Compression of the superior vena cava and right atrium in cardiac tamponade

In an attempt to identify specific angiographic patterns which might be useful in distinguishing cardiac tamponade from constrictive pericarditis and other causes of right atrial hypertension, we studied the angiographic and hemodynamic characteristics of 10 patients with cardiac tamponade and compared these with similar characteristics in a comparable group of patients with either constrictive pericarditis, effusive-constrictive pericarditis, or pericardial effusion with left ventricular failure. Two predictive angiographic patterns of cardiac tamponade were noted: (1) a tapering or local lateral indentation of the intrapericardial portion of the superior vena cava, and (2) an exaggerated phasic variation in the diameter of the superior vena cava at its junction with the right atrium. Using the ratio of the minimum-to-maximum diameter of the intrapericardial superior vena cava (caval compression ratio), a stepwise logistic regression indicated that when this ratio was < 0.62, cardiac tamponade was present with a sensitivity of 80%, a specificity of 90%, and a p value < 0.001. The change in diameter of the superior vena cava between systole and diastole (phasic narrowing ratio) also was a discriminator of cardiac tamponade (p < 0.04). Two-dimensional echocardiographic studies in an additional group of 10 patients with cardiac tamponade demonstrated marked concavity of the right atrial free wall, which corresponded temporally to the angiographic abnormality, but was even more marked than that noted on the cineangiograms. These results indicate that specific changes can be appreciated on superior vena cavography and can be useful in distinguishing cardiac tamponade from other pericardial or myocardial processes associated with right atrial hypertension.     

Coagula tamponade as a complication of open heart surgery: the clinical significance and diagnostic value of transesophageal echocardiography]

The pathogenesis of low cardiac output failure (LOF) immediately after open heart surgery was studied in 41 patients with LOF and 15 control patients without LOF using echocardiography. In 35 patients, transesophageal echocardiography was also performed. Left ventricular (LV) contraction was impaired in 28 of the 41 LOF patients, in whom LV fractional shortening was less than 25%. In the other 13 LOF patients, however, it was greater than 25%. In 12 of these 13 patients, transesophageal echocardiography revealed that accumulating pericardial coagula were localized in the right side of the heart, deforming the right atrial and ventricular chambers. The LV end-diastolic diameter was significantly less than the control, indicating that the pericardial coagula disrupted the distension of the heart. Emergent coagulotomy was performed in 5 patients, and hemodynamic conditions were improved. In spite of "cardiac tamponade", the wall motion and pressure tracings of the right atrium and right ventricle in these patients differed from those in fluid tamponade. Therefore, this condition should be designated "coagula tamponade." In the other 22 patients in whom transesophageal echocardiography was employed, no coagula were observed. Since pericardial coagula can hardly be detected by transthoracic echocardiography, transesophageal echocardiography is indispensable for diagnosing pericardial coagula noted immediately after open heart surgery.     

Echocardiographic study of right ventricular wall motion in cardiac tamponade

Twenty-one patients had M-mode echocardiographic recordings during cardiac tamponade. Seventeen of 21 had posterior motion of right ventricular endocardium at 0.05 second or longer after opening of the mitral valve. Sixteen of 17 patients with a large pericardial effusion without cardiac tamponade had posterior right ventricular wall motion that ceased at 0.05 second or less after opening of the mitral valve. The finding of early diastolic posterior motion of the right ventricular wall may signify diastolic collapse of the right ventricle and aids the echocardiographic identification of cardiac tamponade.     

Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria.

