Show me the POCUS
Cardiac Tamponade
Cardiac tamponade is a medical emergency as a cause of obstructive shock. It is defined as a decompensated cardiac compression caused by pericardial fluid accumulation and rising intrapericardial pressure. The good news here is that we can make the diagnosis of tamponade based on focused cardiac ultrasound (FoCUS).
Physiology recap.
During spontaneous ventilation the negative intrathoracic pressure generated increases RV preload. The blood in the RV restricts full expansion of the LV limiting LV preload. The pulmonary veins also receive less blood as a consequence of the negative intrathoracic pressure. This also causes less LV preload. As a consequence stroke volume and CO drops to lower levels on inspiration when breathing spontaneously. This is the paradoxical pulse. The opposite occurs in a patient undergoing mechanical ventilation as the inspiration causes a drop of RV preload. Under normal circumstances the respirophasic differences of BP due to inspiration is less than 10mmHg as seen on figure 1.
Inspiration
Expiration
Figure 1. Diagram showing normal respirophasic changes in volumes of the ventricles. On inspiration the RV has more preload due to the negative intrathoracic pressure. There is less return of blood from the pulmonary veins plus the interventricular septum gets displaced to the left. The cardiac output thus is lower on inspiration. During expiration the preload of the RV decreases, more blood gets returned on the LV via the pulmonary veins and the preload of the LV which result in LV cardiac output. Blue and red representing RV and LV chambers respectively. Image modified from Patrick J Lynch and Carly Jaffe MD.
Cardiac Tamponade Features
Pericardial fluid accumulates around the heart but it is not the volume per se but the change in pressure that is important that impairs filling of the heart. The right sided heart structures normally operate at a lower pressure than those on the left to keep fluid moving forward. With pericardial fluid, the pressure differential between the right sided chambers and the pericardial fluid restricts movement of flow into the RV. In essence once the pericardial sack generates more pressure than the pressure needed to deliver preload to the RV we have tamponade. The RV then receives less preload which ultimately results in hemodynamic compromise. Keep in mind that a pericardium that accumulates blood slowly has more time to adapt to the changes in pressure than one that does so fast. The importance here is that the volume in the pericardium is not as important as its physiologic effect on the heart and cardiac ultrasound can help us with this.
Patients with tamponade have thus exaggerated respirophasic features. As mentioned, the increased intrapericardial pressure restricts flow to the right sided structures. On inspiration thus the RV tries to accommodate this restriction of flow by invaginating the interventricular septum into the LV. This ultimately results in a lower stroke volume and cadiac output and clinically seen as a drop in BP greater than 10mm Hg. This is called pulsus paradoxus.
Inspiration
Expiration
Figure 2. Diagram showing exaggerated respirophasic changes in the volumes of the ventricles with a pericardial effusion causing tamponade physiology. On inspiration the RV has more preload due to the negative intrathoracic pressure. Blue and red representing RV and LV chambers respectively. Image modified from Patrick J Lynch and Carly Jaffe MD.
Pericardial Effusion
Let's start by showing you what a pericardial effusion looks like on the parasternal short and long axis. Is there pericardial tamponade on these clips?
Pericardial effusion as seen on the parasternal long and short axis. A small anechoic fluid collection is seen on the posterior aspect of the heart on the long axis view. On the short axis view, the collection is seen on the anterior aspect of the pericardium.
Ultrasound features of tamponade
The following are cardiac ultrasound signs suggestive of cardiac tamponade that we will be exploring in this chapter:
1. Right sided chamber collapse. This appears when intrapericardial pressure exceeds intracardiac pressures. Diastolic collapse of the right atrium. During atrial relaxation (end-diastole), the RA volume is minimal but pericardial pressure is at it's highest causing collapse of this chamber. RA collapse that persists for more than 1/3 of the cardiac cycle is highly sensitive and specific of cardiac tamponade. The diastolic collapse of the RV is less sensitive than RA diastolic collapse for cardiac tamponade but it is more specific.
2. Respiratory variation in volumes and flows that can be appreciated with pulsed wave doppler (explained in this section but not part of focused cardiac ultrasound).
Sonographic features of Cardiac Tamponade.
Echocardiography and recently cardiac ultrasound is the primary diagnostic modality for the diagnosis of cardiac tamponade.
Early on right atrial collapse is seen in late diastole is an early sign of tamponade physiology and 100% sensitive. As pericardial pressure increases, the right ventricle presents with diastolic collapse in early diastole. We may also observed bowing of the IVS towards the LV during inspiration and towards the RV during expiration.
We can also observe the IVC diameter and its changes with respiration. With tamponade, the IVC is enlarged and does not vary with inspiration.
Features of tamponade. On the images above we see pericardial fluid. The heart rate is fast as a response to the decreased CO. This makes it difficult to asses the heart movement during diastole. The interrogation here lies on the right sided structures so we need to slow down the speed so that we can time diastole correctly with the cardiac cycle. The features above are typical of cardiac tamponade including diastolic collapse and a plethoric non collapsible IVC.
Slow speed to look at RV
In the clips below the same clip has been slowed so that we can have a better appreciation at the RV and the effects of the surrounding pericardial fluid. The label Diastole on the clip marks the duration of diastole (opening to closing of the mitral valve). RV collapse is seen when the dot appears on the screen. Chronologically the Diastole appears and we observe that the RV collapses almost immediately in the early stages of and throughout almost all diastole in this clip.
Tamponade physiology. Both clips correspond to the same case. On an ultrasound machine you can freeze a clip and go back frame by frame. The idea here is to evaluate the motion of the right ventricle after the mitral valve opens until it closes.
Lets slow it down even more to look at the RV
This is what we would see if we could slow the frame rate on the ultrasound machine:
The same clip as above but slowed further so that you can observe the timing of the RV collapse better. This patient has cardiac tamponade. A white dot appears close to the RV and it is meant to represent the collapse of the RV. The words Diastole appear on the screen for the duration of diastole from onset to end. We can see that the RV collapses almost immediately after diastole begins. The clips above are from the same case with the exception of one clip being slower than the other.