INTRODUCTION — The normal pericardium is a fibroelastic sac surrounding the heart that contains a thin layer of fluid. A pericardial effusion is considered to be present when accumulated fluid within the sac exceeds the small amount that is normally present. Pericardial effusion can develop in patients with virtually any condition that affects the pericardium, including acute pericarditis and a variety of systemic disorders. The development of a pericardial effusion may have important implications for prognosis (as in patients with intrathoracic neoplasm), diagnosis (as in myopericarditis or acute pericarditis), or both (as in dissection of the ascending aorta).
Pericardial effusions may develop rapidly (acute) or more gradually (subacute or chronic). The normal pericardium can stretch to accommodate increases in pericardial volume, with the amount of stretch related to how quickly the effusion develops. The ability to stretch is greater with slowly developing effusions. However, regardless of how quickly an effusion develops, with ongoing accumulation of pericardial fluid into a closed space, eventually the intrapericardial pressure begins to increase. When the intrapericardial pressure becomes high enough to impede cardiac filling, cardiac function becomes impaired, and cardiac tamponade can be considered to be present. (See "Cardiac tamponade".)
A general overview of the diagnosis and treatment of pericardial effusion will be presented here. The full spectrum of causes of pericardial disease, management of specific causes of pericardial disease, and the details of pericardial fluid drainage are discussed separately. (See "Etiology of pericardial disease" and "Acute pericarditis: Clinical presentation and diagnosis" and "Emergency pericardiocentesis".)
ETIOLOGY — Pericardial effusions can occur as a component of almost any pericardial disorder (table 1), but the majority result from one of the following conditions (see "Etiology of pericardial disease"):
●Acute pericarditis (viral, bacterial, tuberculous, or idiopathic in origin)
●Autoimmune disease
●Postmyocardial infarction or cardiac surgery
●Sharp or blunt chest trauma, including a cardiac diagnostic or interventional procedure
●Malignancy, particularly metastatic spread of noncardiac primary tumors
●Mediastinal radiation
●Renal failure with uremia
●Myxedema
●Aortic dissection extending into the pericardium
●Selected drugs
The frequency of the different causes of pericardial effusion varies in published reports, depending primarily upon geography and the patient population (table 2). Patients with hemorrhagic pericardial effusions have a somewhat different distribution of causes, although the overlap with serous effusions is significant. (See "Etiology of pericardial disease", section on 'Spectrum of clinical presentation' and 'Establishing the cause of the effusion' below.)
CLINICAL PRESENTATION — The presence of pericardial effusion may be suspected from the history, physical examination, electrocardiogram (ECG), and chest radiograph.
Signs and symptoms — Unless cardiac tamponade is present, physical signs are so insensitive and nonspecific that they are of historic rather than practical interest. As an example, the ability to percuss cardiac dullness beyond the apical point of maximal impulse is consistent with pericardial effusion, but it depends upon the absence of disease of the lower lobe of the left lung or left pleura and the expertise of the examiner. Ewart's sign (which includes a triangular area of dullness at the tip of the left scapula along with tubular breath sounds and egophony at the same location) suffers from similar limitations [1].
Most patients without a hemodynamically significant pericardial effusion will have no symptoms specific to the effusion, but they may have symptoms related to the underlying cause (eg, fever in the setting of pericarditis, etc). Thus, pericardial effusions are often discovered incidentally during evaluation of other cardiopulmonary diseases. However, patients with a hemodynamically significant pericardial effusion leading to cardiac tamponade usually present with signs and symptoms related to impaired cardiac function (ie, fatigue, dyspnea, elevated jugular venous pressure, edema). (See "Cardiac tamponade".)
ECG findings — The most common electrocardiographic (ECG) findings in patients with a pericardial effusion are sinus tachycardia, low QRS voltage, and electrical alternans.
●Low voltage – Low voltage of the QRS complexes (waveform 1) is present when the total amplitude of the QRS complexes in each of the six limb leads is 5 mm (0.5 mV) or less. Low voltage in the limb leads may or may not be accompanied by low voltage in the chest leads (defined as a total QRS amplitude of 10 mm or less in V1 to V6).
The combination of low voltage and sinus tachycardia should raise concern about pericardial effusion with cardiac tamponade. In one prospective cohort study of 43 patients with a pericardial effusion, cardiac tamponade was present in 23 patients, with low QRS voltage in 14 of those 23 (61 percent) but in none with an effusion without cardiac tamponade [2]. After treatment with either pericardiocentesis or anti-inflammatory medication, low voltage resolved within one week. However, the combination of low voltage and sinus tachycardia is not specific to patients with pericardial effusion, as this may also be seen in patients with chronic obstructive pulmonary disease, pleural effusion, cardiomyopathy, and prior cardiac surgery (table 3). (See "Cardiac tamponade".)
