Pericardial effusion

Definition

Pericardial effusion (per-ih-KAHR-de-ul uh-FU-zhun) is the accumulation of excess fluid around the heart.

The heart is surrounded by a double-layered, sac-like structure called the pericardium. The space between the layers normally contains a very small amount of fluid.

Pericardial effusion is often related to inflammation of the pericardium that's caused by disease or injury, but pericardial effusion can also occur without inflammation. Sometimes, pericardial effusion can be caused by the accumulation of blood after a surgical procedure or injury.

When the volume of fluid exceeds the pericardium's "full" level, pericardial effusion puts pressure on the heart, causing poor heart function. If left untreated, pericardial effusion can cause heart failure or death.

What causes pericardial effusion?

Pericardial effusion, and the possible inflammation of the pericardium resulting from it (called pericarditis), can have many possible causes, including:

• Infection such as viral, bacterial or tuberculous
• Inflammatory disorders, such as lupus
• Cancer that has spread (metastasized) to the pericardium
• Kidney failure with excessive blood levels of nitrogen
• Heart surgery

Who is affected by pericardial effusions?

Since pericardial effusions are a result of many different diseases or conditions, anyone who develops one of the many conditions that can produce an effusion may be affected.

Is pericardial effusion serious?

The seriousness of the condition depends on the primary cause and size of the effusion and whether it can be treated effectively. Causes that can be treated or controlled, such as an infection due to a virus or heart failure, allows the patient to be effectively treated and remain free of pericardial effusions.

Pericardial effusion caused by other conditions, such as cancer, is very serious and should be diagnosed and treated promptly.

Additionally, rapid fluid accumulation in the pericardium can cause cardiac tamponade, a severe compression of the heart that impairs its ability to function. Cardiac tamponade resulting from pericardial effusion can be life-threatening.

What are the symptoms of pericardial effusion?

Many patients with pericardial effusion have no symptoms. The condition is often discovered on a chest x-ray or echocardiogram that was performed for another reason. Initially, the pericardium may stretch to accommodate excess fluid build-up. Therefore, signs and symptoms may not occur until a large amount of fluid has collected over time.

If symptoms do occur, they may result from compression of surrounding structures, such as the lung, stomach or phrenic nerve (a nerve that connects to the diaphragm). Symptoms also may occur due to diastolic heart failure (heart failure that occurs because the heart is unable to relax normally between each contraction due to the added compression).

Symptoms of pericardial effusion include:

• Chest pressure or pain
• Shortness of breath
• Nausea
• Abdominal fullness
• Difficulty in swallowing

Symptoms that pericardial effusion is causing cardiac tamponade include:

• Blue tinge to the lips and skin
• Shock
• Change in mental status

Cardiac tamponade is a severe compression of the heart that impairs its ability to function. Cardiac tamponade resulting from pericardial effusion can be life-threatening and is a medical emergency, requiring urgent drainage of the fluid.

How is pericardial effusion diagnosed?

The tests most commonly used to diagnose and evaluate pericardial effusion include:

• Chest x-ray
• Computed tomography (CT) scan of the chest
• Echocardiogram
• Pericardiocentesis: a procedure that uses a needle to remove fluid from the pericardium; the fluid is then examined to determine the cause of the effusion

How is pericardial effusion treated?

Treatment of pericardial effusion is based on the underlying condition that is causing it and if the effusion is leading to severe symptoms, such as shortness of breath or difficulty breathing.

Depending on the cause, the excess fluid may be either rich in protein (exudate) or watery (transudate). These two categories help physicians determine the best way to treat the cause of a pericardial effusion.

Medical management

The goal of medical management for pericardial effusions is to treat the underlying cause. Medical therapies for pericardial effusions include:

• Nonsteroidal antiinflammatory medications (NSAIDs) can be used to treat pericardial effusions caused by inflammation.
• Diuretics and other heart failure medications can be used to treat pericardial effusions caused by heart failure.
• Antibiotics are used to treat pericardial effusions caused by an infection.
• If a pericardial effusion is related to the presence of cancer, treatment may include chemotherapy, radiation therapy, or medication infused within the chest.

Procedures to treat pericardial effusion

Regardless if the pericardial effusion is transudative (consisting of watery fluid) or exudative (made up of protein-rich fluid), a large pericardial effusion causing respiratory symptoms or cardiac tamponade should be drained to remove the excess fluid, prevent its re-accumulation, or treat the underlying cause of the fluid buildup.

Large pericardial effusions may be drained through:

• Ultrasound-guided pericardiocentesis, a safe and effective procedure to remove excess fluid from the pericardium.
• Video-assisted thoracoscopic surgery (VATS), also known as thoracoscopy is a minimally-invasive technique performed under general anesthesia. VATS allows for visual evaluation of the pericardium and is used when the diagnosis of pericardial effusion has remained undiagnosed despite previous, less-invasive tests. It is also used to drain the excess fluid and prevent its reaccumulation.

Pericardial effusions that cannot be managed through medical management or drainage of excess fluid may require percutaneous (nonsurgical) or surgical treatment.

Percutaneous Balloon Pericardiotomy is a nonsurgical procedure performed using x-ray guidance to view the pericardium and place a balloon dilating catheter. Percutaneous balloon pericardiotomy is 85 to 92 percent successful at relieving reaccumulation of pericardial fluid 30 days following the procedure.

Pericardial Window (Subxyphoid Pericardiostomy) is a minimally invasive procedure in which an opening is made in the pericardium to drain fluid that has accumulated around the heart. A pericardial window can be completed through a small incision below t