Pericardial Effusion and Pericardial Tamponade - Information, Symptoms, and Treatment

“Pericardium” is the medical term for the pericardial sac. This refers to a kind of sac that encloses the heart. Strictly speaking, the pericardium consists of two connected membranes, between which fluid is present. This fluid is also referred to as pericardial fluid and is constantly produced and reabsorbed by the layers of the pericardium. For this reason, the membranes of the pericardium are also referred to as serous tissue layers. To ensure proper function of the pericardium, 10–50 ml of fluid is required between the layers. This space is also known as the pericardial cavity.

In patients with a pericardial effusion, excess fluid accumulates between the layers of the pericardium. The fluid that forms is continuously reabsorbed by the body to maintain stable circulation. However, in the case of a pericardial effusion—usually within a very short time—much more fluid enters the pericardial cavity than is removed, causing it to fill progressively. The heart muscle, constricted by this fluid, loses its ability to function effectively and can no longer completely fill the heart chambers with blood. This impairment primarily affects diastolic filling, further reducing the heart’s pumping capacity. If the fluid accumulates rapidly over a short period, as little as 150–200 ml is enough to cause heart failure. In the case of a chronic effusion that develops over weeks or months, up to 2,000 ml can accumulate before it causes problems.

Many people also refer to this condition as a pericardial effusion, since the affected pericardial cavity is located directly next to the pericardium. Small pericardial effusions are very rarely noticed by those affected. A minor pericardial effusion does not yet cause any noticeable signs or symptoms. It is only when severe effusions occur that numerous symptoms appear. In addition to reduced cardiac output, symptoms often suggest heart failure (cardiac insufficiency). These include clearly visible blood congestion in the neck veins and a bluish discoloration of the lips.

A pericardial tamponade is an acute, life-threatening form of pericardial effusion in which fluid rapidly accumulates in the pericardial cavity, leading to a critical increase in pressure. This restricts the heart’s normal expansion during the filling phase, significantly impairing diastolic filling and preventing the heart from receiving an adequate supply of blood. As a result, ejection fraction decreases, which particularly affects the entire heart and right-sided heart function and can lead to severe heart failure. Typical clinical signs include visible jugular vein distension, a drop in blood pressure, and the characteristic pulsus paradoxus. If left untreated, shock can set in rapidly, which is why pericardial tamponade constitutes an immediate medical emergency.

Various causes can lead to a pericardial effusion. 

• Heart injury
• Heart attack (myocardial infarction)
• Infectious diseases
• Endocarditis
• Cancer (breast and lung cancer)
• Heart surgery
• Bacterial or fungal infections
• Idiopathic (no apparent cause)

Aortic dissection is another rare but life-threatening cause that can lead to rapid bleeding into the pericardium. In about half of all cases, however, no clear cause can be identified (idiopathic).

Is a pericardial effusion dangerous?

Since a pericardial effusion can impair or completely block the heart’s pumping ability, in principle, any pericardial effusion is potentially life-threatening. However, there is one type that is the most dangerous: a bloody pericardial effusion, also known as a hemopericardium. This involves bleeding into the pericardial sac, triggered, among other things, by a ventricular rupture.

This refers to a tear in the heart wall, which can occur, for example, during a massive heart attack. This can be explained by the fact that the heart attack causes muscle tissue to die, and the resulting scar tissue is no longer as stable as before. The tear causes severe and rapid bleeding into the pericardial sac, which can completely compress the heart chambers. This is also known as pericardial tamponade, which constitutes a medical emergency.

If the bleeding is not stopped immediately, the pericardium is not opened, and the blood is not removed, there is an immediate threat to life. An injury to the heart, such as from a knife wound or a gunshot, can also lead to pericardial tamponade. Finally, a tear in the aorta at its origin also regularly leads to a pericardial hemorrhage or pericardial tamponade. 

Hemopericardium is a fortunately very rare but serious and life-threatening complication of cardiac catheterization or pacemaker implantation. In these cases, the cause of the hemopericardium is referred to as iatrogenic, which means “caused by medical intervention.”

Which infectious diseases can lead to a pericardial effusion?