●Electrical alternans – Another ECG pattern that can occur with pericardial effusion and cardiac tamponade is electrical alternans, which is also usually present with sinus tachycardia (waveform 2). This abnormality is characterized by a cyclic beat-to-beat shift in the QRS axis (and more subtly in other waveforms) in the limb and precordial leads in association with mechanical swinging of the heart to-and-fro, usually in a large pericardial effusion. The pattern is usually most apparent in one or more of the precordial leads.
Electrical alternans with sinus tachycardia is a highly specific sign of pericardial effusion, usually with cardiac tamponade, but is only modestly sensitive. As a result, its absence does not exclude cardiac tamponade. QRS alternans with other tachycardias (eg, paroxysmal supraventricular tachycardias or ventricular tachycardia) is a nonspecific finding resulting from alternation in conduction on a beat-to-beat basis, not from mechanical movement of the heart.
Chest radiograph — The findings on chest radiograph are variable, depending on the etiology and size of the effusion and underlying comorbidities. Small to moderate effusions (less than 200 to 300 mL) may not result in significant findings on the chest radiograph, while larger pericardial effusions typically present with an enlarged cardiac silhouette with clear lung fields (image 1). However, an enlarged cardiac silhouette on chest radiograph is not specific and cannot be considered diagnostic for the presence of a pericardial effusion.
DIAGNOSTIC APPROACH — Pericardial effusion should be suspected in the following clinical settings, particularly in patients with any of the disorders known to involve the pericardium (table 1):
●All cases of acute pericarditis.
●Unexplained new radiographic cardiomegaly without pulmonary congestion.
●Unexplained persistent fever with or without an obvious source of infection, which also raises the possibility of purulent pericarditis. (See "Purulent pericarditis".)
●Presence of isolated left (or left larger than right) pleural effusion [3].
●Fever or hemodynamic deterioration in a patient with another disease process that can involve the pericardium.
Once a pericardial effusion is suspected, the diagnostic approach consists of three steps: confirming the presence of a pericardial effusion; assessing its hemodynamic impact, if any; and, whenever possible, establishing the cause of the pericardial effusion.
Establishing the presence of effusion — Clinical evaluation along with electrocardiographic (ECG) and chest radiograph findings may suggest the presence of a pericardial effusion, but additional imaging, usually echocardiography, is required to establish the diagnosis. We perform echocardiography in all patients with suspected pericardial disease (movie 1) [4]. This practice is consistent with the 2015 European Society of Cardiology guidelines for the diagnosis and management of pericardial disease [4].
●Echocardiography – Echocardiography is both specific and sensitive for the detection of pericardial effusion and can also provide information regarding the hemodynamic significance of the effusion. Pericardial fluid appears on an echocardiogram as an echolucent space between the pericardium and the epicardium. Small collections of pericardial fluid, which can be physiologic (25 to 50 mL), may be visible during ventricular systole. Effusions exceeding 25 to 50 mL are seen as an echo-free space throughout the cardiac cycle. Typically, a small (50 to 100 mL) free-flowing pericardial effusion is seen posterior to the left ventricle; this space diminishes and finally disappears as the echo beam approaches the base of the left ventricle and the left atrium (image 2). Accumulation of pericardial fluid above the right atrium in the apical four chamber view with the patient in the left lateral decubitus position is, perhaps, the single most sensitive and specific indication of a pericardial effusion (image 3). However, in the case of a free flowing effusion, the site of accumulation may be positional as there is gravity dependence. As the effusion increases in size, it is typically seen anterior to the right ventricle. (See 'Quantification of the pericardial effusion' below.)
Although M mode echocardiography can identify an effusion (image 4), two-dimensional echocardiography permits a better estimate of the size of the effusion, its distribution, and its distance from potential puncture sites (movie 1). (See "Echocardiographic evaluation of the pericardium".)
In patients with non-diagnostic transthoracic echocardiography (TTE) in whom the suspicion of a pericardial effusion remains high, and in effusions containing clots (eg, after cardiac surgery), transesophageal echocardiography (TEE) is helpful in making the diagnosis.
●Cross-sectional imaging – In cases with a high suspicion for pericardial effusion but non-diagnostic echocardiography, additional thoracic imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is helpful in establishing the presence of an effusion. We do not routinely perform CT or MRI unless both TTE and TEE are non-diagnostic, or unless there is concern for other pericardial pathology (eg, pericardial thickening and constrictive pericarditis). CT and MRI may be useful when quantification and localization of pericardial fluid is important, when the effusion is complex, and when epicardial fat and pleural effusions need to be excluded. These imaging modalities (especially MRI) also are capable of characterizing the nature of the effusion [5]. (See "Constrictive pericarditis: Diagnostic evaluation and management", section on 'Evaluation'.)
●Cardiac biomarkers – Among patients with pericardial effusion, cardiac biomarkers (CK-MB, troponin) may be elevated in those in whom the effusion occurs in association with acute myopericarditis or myocardial infarction. Troponin elevations, typically modest, may occur in association with a variety of other acute illnesses. (See "Elevated cardiac troponin concentration in the absence of an acute coronary syndrome" and "Acute pericarditis: Clinical presentation and diagnosis", section on 'Cardiac biomarkers' and "Myopericarditis".)
