PERICARDIAL EFFUSION

Etiology The normal pericardial space contains 15 to 50 mL of pericardial fluid, a plasma ultrafiltrate secreted by the mesothelial cells that line the serosal layer. A larger volume of fluid may accumulate in association with any of the forms of acute pericarditis previously discussed. In addition, noninflammatory serous effusions may result from conditions of (1) increased capillary permeability (e.g., severe hypothyroidism); (2) increased capillary hydrostatic pressure (e.g., congestive heart failure); or (3) decreased plasma oncotic pressure (e.g., cirrhosis or the nephrotic syndrome). Chylous effusions may occur in the presence of lymphatic obstruction of pericardial drainage, most commonly caused by neoplasms and tuberculosis. Pathophysiology Because the pericardium is a relatively stiff structure, the relationship between its internal volume and pressure is not linear, as shown in curve A in Figure 14.2. Notice that the initial portion of the curve is nearly flat, indicating that at the low volumes normally present within the pericardium, a small increase in volume leads to only a small rise in pressure. However, when the intrapericardial volume expands beyond a critical level (see Fig. 14.2, arrow), a dramatic increase in pressure is incited by the nondistensible sac. At that point, even a minor increase in volume can translate into an enormous compressive force on the heart.

steep portion of curve A) and the potential for severe cardiac chamber compression.Figure 14. 14. may complain of a dull constant ache in the left side of the chest. results in marked elevation of pericardial pressure (see Fig. if the pericardial effusion accumulates slowly. In addition. or hiccups (resulting from phrenic nerve stimulation). and the heart sounds may be muffled. the effusion may cause symptoms resulting from compression of adjacent structures.2 Schematic representation of the volume–pressure relationship of the normal… More » Three factors determine whether a pericardial effusion remains clinically silent or whether symptoms of cardiac compression ensue: (1) the volume of fluid. For example. as may occur in the presence of tumor or fibrosis of the sac. the pericardium gradually stretches. such as dysphagia (difficult swallowing because of esophageal compression).4). With this adaptation. and (3) the compliancecharacteristics of the pericardium. the pericardium can accommodate larger volumes without marked elevation of intrapericardial pressure. dyspnea (shortness of breath resulting from lung compression). hoarseness (due to recurrent laryngeal nerve compression). as described later in the chapter. (2) the rate at which the fluid accumulates. Clinical Features A spectrum of possible symptoms is associated with pericardial effusions. a friction rub that had been present during the acute phase of pericarditis may disappear if a large effusion develops and separates the inflamed layers from one another. over weeks to months. In fact. Dullness to percussion of the left lung over the angle of the scapula may be present (known as the Ewart sign) owing to compressive atelectasis by the enlarged pericardial sac. as may occur in chest trauma with intrapericardial hemorrhage. a large pericardial fluid “insulates” the heart from the chest wall. Even lesser amounts of fluid may cause significant elevation of pressure if the pericardium is pathologically noncompliant and stiff. .2. or may present with findings of cardiac tamponade. In contrast. A sudden increase of pericardial volume.2.4 Clinical Features of Large Pericardial Effusion On examination (Table 14. curve B). 14. Table 14. the patient with a large effusion may be asymptomatic. such that the volume–pressure relationship curve shifts toward the right (see Fig.

which can identify pericardial collections as small as 20 mL. the cardiac silhouette enlarges in a globular. Figure 14. pericardiocentesis should be performed therapy is directed toward the underlying for therapeutic drainage and for analysis disorder (e. However. This noninvasive technique can quantify the volume of pericardial fluid. However. the ECG may demonstrate reduced voltage of the complexes. If the cause is not evident. a result of a constantly changing electrical axis as the heart swings from side to side within the large pericardial volume (Fig. Figure 14. and when necessary.Diagnostic Studies The chest radiograph may be normal if only a small pericardial effusion is present.. In large effusions. if more than approximately 250 mL has accumulated. the height of the QRS complex may vary from beat to beat (electrical alternans). 14. Rhythm strip of lead V1 showing alternating height of the QRS complex… More » One of the most useful laboratory tests in the evaluation of an effusion is echocardiography (Fig.4 Two-dimensional echocardiogram (parasternal short-axis view) of a pericardial effusion (PE… hemodynamic compression of the Treatment cardiac chambers becomes evident. help direct the placement of a pericardiocentesis needle.4). An asymptomatic effusion. the clinical state of the patient determines whether pericardiocentesis (removal of pericardial fluid) should be undertaken. 14.3). then If the cause of the effusion is known. In the presence of very large effusions. determine whether ventricular filling is compromised. even of large volume.g. can be observed for long periods without specific intervention. uremic effusion). symmetric fashion.3 Electrical alternans. intensive dialysis for of the fluid. if serial examination demonstrates a precipitous rise in pericardial volume or if .

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