video
clip)
24 Cardiac Tamponade
317
diac cycle [6]. Chamber collapse will initially
be evident in the right atrium, typically during
early systole when intra- atrial pressure is lowest (Supplementary Videos 24.5 and 24.6). As
tamponade progresses, the right atrial collapse
will persist for longer periods of the cardiac
cycle. The use of M-mode may aid in assessing
the duration of collapse. Right atrial collapse
present for greater than 1/3 of the cardiac cycle
has been reported to have both a sensitivity and
specicity close to 100% for the diagnosis of
cardiac tamponade. [7] Left atrial collapse may
also accompany right atrial collapse in the later
stages of tamponade [8]. Right ventricular (RV)
free wall collapse will be evident in 2D mode
as tamponade progresses. In contrast to right
atrial collapse, RV collapse will be observed in
diastole, when intraventricular pressure is lowest. Initially, RV chamber size will be preserved
in inspiration owing to increased venous return
during inspiration, but as intracardial pressure
rises, collapse will occur throughout the respiratory cycle [6, 9]. As observed in atrial collapse,
the duration of RV free wall collapse correlates
with the severity of tamponade, and the use of
M-mode may aid in identifying normal RV free
wall relaxation during diastole (Fig.24.5a) or
recognizing and quantifying the duration of collapse (Supplementary Videos 24.7 and 24.8; and
Fig.24.5b) [6, 9]. Although RV stroke volume
will decrease as free wall collapse develops,
blood pressure will remain preserved throughout the respiratory cycle, and early detection of
RV free wall collapse may be an earlier indicator of tamponade than pulsus paradoxus [10].
Conversely, the absence of right-sided chamber
collapse has been demonstrated to have a 90%
negative predictive value for the exclusion of a
diagnosis of tamponade [6]. Impaired RV lling and diastolic collapse can, in fact, manifest
along a continuum, spanning from normal diastolic RV lling with a large chronic effusion
(Supplementary Videos 24.9 and 24.10), intermittent RV collapse (Supplementary Videos
24.11 and 24.12), regular diastolic RV collapse (Supplementary Videos 24.13, 24.14, and
24.15), and RV lling that appears restricted
throughout diastole (Supplementary Videos
24.16 and 24.17), only to be conrmed (in the
same patient) by post- pericardiocentesis imaging (Supplementary Videos 24.18 and 24.19).
In rare situations, chamber collapse may not be
readily observed in patients with signicantly
elevated pericardial pressures. Severe pulmonary hypertension with accompanying right
heart failure and left ventricular failure with
signicantly elevated left ventricular diastolic
pressure, and the use of positive pressure ventilation may complicate the echocardiographic
diagnosis of tamponade by blunting chamber
collapse [6].
Inferior Vena Cava Plethora
As cardiac tamponade develops, increased pericardial pressure leads to increased right-sided
intracardiac pressure, and venous return to the
right-sided cardiac chambers becomes increasingly impaired. While this manifests clinically
as jugular venous distension, impaired venous
return and increased right-sided chamber pressure can be assessed echocardiographically by
detection of inferior vena cava (IVC) plethora
[2]. The IVC can be assessed using subxiphoid
views in 2D mode. Using this view, IVC and
hepatic vein distension can be detected in
patients with cardiac tamponade. Plethora of the
IVC is dened as an IVC diameter greater than
2cm with less than a 50% reduction in diameter
during inspiration. Assessment of variation of
IVC diameter throughout the respiratory cycle
is most easily assessed utilizing M-mode [6].
While IVC plethora can be seen in a variety of
conditions and is not specic to tamponade, its
presence in the setting of pericardial effusion
and supportive clinical factors is highly suggestive of the diagnosis. Furthermore, IVC plethora
has been demonstrated to be highly sensitive
(>90%) for detecting cardiac tamponade, and its
absence is often reassuring in helping to exclude
the diagnosis [11].
318
G. Allen and M. Antkowiak
Fig. 24.5 (a) M-mode
still from PLAX view
with a slice through RV
free wall, septum, and
mitral leaets. Dotted
lines dene the
boundaries of diastole,
include mitral leaet
excursion, and
correspond with the
ECG diastole signature.
A large downward arrow
demonstrates normal RV
free wall relaxation and
RV dilation during
diastole. (b) M-mode
still from PLAX view
with a slice through RV
free wall, septum, but
missing the mitral
leaets. A large
downward arrow
corresponds with the
ECG diastole signature
and demonstrates
depression/collapse of
the RV-free wall in
mid-diastole, consistent
with tamponade
physiology
a
b
Ventricular Interdependence
andSeptal Bounce
Although not typically required to support a diagnosis of cardiac tamponade, echocardiography
can be used to demonstrate ventricular interdependence, the hallmark pathophysiology of the
condition. Utilizing parasternal long and shortaxis views in 2D echocardiography with the
assistance of M-mode, ventricular size and septal
positioning can be assessed throughout the respiratory cycle. In patients with increased pericardial pressure and tamponade physiology, these
views will demonstrate increased RV chamber diameter, septal displacement or “bounce”
towards the left ventricle, and decreased left
ventricular chamber diameter during inspiration
as compared with expiration [6].