Quantification of the pericardial effusion — While echocardiography is an excellent method for detection and estimation of the size of pericardial effusions, it cannot precisely quantitate effusions because it is usually difficult to visualize and measure the entire pericardial sac in any one sector scan plane. Magnetic resonance imaging and computed tomography have advantages for fluid quantification. However, if quantitation is desirable or required, a reasonable echocardiographic approach is to grade effusions as small, medium, or large as determined by the size of the echo-free space surrounding the heart.
●Small effusions (50 to 100 mL) are only seen posteriorly, typically less than 10 mm in thickness, and only cause minimal separation between the epicardial (visceral) pericardium and the thicker parietal pericardial sac.
●Moderate effusions (100 to 500 mL) tend to be seen along the length of the posterior wall but not anteriorly; the echo-free space is 10 to 20 mm at its greatest width.
●Large effusions (>500 mL) tend to be seen circumferentially (image 5 and image 6); the echo-free space is greater than 20 mm at its greatest width.
Though size is relevant, as mentioned earlier, the hemodynamic consequence of a pericardial effusion is also related to the rate of fluid accumulation.
Assessing hemodynamic impact — Once it is determined that a pericardial effusion is present, the next step is to determine its hemodynamic significance. The potential hemodynamic impact of an effusion ranges from none to mild compromise to the most extreme manifestation, cardiac tamponade (which, when severe enough, causes shock and circulatory collapse). Cardiac tamponade occurs when the intrapericardial pressure due to the accumulating pericardial effusion is elevated enough to impair filling of the cardiac chambers. (See "Cardiac tamponade".)
Factors that determine the degree of hemodynamic compromise include the volume of pericardial fluid, the rate at which the effusion accumulates, and whether or not the pericardium is scarred or adherent. Localized pericardial adhesions or organization of the pericardial fluid can result in localized, and thus atypical, cardiac tamponade. Diffuse pericardial inflammation and/or scarring with effusion can result in effusive constrictive pericarditis [6].
Acute versus subacute cardiac tamponade — Cardiac tamponade can occur acutely (eg, due to rupture of the heart or aorta, trauma, or as a complication of catheter or pacemaker procedures) or subacutely (eg, due to neoplasm, uremia, or idiopathic pericarditis). (See "Cardiac tamponade".)
●Acute cardiac tamponade is by definition rapid in onset, may be associated with chest pain and dyspnea, and is life-threatening if not promptly treated. The jugular venous pressure is markedly elevated, while hypotension is common due to the decline in cardiac output. The heart sounds are often muted. In most acute cases, the effusion is relatively small because the pericardium cannot stretch rapidly.
●Subacute cardiac tamponade is a less dramatic process. Patients may be asymptomatic or complain of dyspnea, chest discomfort or fullness, fatigability, or other symptoms referable to increased filling pressures and limited cardiac output. Peripheral edema may be seen with more chronic cardiac tamponade. The physical examination in subacute cardiac tamponade may reveal hypotension with a narrow pulse pressure, reflecting the limited stroke volume. However, patients with preexisting hypertension may remain hypertensive due to the increased sympathetic activity that is usually present in cardiac tamponade [7].
Diagnosis of cardiac tamponade — The diagnosis of cardiac tamponade is based upon clinical and imaging evidence. Almost all patients with cardiac tamponade have one or more of the following physical findings (see "Cardiac tamponade", section on 'Physical findings'):
●Sinus tachycardia
●Elevated jugular venous pressure
●Pulsus paradoxus
Echocardiography plays an important role in the diagnosis of cardiac tamponade. The echocardiographic features of cardiac tamponade are discussed in detail separately but include the following (see "Cardiac tamponade", section on 'Echocardiography'):
●Collapse of the right atrium at end-diastole and the right ventricle in early diastole (movie 2 and movie 3).
●Reciprocal changes in left and right ventricular volumes with respiration, which are important in the pathogenesis of pulsus paradoxus (figure 1). (See "Pulsus paradoxus in pericardial disease".)
●Increased respiratory variation of mitral and tricuspid valve inflow velocities (drop in mitral flow by 30 percent, and tricuspid valve flow by 60 percent on the first beat of inspiration and expiration, respectively).
●Dilation (plethora) of the inferior vena cava and less than a 50 percent reduction in its diameter during inspiration, reflecting systemic congestion (image 7 and image 8).
Establishing the cause of the effusion — Clinical data and examination of the pericardial fluid and pericardium can be used to establish the cause of the effusion. Frequently, the cause of a pericardial effusion is suspected by the clinical setting in which it occurs. Examples include patients with breast or lung cancer, a recent myocardial infarction, severe hypothyroidism, or end-stage kidney disease. In other cases, the diagnosis may be less apparent. In cases where the cause is not apparent, confirming the precise etiology of a pericardial effusion generally requires sampling of the effusion and/or the pericardium for laboratory analysis. The frequency of different causes of pericardial effusion varies in published reports, depending in part upon geography and patient demographics, as well as the aggressiveness with which an underlying diagnosis is sought (table 2) [8-11]. (See 'Etiology' above and "Etiology of pericardial disease".)