When ventricular free wall rupture after acute myocardial infarction is not followed by sudden death, it is referred to as subacute ventricular rupture. The sensitivity and specificity of clinical, hemodynamic and echocardiographic diagnostic variables obtained at bedside are unknown and were therefore prospectively studied in 1,247 consecutive patients with acute myocardial infarction including 33 patients with subacute ventricular rupture diagnosed at operation (group A) and 1,214 patients without ventricular rupture (at operation, postmortem study or at discharge) (group B). The incidence of syncope, recurrent chest pain, hypotension, electromechanical dissociation, cardiac tamponade, pericardial effusion, high acoustic intrapericardial echoes, right atrial and right ventricular wall compression identified in two-dimensional echocardiograms and hemopericardium demonstrated during pericardiocentesis was higher in group A than in group B (p less than 0.00001). The presence of cardiac tamponade, pericardial effusion greater than 5 mm, high density intrapericardial echoes or right atrial or right ventricular wall compression had a high diagnostic sensitivity (greater than or equal to 70%) and specificity (greater than 90%). The number of false positive diagnoses was always high for each diagnostic variable alone (greater than 20%), but the combination of clinical (hypotension), hemodynamic (cardiac tamponade) and echocardiographic variables allowed a sensitivity of greater than or equal to 65% with a small number of false positive diagnoses (less than 10%) and provided useful information for therapeutic decisions. The diagnosis of subacute ventricular rupture requires a surgical decision. Twenty-five (76%) of the 33 patients with subacute ventricular rupture survived the surgical procedure and 16 (48.5%) are long-term survivors. Thus, subacute ventricular wall rupture is a relatively frequent complication after acute myocardial infarction that can be accurately diagnosed and successfully treated.     

Two-dimensional echocardiography in cardiac tamponade occurring after cardiac surgery

Cardiac tamponade is an important complication after cardiac surgery, yet little has been published on the echocardiographic diagnosis of this situation. The two-dimensional echocardiograms of 11 patients who required surgical relief of cardiac tamponade complicating cardiac surgery were therefore reviewed. Four had nonloculated pericardial effusions surrounding both ventricles. The other seven patients had a loculated posterior pericardial effusion; in three of these the effusion altered left ventricular posterior wall contour so that it was concave toward the effusion in the long-axis view; in two, a strikingly abnormal motion of the left ventricular posterior wall was noted, such that the width of the posterior pericardial space diminished in systole and widened abruptly in early diastole. The quantity of pericardial contents (fluid, blood or clot) evacuated surgically was smaller than usually encountered in patients with tamponade due to various "medical" conditions. Thus, unlike tamponade with other pericardial effusions, tamponade after cardiac surgery is due to a pericardial effusion that is smaller in volume, often loculated posteriorly and associated with certain unique two-dimensional echocardiographic features.     

Echocardiographic manifestations of tense pericardial effusion

Echocardiography has emerged as a sensitive study in the evaluation of pericardial effusion. The specificity of echocardiographic signs in cardiac tamponade remains undefined, however. Two such signs, early diastolic collapse of the right ventricular free wall and late diastolic collapse of the right atrial wall, were observed in two patients without clinical evidence of cardiac tamponade. Increased intrapericardial pressure was documented in each patient. Accumulation of pericardial fluid under high pressure results in a reversal of the instantaneous transmural pressure gradients in early and late diastole, causing collapse of the right ventricular and the right atrial wall, respectively; however, such a tense pericardial effusion may not cause hemodynamic embarrassment severe enough to yield clinical signs of cardiac tamponade.     

Primary Cardiac Angiosarcoma with Spontaneous Ruptures of the Right Atrium and Right Coronary Artery

Primary tumors of the heart are rarely seen. Cardiac angiosarcomas are malignant tumors that almost always have a poor prognosis. Atrium rupture and coronary artery fistula are very rare complications of primary cardiac angiosarcoma. We describe a 57‐year‐old man suffering from primary cardiac angiosarcoma with spontaneous ruptures of the right atrium and right coronary artery (RCA). Theoretically, either of these ruptures invariably results in pericardial effusion and tamponade that is rare but potentially life threatening. In this instance, however, the patient might have developed fibrous adhesions resulted from previous bloody pericardial effusion. A massive pericardial effusion was localized, which consequently prevented cardiac tamponade and hemodynamic collapse. Echocardiography revealed the tumor progression leading to detectable infiltration of solid mass into the right atrial (RA) wall, which is close to RCA. And color Doppler displayed the flow into the pericardial cavity through a disrupted RA wall and perforated RCA. Echocardiography remains the primary method of choice for evaluation of cardiac masses.     