Numerous infectious diseases can also lead to pericardial effusion. For example, it frequently occurs alongside tuberculosis, herpes, and HIV. Furthermore, pericardial effusion and heart failure are mutually reinforcing conditions. While the constriction of the heart muscle leads to a drastic reduction in cardiac output, heart failure—due to insufficient cardiac output—also triggers fluid accumulation in the pericardial cavity. In addition, this condition is often a risk factor for heart surgery. It is not uncommon for a mild inflammation of the pericardium (pericarditis) to develop, which can quickly lead to an effusion.

Finally, several types of cancer can also lead to this condition. In addition to breast and lung cancer, leukemia is also known to trigger severe pericardial effusion. Furthermore, rheumatoid arthritis, ulcerative colitis, and Crohn’s disease can lead to these classic symptoms. These are three particularly severe immunological disorders.

A severe pericardial effusion can lead to numerous secondary conditions. Patients typically suffer from

• severe shortness of breath,
• low exercise tolerance, and
• a painful cough.

However, if the condition remains untreated, the lips quickly turn blue and a condition known as pericardial tamponade develops. This is a condition in which the heart can no longer function properly due to the enormous pressure from the pericardial cavity. In addition, the coronary arteries are often constricted by the ever-expanding pericardium. As a result, they can no longer supply the heart with oxygen and the necessary nutrients. Ultimately, this usually leads to cardiac arrest and the patient’s death. In severe cases, this can lead to a rapid increase in pericardial volume with life-threatening consequences.

If a pericardial effusion is suspected, prompt action is required. Even a mild case can lead to a severe pericardial effusion and, consequently, to serious complications. For this reason, an ultrasound examination of the heart (echocardiography) is ordered even at the slightest suspicion. In addition to the amount of fluid, a so-called electrical alternans on the ECG may also indicate a significant effusion. In some cases, a computed tomography (CT) scan is also performed. If these tests confirm the suspicion, it may also be necessary to remove some fluid from the pericardial cavity. This procedure is medically referred to as a pericardial puncture. The fluid removed must then be examined, primarily for cancer cells and pathogens.

CT scan of a pericardial effusion; By James Heilman, MD – Own work, CC BY-SA 3.0, Link

Afterward, a medical history is usually taken. The medical history focuses in particular on previous illnesses, infections, or traumatic events. Among other things, this helps identify all risk factors as well as any hereditary diseases the patient may have. In most cases, the medical history review yields no specific findings; however, many dangerous diseases can be ruled out as the cause.

For medical diagnosis and treatment, however, it is sufficient if the patient complains of shortness of breath and persistent fatigue and if the excessive pericardial fluid is clearly visible on an ultrasound or CT scan. In severe cases, this fluid surrounds the entire heart and is therefore clearly visible.

Treatment of a pericardial effusion generally depends on the severity of the condition and its cause. A chronic effusion rarely leads to serious complications and is generally no longer treated, particularly in elderly patients. This is due, among other things, to the fact that any treatment carries risks, which can have serious consequences, especially in advanced age. Therefore, invasive procedures (such as a puncture or drainage) are generally avoided in older patients with few symptoms. An acute pericardial effusion, on the other hand, poses an immediate threat and should be treated regardless of age. 

In general, treatment depends on the underlying condition. In cases of mild effusions caused by infections, the infectious disease is treated first. In some cases, particularly with viral infections, a few days of bed rest may be sufficient. A visit to the doctor is nevertheless essential, as severe pericardial effusions can quickly become life-threatening. If pain is present, medication may be necessary and helpful. Typically, small doses of ibuprofen are used. In the case of a persistent infectious disease, especially if caused by bacteria, however, specific treatment with antibiotics is initiated.

In some cases, medication does not work. In such cases, a procedure known as a pericardial puncture may be necessary. During this procedure, a needle is inserted into the patient’s pericardial cavity, and a cannula is then used to remove the excess fluid. This procedure can be used for both diagnostic and therapeutic purposes and is referred to as a diagnostic pericardial tap. In acute cases, the tap is primarily intended to quickly relieve pressure on the heart.