In many cases, the specific etiology of a pericardial effusion cannot be established even when fluid and/or pericardial tissue is available for analysis. The likelihood of establishing a specific cause appears to increase with larger effusions. In series of patients with acute pericarditis (including those with small or undetectable effusions), the underlying diagnosis was established in only about 15 to 20 percent [12,13]. In contrast, studies evaluating moderate to large pericardial effusions have revealed diagnoses in up to 90 percent of cases when very aggressive diagnostic approaches are taken [9]. Such aggressive approaches are often not warranted in clinical practice, however, given the benign natural history of many of these effusions. (See "Acute pericarditis: Clinical presentation and diagnosis", section on 'Establishing a definite etiology'.)
Clinical assessment — Selected clinical information may be helpful for establishing the etiology of a pericardial effusion. This was illustrated in a review of 322 patients with a moderate or large pericardial effusion [8]. In 60 percent of patients, the cause of the effusion was a known medical condition. In the remaining patients, the cause of the effusion was assessed based upon the following features:
●The size of the effusion
●The presence or absence of cardiac tamponade
●Inflammatory signs (defined as two or more of the following features: characteristic chest pain; pericardial friction rub; fever >37°C; and diffuse ST segment elevation)
The presence or absence of these features suggested, but did not confirm, a specific diagnosis [8]:
●The presence of inflammatory signs was associated with acute idiopathic pericarditis (likelihood ratio 5.4).
●A large effusion without inflammatory signs or cardiac tamponade was associated with chronic idiopathic pericardial effusion (likelihood ratio 20).
●Cardiac tamponade without inflammatory signs was associated with a malignant effusion (likelihood ratio 2.9).
Laboratory tests — If the initial history and physical examination do not suggest a specific diagnosis, extensive laboratory testing seeking an etiology is unlikely to be helpful. In such cases, we limit routine testing to:
●Complete blood count
●Chemistry profile and renal function
●Thyroid function
●Chest radiography
A serum antinuclear antibody (ANA) test should be considered in a young woman with an effusion and associated acute pericarditis since, rarely, this can be the initial presentation of systemic lupus erythematosus. A careful history directed toward the presence of a coexisting rheumatologic disorder should also be obtained. It is important to keep in mind that a positive ANA is a non-specific finding. In cases where a rheumatologic diagnosis is being considered in a patient with pericarditis and an effusion, a rheumatology consultation should be sought.
Pericardial fluid analysis and biopsy — Drainage of a pericardial effusion is often performed for therapeutic benefit (ie, in cardiac tamponade). However, pericardial fluid drainage and analysis should be considered for diagnostic purposes in patients without cardiac tamponade if there is significant uncertainty regarding the diagnosis or if knowledge of a particular diagnosis would change the management of the patient (ie, the presence of metastatic malignancy). In addition, pericardial biopsy can be an important part of the diagnostic approach.
The invasive nature of pericardiocentesis and pericardial biopsy must be weighed against two factors: a relatively low diagnostic yield from the procedure, and the clinical relevance of a specific diagnosis, as many low-risk patients can be managed empirically without making a specific diagnosis. The yield of diagnostic pericardiocentesis has varied in different series, but in most, a definitive diagnosis has been made following pericardiocentesis in less than 40 percent of cases [9,10,12]. When an etiology for the pericardial effusion was confirmed, malignancy, purulent infection, and tuberculosis were the most frequently identified causes.
We consider pericardial fluid analysis and pericardial biopsy separately since they are frequently helpful, but many patients are successfully managed without either procedure. Our approach is in general agreement with the 2015 European Society of Cardiology guidelines for the diagnosis and management of pericardial disease [4].
We perform pericardial fluid analysis in the following settings:
●In any patient undergoing therapeutic pericardiocentesis for treatment of cardiac tamponade. (See 'Indications and objectives' below.)
●When there is a clinical suspicion of purulent, tuberculous, or neoplastic pericarditis. (See "Purulent pericarditis" and "Tuberculous pericarditis" and "Pericardial disease associated with malignancy".)
●In patients with moderate-to-large pericardial effusions of unknown etiology that do not respond rapidly to anti-inflammatory therapy.
In patients with chronic pericardial effusions, we do not recommend repeated diagnostic pericardiocentesis due to its low yield.
The biochemical, immunologic, cytologic, and bacteriologic characteristics of an effusion can be established by laboratory analysis of the pericardial fluid. In some cases this analysis can also determine the etiology of the effusion [14,15]. Among the most helpful diagnostic studies are:
●Gram stain and bacterial and fungal culture.
●Cytology.
●AFB stain and mycobacterial culture along with adenosine deaminase, interferon-gamma, or lysozyme (for tuberculous pericarditis) [16].
●Polymerase chain reaction.