An echocardiographic study of the interventricular septum in constrictive pericarditis.

Ten patients with constrictive pericarditis were studied echocardiographically with specific reference to inter-ventricular septal dynamics. Abnormal movement of the interventricular septum was present in 8 patients and consisted of flattening in systole and unusual posterior motion in diastole. The aetiology of this type of movement is at present unknown but may be related to restriction of normal cardiac rotational dynamics. The interventricular septum also showed diminished degree of thickening (mean 21-2%). The amplitude of excursion was generally at the upper limit of or greater than normal. Left ventricular posterior wall amplitude of excursion was normal. Flattening of left ventricular posterior wall diastolic movement was seen in 4 patients. Right ventricular end-diastolic dimension was slightly increased (1-2 to 1-7 cm/m2) in 5 of 8 patients with abnormal septal motion, but no haemodynamic evidence of diastolic volume overload was found. Posterior pericardial thickening was noted echocardiographically when posterior calcification was present. We conclude that the most common though non-specific feature of the echocardiogram in patients with constrictive pericarditis is abnormal septal motion. Flattening of left ventricular posterior wall diastolic movement, posterior pericardial thickening, and epicardial-pericardial separation may also occur.     

Tamponade in patients undergoing cardiac surgery: A clinical-echocardiographic diagnosis

The purpose of this study was to evaluate the sensitivity of current echocardiographic criteria in detecting cardiac tamponade in the patient who has undergone cardiovascular surgery. Because the current echocardiographic criteria for tamponade were initially developed and studied predominantly in patients with medical problems, relatively less information is available in patients who have undergone cardiac surgery. Of 848 consecutive patients who underwent cardiovascular surgery, patients were selected for the study if they had clinical or hemodynamic deterioration and had undergone an echocardiogram just before a successful pericardiocentesis or a surgical evacuation of pericardial blood or clot. The echocardiograms were evaluated for evidence of chamber collapse, cardiac motion, Doppler flow variations, and the location and width of pericardial separation. Fourteen patients were identified who met the inclusion criteria (clinical or hemodynamic deterioration, recent echocardiogram, and successful intervention) for cardiac tamponade. The clinical and hemodynamic findings were hypotension (13 patients), low cardiac output (7), low urine output (3), cardiopulmonary arrest (1), elevated central venous pressure (1), and shortness of breath (1). In these patients current echocardiographic criteria were seen infrequently: chamber collapse in the right atrium (6 of 14 patients) and right ventricle (4 of 14); Doppler flow variation (2 of 5); and swinging heart (0 of 15), whereas increased pericardial separation (≥10 mm) was seen in all (14 of 14) the patients. Although the sensitivity of current echocardiographic criteria for tamponade was not high (0% to 43%), the sensitivity of a combined index (unexplained clinical or hemodynamic deterioration and pericardial echo separation width ≥10 mm) was high (100%) in this group of patients who had undergone surgery. In this study standard echocardiographic criteria were found to be relatively unreliable in detecting cardiac tamponade in patients who had undergone cardiac surgery. However, the presence of ≥10 mm of pericardial separation (fluid/clot) and unexplained clinical or hemodynamic deterioration appeared to be sensitive in detecting tamponade.     

Pericardial clot after open heart surgery: its specific localization and haemodynamics

Transoesophageal echocardiography disclosed a localized pericardialblood clot compressing the right atrium (RA) and/or right ventricle(RV) in 15 patients suffering from low cardiac output failuresoon after open-heart surgery. The left ventricular end-diastolicdiameter was small (38.4 ± 10.1 mm) and its fractionalshortening normal (34.9 ± 10.2%). These findings suggestedcardiac tamponade as a result of pericardial clot. However,the ‘y’ trough of the RA pressure tracing was prominent,which is not characteristic of typical cardiac tamponade, butrather of constrictive pericarditis. This implies thereforethat the pathophysiology of cardiac tamponade by pericardialclot differs from that of tamponade by fluid. Emergency open-chestremoval of the pericardial clot was performed in seven patients,with good results. Pericardial clot produces low cardiac outputsoon after open-heart surgery, but its location is specificand its haemodynamics are not characteristic of cardiac tamponade.     