24 Cardiac Tamponade
319
Spectral Doppler Flow Variation
While pericardial effusion and tamponade
physiology can be detected and characterized
utilizing 2D echocardiography, in the hands of
an experienced ultrasonographer, techniques
utilizing spectral (pulse wave) Doppler modes
can be applied to further support a diagnosis of
tamponade [6]. Cardiac tamponade is associated with exaggerated variations in systemic
and pulmonary venous return, resulting in
exaggerated respirophasic changes in diastolic
lling velocities and cardiac output [2]. These
variations can be assessed clinically via assessment of pulsus paradoxus and with echocardiography using pulse wave Doppler [12]. In
patients with suspected cardiac tamponade,
respiratory cycle variations in right and left
ventricular inow across the mitral and tricuspid valves are commonly assessed [6, 13].
After obtaining an apical 4-chamber view,
right and left ventricular inow can be evaluated using pulse wave Doppler while positioning probe alignment across the tricuspid and
mitral valves, respectively. The peak velocity
of the passive ventricular lling (represented
by the E wave) can then be assessed throughout
the respiratory cycle [13–15]. In healthy
patients without cardiac tamponade, tricuspid
and mitral inow will vary by less than 5%
(Figs.24.6 and 24.7, respectively). In patients
with tamponade physiology, peak tricuspid
inow will decrease by more than 40% during
expiration (Fig.24.8), while mitral inow will
decrease by more than 25% during inspiration
(Fig. 24.9) [13–15]. Spectral Doppler is less
commonly used in the evaluation of cardiac
tamponade to assess respirophasic changes in
ventricular output in patients in normal sinus
rhythm [6]. These variations are not reliable
indicators of tamponade physiology in patients
with irregular cardiac rhythms. Left ventricular
output is best assessed using an apical vechamber view with probe positioning over the
left ventricular outow tract. A decrease in
peak left ventricular output velocity of greater
than 10% during inspiration is associated with
tamponade physiology (Fig.24.10). Right ventricular outow is best assessed by positioning
a pulse wave Doppler probe across the pulmonic valve in a suprasternal or modied parasternal view. An inspiratory increase in right
ventricular outow of greater than 10% suggests cardiac tamponade [13, 15]. Alternatively,
an aortic arch view from the sternal notch can
also be used to corroborate these ndings
(Fig. 24.11). Lastly, spectral Doppler can be
applied to the assessment of hepatic vein ow
reversal utilizing subxiphoid windows to further support a diagnosis of cardiac tamponade
[6]. In the absence of tamponade, Doppler
assessment of the hepatic vein demonstrates
biphasic inow with reversal of ow during
atrial contraction (Supplementary Videos 24.20
and 24.21). In tamponade, hepatic vein ow
will be decreased and even reversed during
diastole (Fig.24.12). Hepatic vein ow can be
challenging to assess via Doppler echocardiography in many patients, but in the presence of
clear windows, the presence or absence of diastolic reversal of hepatic vein ow has been
demonstrated to have a high positive and negative predictive value in the diagnosis of cardiac
tamponade [6, 15].
320
Fig. 24.6 Atria on top
(Mayo) apical
4-chamber view with
pulse wave Doppler
indicator situated just
below the leaets of the
tricuspid valve. Cartoon
images on the left and
right represent how
standard (left) and Mayo
(right) apical
4-chambers (A4C) views
appear with respect to
the indicator. Note the
negligible variation of
RV inow velocities
with inspiration (upward
deection of chest wall
impedance) and
exhalation (downward
deection) at the bottom
of the image
Fig. 24.7 Atria on top
(Mayo) A4C view with
pulse wave Doppler
indicator situated just
below the leaets of the
mitral valve. Similar
cartoon representations
of standard and Mayo
A4C views are on the
left and right of the echo
image, respectively.