Parameters such as protein, LDH, glucose, red cell count, and white cell count are rarely helpful in establishing an etiology; specifically, Light's criteria, used for differentiating transudative versus exudative pleural effusions, do not reliably distinguish exudative from transudative pericardial effusions and should not be applied to pericardial fluid analysis [17,18]. However, a polymerase chain reaction for specific viruses can be ordered when management may be affected by the results, such as identifying CMV in a transplant patient, although the yield of PCR remains fairly low in many instances [19]. (See "Etiology of pericardial disease" and "Tuberculous pericarditis" and "Approach to the diagnosis of cytomegalovirus infection".)
If patient characteristics and local expertise favor pericardial drainage via percutaneous pericardiocentesis, analysis is limited to the pericardial fluid. However, whenever surgical drainage is performed, we also recommend pericardial biopsy. In addition, pericardial biopsy should be performed in any patient in whom there is ongoing diagnostic uncertainty as to the etiology, if a specific diagnosis would significantly change the management.
Pericardioscopy enables endoscopic inspection and targeted biopsy of the parietal and visceral pericardium [1]. This approach has been used in patients with unexplained pericardial effusions or to diagnose recurrent idiopathic effusion [20-23]. When performed in one of the few centers with a special interest and expertise in using this approach, a specific diagnosis was established in 49 to 65 percent of patients, a value higher than generally obtained by pericardial biopsy performed under fluoroscopic guidance [20-22].
TREATMENT — Several issues must be considered in the management of patients with a pericardial effusion, including [24]:
●Presence of cardiac tamponade resulting from a hemodynamically significant effusion (See "Cardiac tamponade".)
●Diagnosis and treatment of the underlying disease (See 'Underlying disease' below.)
●Initial management of large effusions in asymptomatic patients (See 'Initial management of asymptomatic patients with large effusions' below.)
●Management of patients with a chronic large effusion or recurrent idiopathic effusion (See 'Chronic and recurrent effusions' below.)
Pericardial fluid drainage
Indications and objectives — The indications for urgent pericardial fluid drainage (algorithm 1) depend on the level of hemodynamic compromise associated with the effusion [4]:
●Patients with a pericardial effusion and evidence of hemodynamic compromise (ie, cardiac tamponade) should undergo urgent drainage of the pericardial effusion for therapeutic (and potentially diagnostic) purposes.
●Patients with a pericardial effusion who are hemodynamically stable with no evidence of cardiac tamponade do not require immediate drainage of the effusion for therapeutic purposes. However, sampling of the effusion may be indicated for diagnostic purposes in patients without a clear etiology for the effusion.
The choice between pericardiocentesis and open surgical drainage is based upon local preference and experience, and upon individual patient considerations. Pericardial fluid drainage should achieve several objectives, including:
●Immediate treatment and relief of cardiac tamponade, when present
●Procurement of fluid for appropriate analysis (which may include biochemical, cytologic, bacteriologic, and/or immunologic testing)
●Assessment of hemodynamics after pericardial pressure has been lowered to exclude effusive constrictive pericarditis
If there is a strong suspicion of constrictive pericarditis or effusive-constrictive pericarditis and the patient is hemodynamically stable to allow for the extra time required, a right heart catheterization should precede pericardiocentesis, and the right heart catheter should remain in place until the procedure has been completed. Right heart and pericardial pressures are recorded simultaneously; the catheter is then pulled back to the right atrium, where pressure is monitored during and immediately after the procedure. (See "Pulmonary artery catheterization: Interpretation of hemodynamic values and waveforms in adults".)
Percutaneous pericardiocentesis versus surgical drainage — The choice between surgical versus percutaneous pericardiocentesis should be based on the individual experience at a particular institution and specific clinical factors (algorithm 1). Both techniques allow for rapid relief of cardiac tamponade, and pericardial fluid can be sampled or drained either by percutaneous pericardiocentesis or via surgical incision. A brief discussion of the two techniques follows, with a more extensive discussion comparing the two techniques presented separately. (See "Cardiac tamponade", section on 'Choosing percutaneous or surgical drainage'.)
Percutaneous catheter drainage, or pericardiocentesis, is the more common method in most hospitals for draining a pericardial effusion. This can be performed under fluoroscopic or echocardiographic guidance and may be followed by continuous catheter drainage [25-27]. In this approach, an indwelling catheter is placed in the pericardial space, with intermittent or continuous fluid removal until the rate of fluid return is negligible (<25 mL over 24 hours), at which point the catheter is removed. An extensive discussion of pericardiocentesis is presented separately. (See "Emergency pericardiocentesis".)
Surgical pericardiectomy and drainage, though less commonly performed than pericardiocentesis, is often preferred in the following settings:
●The pericardial effusion has reaccumulated after prior percutaneous drainage
●The pericardial effusion is loculated
●Biopsy of the pericardium is desired for diagnostic purposes
●The patient has a coagulopathy
Percutaneous balloon pericardiotomy is an alternative approach that has primarily been used in patients with malignant effusions in whom the quality of remaining life is paramount [28]. (See "Pericardial disease associated with malignancy", section on 'Balloon pericardiotomy'.)