心律失常射频导管消融术中心包填塞的发生率、原因及处理策略分析

目的:分析心律失常射频导管消融术中心包填塞的发生率、原因及处理转归,探讨更有效的预防及处理措施。方法:回顾分析我院心律失常中心2016年1月至2018年12月实施射频导管消融术患者共2211例,其中15例(0.68%)发生心包填塞。分析心包填塞发生率、原因及处理转归情况。结果:2211例射频导管消融的患者中,934例室上性心动过速患者中无心包填塞;707例房性心律失常患者中有10例(1.41%)发生心包填塞,其中9例是使用非压力导管导致术中出现心包填塞;570例室性心律失常患者中有5例(0.88%)发生心包填塞。根据消融过程及开胸结果,12例可确定心脏穿孔位置,分别在右心室流出道(RVOT)游离壁3例、左心房顶部4例、右心室心尖部2例及其他位置3例。术中及时心包穿刺引流,9例患者顺利拔除心包引流管,6例需要外科开胸手术,所有患者经抢救后均恢复良好,无死亡病例发生。结论:心律失常射频导管消融术中心包填塞发生率较低,其发生率与房性心律失常消融、操作损伤及有无压力监测相关。此外与特定解剖部位(比如RVOT游离壁、左心房前顶部等)局部薄弱或导管难以稳定贴靠导致过度消融相关。心包填塞大多经心包穿刺引流后预后良好。     

Influence of acute right ventricular dysfunction on cardiac tamponade

Echocardiographic and hemodynamic data were measured in nine closed chest dogs during graded cardiac tamponade (pericardial pressure 5, 10, 15 mm Hg) before and after production of diffuse acute ischemic right ventricular dysfunction. Right ventricular dysfunction was produced by intracoronary injection of nonradioactive microspheres (mean diameter +/- SD 54 +/- 4 microns) and caused a significant increase in right atrial pressure (7.6 +/- 1.4 vs. 1.6 +/- 1 mm Hg, p less than 0.001) and cross-sectional areas of both the right atrium (8.3 +/- 0.3 vs. 5.6 +/- 0.2 cm2, p less than 0.001) and right ventricle (8.8 +/- 0.4 vs. 5.7 +/- 0.4 cm2, p less than 0.001). Right atrial and ventricular collapse required a significantly larger pericardial effusion and pericardial pressure after right ventricular infarction than before. Mean aortic pressure had fallen 1.9 +/- 2% and 6.5 +/- 6.9% at the time of right atrial collapse (p = NS before vs. after right ventricular dysfunction) and 3 +/- 4.1% and 20.1 +/- 20.8% at the time of right ventricular collapse (p less than 0.03) before and after right ventricular dysfunction, respectively. In the presence of ischemic right ventricular dysfunction, echocardiographic signs of cardiac tamponade are less sensitive and occur later in the hemodynamic progression of cardiac tamponade. Pulsus paradoxus with cardiac tamponade was not prevented by coexisting ischemic right ventricular dysfunction.     

Frequency of cardiac contusion in nonpenetrating chest injury

Seventy-five patients with nonpenetrating chest injuries were evaluated with electrocardiography, cardiac enzyme determination, 2-dimensional echocardiography and radionuclide ventriculography to document the incidence of cardiac abnormalities. Although the electrocardiograms showed ST-T wave changes in 25 patients (33%), sensitivity (47%) and specificity (79%) for echocardiographic and radionuclide abnormalities were poor. Cardiac enzymes were abnormal in 10 patients (13%), sensitivity for echocardiographic or radionuclide abnormalities, or both, was 29% and specificity 90%. Wall motion abnormalities were detected in 11 patients (18%) by radionuclide studies and in 3 patients (6%) by echocardiography. A pericardial effusion was present in 5 patients (10%). Two patients (4%) died of noncardiac causes; neither had wall motion abnormalities. This study documents the favorable outcome of patients with blunt chest injuries and does not suggest that echocardiography or radionuclide studies should be performed routinely on such patients.     