Note the negligible
variation of LV inow
velocities with
inspiration and
exhalation
G. Allen and M. Antkowiak
24 Cardiac Tamponade
Fig. 24.8 Atria on top
(Mayo) A4C view with
pulse wave Doppler
indicator situated just
below the leaets of the
tricuspid valve. Similar
cartoon representations
of standard and Mayo
A4C views are on the
left and right,
respectively. Note the
signicant variation of
RV inow velocities
with greater velocities
during augmented RV
lling on inspiration,
with depression during
exhalation
Fig. 24.9 Atria on top
(Mayo) A4C view with
pulse wave Doppler
indicator situated just
below the leaets of the
mitral valve. Similar
cartoon representations
of standard and Mayo
A4C views are on the
left and right,
respectively. Note
signicant variation of
LV inow velocities
with signicantly
limited inow velocities
during inspiration and
augmented LV lling
velocities during
exhalation
321
322
Fig. 24.10 Atria on top
(Mayo) apical
5-chamber view with
pulse wave Doppler
indicator situated within
the left ventricular
outow tract (LVOT),
just behind the aortic
valve. Note how peak
velocities and volume
time integrals (VTI)
across the LVOT are
augmented during
exhalation (exp) when
LV preload is
accentuated and
depressed during
inspiration (insp) when
RV lling is augmented
and ventricular
interdependence is
restricting LV preload
Fig. 24.11 Similar
capture of aortic ow
velocities and volume
time integrals (VTI) in
the descending aortic
arch, taken from a
sternal notch view,
demonstrating the same
respirophasic variation
in VTI with stroke
volume most augmented
during exhalation, when
ventricular
interdependence is
favoring LV preload
G. Allen and M. Antkowiak
24 Cardiac Tamponade
323
Fig. 24.12 Pulse wave Doppler measurements from the
hepatic vein, feeding into the inferior vena cava. Downward
augmented ow velocities labeled “S” and “D” demonstrate accelerated ow toward the atrium during systole
and diastole during inspiration, when intrathoracic pressure is lowest and venous return to the heart is augmented.
Note that these ow velocities are blunted during exhala-
Summary Points
• Cardiac tamponade is a life-threatening yet
treatable condition that can be rapidly fatal if
recognition and denitive management are
delayed. While ultimately a clinical diagnosis,
echocardiography plays a crucial role in establishing the presence of pericardial effusion and
additional ndings that support clinical signs of
tamponade physiology. Once a diagnosis of
cardiac tamponade is established, denitive
management with pericardiocentesis can be
safely supported with the use of several welldescribed ultrasound-guided approaches. The
use of ultrasound guidance in pericardiocentesis will be discussed elsewhere in this text.
References
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and treatment. J Am Coll Cardiol. 1983;1:240–51.
tion when venous return to the right heart is blunted. The
downward arrow represents where one might also nd
augmented reversals in diastolic ow (reux back into the
IVC and hepatic vein during more extreme conditions of
tamponade). Supplementary Videos 24.20 and 24.21 demonstrates IVC plethora on the right and reux ow back
into the IVC and the hepatic vein on the right
2. Spodick DH. Acute cardiac tamponade. N Engl J
Med. 2003;349:684–90.
3. Reddy PS, Curtiss EI, Uretsky BF. Spectrum of
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and both atria in patients with pericardial effusion
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HL.Usefulness of right ventricular diastolic collapse
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Ultrasound-Guided Pericardiocentesis
LisaRapoport andPranjalGupta
25
Learning Objectives
1. Discuss various approaches for
pericardiocentesis.
2. Review ultrasound techniques for verifying
needle placement prior to catheterization of
the pericardial space.
3. Describe the use of ultrasound to identify
post-pericardiocentesis complications.
although ultimately cardiac tamponade is a clinical diagnosis, certain echocardiographic clues can
point toward obstructive physiology.
Evaluation ofPericardial Eusion
onEchocardiogram
Transthoracic Echocardiogram
Background
Pericardiocentesis is the aspiration of pericardial
uid from the pericardial sac. In cases with
obstructive physiology, pericardiocentesis is
indicated as a potentially life-saving procedure.
Echocardiography is extremely sensitive and
specic for detecting pericardial effusions.
Applying the physiologic concept of ventricular
interdependence allows echocardiography to
assess for hemodynamic signicance. Furthermore,
L. Rapoport (*)
Emergency and Critical Care Medicine, Kaiser
Permanente Santa Clara, Santa Clara, CA, USA
Department of Emergency Medicine, Stanford
University School of Medicine,
Santa Clara, CA, USA
P. Gupta
Critical Care Fellow, Stanford University School of
Medicine, Stanford, CA, USA
e-mail: pranjalgupta@stanford.edu
Point-of-care ultrasound (POCUS) can visualize
the separation of the pericardium from the myocardium with high sensitivity with as little as
15–35mL of uid [1]. Care must be taken to differentiate a pericardial effusion from an epicardial
fat pad, of which the fat pad is usually hyperechoic, granular, and moves in synchrony with the
external cardiac border [2]. A pleural effusion can
be confused with a pericardial effusion, but the
two are differentiated via the descending thoracic
aorta on parasternal long-axis view (PLAX): A
pleural effusion will be adjacent or inferior to the
descending aorta, while a pericardial effusion will
be anterior [1]. Additionally, not all hemodynamically signicant pericardial effusions need to be
circumferential, as is seen in post-procedural effusions that cause obstructive physiology in a single
cardiac chamber. Therefore, to best characterize a
pericardial effusion, multiple different views
should be obtained, as a single view can misrepresent the volume or location. Of note, the size of
the effusion does not predict tamponade, but
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_25
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