Preparation for elective pericardiocentesis — Prior to elective pericardiocentesis, several preparatory steps should be performed in an effort to optimize procedural success and minimize the potential for complications. Patients should undergo echocardiography to best define the effusion, and patients should be evaluated for bleeding risk.
Echocardiography — An echocardiogram should be done to document the presence of effusion, confirm the location and size of the effusion, and determine if the effusion is loculated. The effusion should be evaluated for evidence of right heart compression and reciprocal respiratory variation of left and right ventricular diastolic dimension, supporting the diagnosis of cardiac tamponade. (See "Cardiac tamponade", section on 'Echocardiography'.)
Echocardiography also provides direct visualization of cardiac structures and adjacent organs, which allows for better determination of the optimal access site and approach. (See 'Pericardiocentesis technique' below.)
Clotting and bleeding disorders — Unless the procedure is very urgent or emergent, a clotting profile and platelet count should be obtained and the results should be available before beginning the procedure. Patients with a thrombocytopenia or a bleeding diathesis, or those who have been treated with anticoagulants or thrombolytics may be at increased risk for hemorrhagic complications following pericardiocentesis.
●In patients on heparin, the procedure can be postponed until the partial prothrombin time is normal, or protamine can be given to reverse the heparin effect.
●In patients on chronic warfarin in whom the INR exceeds 1.4, the options are:
•Postpone the procedure until the INR is normal
•Administer vitamin K and/or fresh frozen plasma (and platelets if thrombocytopenia is also present)
•Manage the patient without pericardiocentesis
•Open surgical drainage
In the absence of hemodynamic compromise consistent with cardiac tamponade, it is generally preferred to delay the procedure until the INR has normalized or to manage the patient without pericardiocentesis. If cardiac tamponade is present and felt to be life threatening, it may not be possible to wait for the INR to normalize, and pericardiocentesis may need to be done on an emergent basis. (See "Emergency pericardiocentesis".)
Pericardiocentesis has been safely performed following prophylactic platelet transfusion in patients with thrombocytopenia. Among a cohort of 212 patients with cancer and pericardial effusion who underwent percutaneous pericardiocentesis, including 35 (17 percent) with severe thrombocytopenia (platelet count less than 50,000/microliter) who received a prophylactic platelet transfusion prior to the procedure, there was no significant difference in risk of bleeding associated with the platelet count [29].
Procedure location — Regardless of the route of approach, the procedure should be performed in the cardiac catheterization laboratory or a procedure room with catheterization laboratory capabilities, even if fluoroscopy is not used. This allows for invasive hemodynamics to be more readily and accurately monitored and recorded in this environment, along with continuous standard electrocardiographic (ECG) monitoring. Additionally, this setting is preferred should a life-threatening complication arise. It is important to have a skilled nurse, a monitor technician, and a sonographer present to assist with the procedure.
Pericardiocentesis technique — Although the greatest experience has previously been with fluoroscopic guidance and a subcostal approach, echocardiographic guidance is becoming increasingly popular, and, in experienced hands, it is now the preferred method in many institutions [27,30-32]. Echocardiography offers several advantages over fluoroscopy:
●Echocardiography permits identification of the configuration of the effusion, particularly where it is closest to the skin.
●Monitoring the position of the needle during the initial puncture is easier and more convenient than with fluoroscopy.
●Patient and staff are not exposed to radiation.
●Agitated saline with microbubbles, rather than radiopaque contrast, is used to verify that the needle is in the pericardial effusion.
Echocardiographic guidance allows the operator to select the shortest route to the effusion, generally near the cardiac apex or along an edge of the sternum, as well as the utilization of a puncture site with the largest collection of fluid and shortest distance from the skin. In the largest published series (1127 therapeutic echocardiographically-guided pericardiocentesis cases), the para-apical location was the most frequently utilized location (68 percent), while the subcostal or subxiphoid was utilized as the ideal location in only 15 percent of cases [27]. When the apical route is chosen, the needle is directed parallel with the long axis of the left ventricle towards the aortic valve. For parasternal insertion, the puncture is made 1 cm lateral to the sternal edge in an effort to avoid both inadvertent puncture of the internal mammary artery when too medial as well as pneumothorax when too lateral.
Once the pericardial space has been accessed, a thin-walled pigtail catheter should be inserted for ongoing drainage. This catheter, with a three-way stopcock attached, may also be used for pericardial pressure measurement. Following catheter insertion and initial pericardial pressure measurement, fluid is then aspirated, and pressures are often remeasured every several minutes to ascertain the hemodynamic result. We also agree with the 2015 European Society of Cardiology guidelines, which recommend drainage of fluid in <1000 mL sequential steps to avoid acute right ventricular dilatation, although this is a rare complication [4,33]. The procedure is continued until pericardial pressure is <5 mmHg, at least during inspiration.