Diagnosis of cardiac tamponade by echocardiography: changes in mitral valve motion and ventricular dimensions, with special reference to paradoxical pulse.

The echocardiographic findings in three patients who presented with pericardial effusion and cardiac tamponade are described. Cyclic respiratory changes affected the diastolic movement of the anterior mitral leaflet, viz., during inspiration its anterior excursion decreased in amplitude and the E-F slope diminished. This inspiratory alteration in mitral valve motion was accompanied by an increase in right ventricular dimensions and a reciprocal decrease in left ventricular dimensions. Pericardial paracentesis confirmed the presence of effusion and relieved cardiac tamponade in all the patients. Repeat echocardiography, performed in two of the patients immediately after the pericardial tap, showed that the E-F slope had become steeper and that phasic respiratory variations in the diastolic motion of the anterior mitral leaflet were no longer present. The compatibility of our observations with the theories which endeavor to explain the mechanism of the paradoxical pulse in pericardial effusion with cardiac tamponade is discussed. We suggest that the abnormalities in anterior mitral leaflet motion defined by echocardiography constitute a useful addition to the study of patients with suspected cardiac tamponade resulting from pericardial effusion.     

Cardiac lymphoma associated with superior vena caval syndrome and cardiac tamponade: case history

A sixty-three-year-old patient with malignant histiocytic lymphoma of the heart presented with both superior vena cava syndrome and cardiac tamponade. A two-dimensional echocardiogram showed a large tumor mass in the right atrium and pericardial effusion with right ventricular compression. Superior and inferior vena cavagrams disclosed a lobulated tumor located in the right atrium that extended into and obstructed the superior vena cava. After the pericardial effusion was drained and the diagnosis was established, the patient was irradiated and given chemotherapy with resolution of the tamponade and superior vena cava obstruction.     

Quantitative Echocardiographic Assessment in Pericardial Disease

Although echocardiography has been used for diagnosing pericardial effusions since 1965, the grading of such effusions for size, and also the diagnosis of tamponade have depended almost entirely on qualitative observations or "signs." The categorization of pericardial effusions into small, moderate, or large according to the width of pericardial space is very roughly semiquantitative. Diagnostic criteria for tamponade are based on altered ventricular or atrial wall contour, and on phasic respiratory fluctuations of ventricular size and flow velocities. We review a new approach to pericardial effusion volume estimation, based on assessing the pericardial sac volume as well a s cardiac volume by the ellipsoid formula. A new quantitative criteria for tamponade (i.e., biatrial width to cardiac width) (annular level) ratio may be useful, a ratio < 0.85 indicating tamponade, reflecting late diastolic biatrial collapse. The echo diagnosis of pericardial constriction depends on pericardial thickening combined with various abnormalities of septal and ventricular wall motion, some of them subtle. We review a new two-dimensional echo "sign" present in some cases of pericardial constriction: abnormal posterior displacement of the left atrial posterior wall, and reduced angle (< 150°) between it and left ventricular wall in long-axis view. Measurements reflecting the fluctuation of certain Doppler parameters can also be useful in diagnosis of this entity.     