Additional discussion regarding the technical aspects of pericardiocentesis is presented separately. (See "Emergency pericardiocentesis", section on 'Technique overview'.)
Complications of pericardiocentesis — Pericardiocentesis performed electively under controlled conditions is generally safe and effective. The incidence of major complications in experienced hands is 1.2 to 1.6 percent [27,30,34,35]. In the largest series, major complications occurred in only 1.2 percent of cases of echocardiographically-guided pericardiocentesis [27].
Bleeding during pericardiocentesis may be silent, induce typical pericardial pain, or be the cause of acute cardiac tamponade. When pressure measurement, fluid analysis, or contrast injection (using saline bubbles or radiopaque media) demonstrate that a cardiac chamber has been entered and this event is followed by pain or hemodynamic deterioration, the central venous pressure should be reassessed. A value higher than that measured before the puncture indicates cardiac tamponade until proven otherwise.
Management following pericardiocentesis — Following the initial pericardiocentesis, the patient should be observed in a unit equipped to monitor the electrocardiogram, the patency of the pericardial catheter, and the rate of drainage into a sealed container under slight negative pressure. In most cases, pericardiocentesis does not completely evacuate the effusion, and active secretion of fluid or bleeding may result in reaccumulation of an effusion. For these reasons, we recommend that the pericardial catheter be left in place for 24 to 48 hours or until the volume of drainage is less than 25 mL/day.
Extended pericardial catheter drainage of pericardial effusions requiring intervention is associated with lower recurrence rates [26,36]. In a study of 157 consecutive patients with pericardial effusion treated with pericardiocentesis, the rate of recurrent pericardial effusions was significantly lower in patients treated with extended (mean 38 hours) catheter drainage (12 versus 52 percent among those without extended catheter drainage) [36].
Underlying disease — In patients with a pericardial effusion who are hemodynamically stable with no evidence of cardiac tamponade, immediate drainage of the effusion is not required. Instead, diagnosis of the underlying cause of the effusion, with treatment aimed at the underlying condition rather than the effusion itself, may result in clinical improvement and resolution of the effusion without the need for percutaneous or surgical drainage.
The management of specific underlying disease states associated with pericardial effusion, including acute pericarditis, uremia, and malignancy, is discussed separately. (See "Acute pericarditis: Treatment and prognosis" and "Recurrent pericarditis", section on 'Treatment' and "Tuberculous pericarditis", section on 'Treatment' and "Purulent pericarditis", section on 'Treatment' and "Pericardial disease associated with malignancy", section on 'Treatment'.)
Initial management of asymptomatic patients with large effusions — Patients who are diagnosed with a large pericardial effusion with minimal or no evidence of hemodynamic compromise do not require immediate intervention for therapeutic reasons, but pericardial fluid sampling for diagnostic purposes may be indicated (algorithm 1). Such patients may be treated conservatively, with careful hemodynamic monitoring, serial echocardiographic studies (every five to seven days or sooner if clinically indicated), avoidance of volume depletion (including avoidance or judicious use of diuretics), and therapy aimed at the underlying cause of the pericardial effusion. Effusions that progressively enlarge, lead to worsening symptoms suggesting definite cardiac tamponade, or that are otherwise refractory to a conservative approach should be treated with pericardial fluid drainage.
Chronic and recurrent effusions — In patients with large chronic effusions, we perform pericardiocentesis initially because the effusion may not reaccumulate (algorithm 1). If pericardiocentesis is undertaken, careful follow-up over days to weeks is essential because of the significant and unpredictable incidence of future cardiac tamponade. If the effusion reaccumulates, we perform repeated pericardiocentesis or pericardiectomy. The major indication for pericardiectomy is the reaccumulation of pericardial fluid despite repeated pericardiocenteses. For both chronic and recurrent effusions, the 2015 European Society of Cardiology (ESC) guidelines for the management of pericardial disease suggested surgical pericardiectomy only in patients with symptomatic effusions in whom medical therapy and repeated pericardiocentesis were not successful [4]. (See 'Pericardial fluid drainage' above and "Recurrent pericarditis", section on 'Role of pericardiectomy'.)
Pericardial effusions may persist for extended periods and can also recur with repeated episodes of pericarditis. As in other cases of pericardial effusion, management in these settings is based upon the treatment of the underlying disorder, with percutaneous drainage of the effusion reserved for hemodynamically significant or persistently symptomatic effusions [37].
Pericardial effusions that are present for weeks to months, or longer, are referred to as chronic effusions or chronic effusive pericarditis. In such cases, the diagnostic work-up often fails to reveal the cause, although an etiology may emerge over time.
The incidence and significance of chronic effusions has varied somewhat in different reported case series:
●In a report of 100 consecutive patients with idiopathic chronic large pericardial effusion who presented to one of three Italian referral centers between 2000 and 2015, only eight patients developed cardiac tamponade during follow-up (mean 50 months) [38]. While 45 patients underwent a drainage procedure at some point, there was significant regression of the effusion over follow-up in the remaining patients without a drainage procedure.
●In a series of 1108 patients who initially presented with pericarditis between 1977 and 1992, only a very small fraction (28 patients, 2.5 percent) had a large idiopathic effusion that persisted for a median duration of three years [39]. In this study, 58 percent developed cardiac tamponade at some point during follow-up (median three years).
Thus, although chronic effusions are often asymptomatic and hemodynamically tolerated, cardiac tamponade can unexpectedly occur at any time.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pericardial disease".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Cardiac tamponade (The Basics)")
●Beyond the Basics topics (see "Patient education: Pericarditis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Etiology – Pericardial effusion can develop in patients with virtually any condition that affects the pericardium (table 1), including acute pericarditis and a variety of systemic disorders. The frequency of different causes of pericardial effusion varies in published reports, depending on factors including geography and patient demographics, as well as the aggressiveness with which an underlying diagnosis is sought (table 2). (See 'Introduction' above and 'Etiology' above.)
●Clinical presentation – The presence of pericardial effusion may be suspected from the history, physical examination, ECG, and chest radiograph. However, in the absence of cardiac tamponade, physical signs are not sensitive or specific for pericardial effusion. (See 'Clinical presentation' above.)
●Diagnosis and evaluation – The approach to diagnosis and evaluation of pericardial effusion consists of the following steps:
•Diagnosis – The presence of pericardial effusion is usually established with echocardiography. (See 'Establishing the presence of effusion' above.)
•Assess the hemodynamic impact – Both clinical and echocardiographic findings can be helpful in assessing the hemodynamic impact of a pericardial effusion. Cardiac tamponade occurs when the intrapericardial pressure from an accumulating pericardial effusion impedes filling of one or both ventricles. (See 'Assessing hemodynamic impact' above.)
•Establish the cause – In some cases, the most likely cause of the pericardial effusion will be clear due to the presence of another illness or systemic disorder known to involve the pericardium. If the cause is not apparent, the routine use of a broad panel of screening laboratory tests is not usually helpful. In such cases, evaluation of the pericardial fluid and pericardium itself may suggest an etiology, particularly if the effusion is large. (See 'Establishing the cause of the effusion' above.)
●Management – The management of a pericardial effusion involves the management of its hemodynamic consequences (ie, cardiac tamponade) and treatment of the underlying cause. Treatment of hemodynamically stable pericardial effusions should focus on treatment of the underlying condition rather than the effusion itself. This may result in clinical improvement and resolution of the effusion without the need for percutaneous or surgical drainage. (See 'Underlying disease' above.)
●Role of pericardiocentesis – Decisions regarding pericardial fluid drainage depend on the level of hemodynamic compromise associated with the effusion (algorithm 1) (see 'Indications and objectives' above):
•Hemodynamic compromise – Patients with a pericardial effusion and evidence of hemodynamic compromise (ie, cardiac tamponade) should undergo urgent drainage of the pericardial effusion for therapeutic (and potentially diagnostic) purposes.
•Hemodynamically stable – Patients with a pericardial effusion who are hemodynamically stable with no evidence of cardiac tamponade do not require immediate drainage of the effusion for therapeutic purposes. However, sampling of the effusion may be indicated for diagnostic purposes in patients without a clear etiology for the effusion. Patients in whom the initial approach is observation should undergo serial echocardiographic studies (every five to seven days or sooner if clinically indicated), avoid volume depletion (including avoidance or judicious use of diuretics), and receive therapy aimed at the underlying cause (if known) of the pericardial effusion. (See 'Initial management of asymptomatic patients with large effusions' above.)
●Pericardiocentesis technique – We recommend using an echocardiographically guided approach for pericardiocentesis whenever possible. Echocardiographic guidance allows the operator to select the shortest route to the effusion, generally near the cardiac apex or along an edge of the sternum, as well as utilizing a puncture site with the largest collection of fluid and shortest distance from the skin.
Once the pericardial space has been accessed, a thin-walled pigtail catheter is inserted for ongoing drainage. This catheter, with a three-way stopcock attached, may also be used for pericardial pressure measurement. (See 'Pericardiocentesis technique' above.)
●Management following pericardiocentesis – Pericardiocentesis does not completely evacuate the effusion in most cases, and active secretion of fluid or bleeding may result in reaccumulation of an effusion. For these reasons, we recommend that the pericardial catheter be left in place for 24 to 48 hours or until the volume of drainage is less than 25 mL/day. (See 'Management following pericardiocentesis' above.)
●Management of chronic pericardial effusions – Pericardial effusions that are present for three months or more are referred to as chronic effusions or chronic effusive pericarditis. In patients with large chronic effusions, we perform pericardiocentesis alone initially because the effusion may not reaccumulate. If pericardiocentesis is undertaken, careful follow-up over days to weeks is essential because of the significant and unpredictable risk of future cardiac tamponade. If the effusion reaccumulates, we perform repeated pericardiocentesis or pericardiectomy. (See 'Chronic and recurrent effusions' above.)