Mechanism of electrical alternans in patients with pericardial effusion

Electrical alternans concomitant with pericardial effusion has been considered a pathognomonic sign suggestive of a large effusion with cardiac tamponade, particularly if there is P wave alternans as well as QRS alternans. However, the mechanism of this phenomonon remains controversial. A patient with pericardial effusion secondary to adenocarcinoma of the lung with metastases, pericardial effusion, electrical alternans, and cardiac tamponade was studied by echocardiography, right and left heart catheterization, and pericardiocentesis. Hemodynamic data were consistent with cadiac tamponade. The echocardiogram demonstrated a large anterior and posterior pericardial effusion. Noncongruous motion of the septum and posterior wall was pericardial effusion. Noncongruous motion of the septum and posterior wall was recorded at a rate equal to the heart rate. In addition, congruous motion of the septum and posterior wall was recorded at a rate that was half the heart rate and corresponded to the electrical alternans. The congruous movement disappeared after pericardiocentesis, as did the electrical alternans. The electrical alternans is synchronous with and due to the pendulous movement of the heart within the pericardial sac, as demonstrated by echocardiogram and cineangiograms.     

Correlation of echocardiographic and clinical findings in patients with pericardial effusion.

Clinical data and echocardiographic findings were correlated in 20 patients with pericardial effusion. Moderate to large effusions were associated with increased motion of the entire heart within the pericardial sac. A correlation was found between the estimated volume of fluid and the diastolic excursion and velocity of the right ventricular and left ventricular walls (P less than 0.01). For any given volume of fluid as estimated from the echocardiogram neoplastic effusions resulted in greater increments in wall motion (P less than 0.02). Patterns of "pseudo" mitral valve prolapse occurred and were correlated with the extent and timing of cardiac swinging and heart rate. A diminished E-F slope of the mitral valve echo and notch on the right ventricular epicardial echo during early systole were found in all four patients with pericardial tamponade. These preliminary observations suggest that echocardiographic examination of patients with pericardial effusion may provide clues to the presence or absence of tamponade in addition to providing an estimate of the quantity of fluid in the pericardial sac.     

Right ventricular infarction. Clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction.

Twelve patients with a clinical diagnosis of right ventricular infarction are described. All had acute inferior wall myocardial infarction associated with the bedside findings of jugular venous distension, clear lungs on auscultation, and arterial hypotension. Hemodynamically, there was elevation of right-sided filling pressures not explained by normal or minimally elevated pulmonary wedge pressures. Four patients had an incorrect diagnosis of acute cardiac tamponade. However, a review of the data showed that the hemodynamic features of right ventricular infarction more closely resemble those of pericardial constriction, a point that may be helpful in distinguishing right ventricular infarction from cardiac tamponade. Invasive and noninvasive techniques that exclude the presence of pericardial fluid and suggest enlargement and abnormal contractility of the right ventricle were helpful in establishing the diagnosis of right ventricular infarction in several patients.     

Usefulness of right ventricular diastolic collapse in diagnosing cardiac tamponade and comparison to pulsus paradoxus

To compare the sensitivity, specificity and predictive value of right ventricular (RV) diastolic collapse and pulsus paradoxus as signs of cardiac tamponade, 21 consecutive patients with pericardial effusion and suspected cardiac tamponade underwent prospective hemodynamic and echocardiographic evaluation. Simultaneous hemodynamic and echocardiographic data were obtained in all patients before and after pericardiocentesis. Cardiac tamponade was considered present when there was diastolic equilibration of the intrapericardial, right atrial and pulmonary capillary wedge pressures and elevation of these pressures to more than 10 mm Hg. RV diastolic collapse was 93% sensitive and 100% specific in diagnosing cardiac tamponade, whereas pulsus paradoxus was only 79% sensitive and 40% specific. The positive and negative predictive values of RV diastolic collapse (100% and 83%) were considerably better than pulsus paradoxus (81% and 40%) and demonstrate that RV diastolic collapse is more sensitive, specific and predictive of cardiac tamponade than is pulsus paradoxus. Serial simultaneous hemodynamic and echocardiographic observations at multiple points during pericardiocentesis in a smaller subgroup (5 patients) also suggest that the hemodynamic effects of RV diastolic collapse in cardiac tamponade are mediated by an increase in intrapericardial pressure.