Approach

Cardiac tamponade is a medical emergency requiring urgent treatment.

Patients with confirmed tamponade on echocardiographic evaluation require stabilisation with pericardial drainage through needle pericardiocentesis or surgical drainage; the preferred approach will depend on the underlying tamponade aetiology and on patient comorbidities.[15] Following intervention, patients must be monitored (preferably in an intensive care unit) for pericardial decompression syndrome: a rare, but life-threatening complication of pericardial drainage that results in paradoxical haemodynamic instability and/or pulmonary oedema.[47]​​

Medical therapy is generally ineffective in the treatment of tamponade. Intravenous fluids may be given to hypovolaemic patients; however, this only provides temporary stability.[48][49] Inotropes are ineffective, and neither vasodilators or diuretics are recommended in tamponade management.[15]​ Positive pressure mechanical ventilation may further decrease cardiac filling, as it increases intrathoracic pressure, and therefore should be avoided.[50]​​​​

Concomitant management of any identified underlying aetiologies is key.[15] Further diagnostic investigation is required in patients without an apparent cause of tamponade.​

Management of patients without haemopericardium, trauma, or purulent effusion

In the absence of haemorrhage, trauma, and purulence, patients with cardiac tamponade should be treated with needle pericardiocentesis under echocardiographic or fluoroscopic guidance.[15]​ Pericardiocentesis should be undertaken immediately in patients presenting with sudden haemodynamic collapse and large pericardial effusion. In extreme, life-threatening circumstances where tamponade is known or suspected but imaging guidance is not available, pericardiocentesis should be attempted by experienced operators using anatomical landmarks.

Major complications include: laceration of the coronary arteries or myocardium, laceration of the liver or abdominal viscera, air embolus, pneumothorax, damage to the phrenic nerve, or arrhythmias.[51][52] Such complications occur in 1.5% to 2.0% of cases using echocardiographic guidance and in about 1% of cases using fluoroscopic guidance.[34][53]

Pericardiocentesis is contraindicated in aortic dissection and relatively contraindicated in patients with severe coagulopathy.[15]​ Immediate surgical drainage may be considered as an alternative option if pericardiocentesis is contraindicated.

Management of patients with haemopericardium, trauma, or purulent effusion

Surgical drainage is indicated in the management of cardiac tamponade complicated by haemopericardium, trauma, or purulent effusion.[15]

Although several surgical modalities exist for pericardial drainage, there is a lack of randomised trials comparing outcomes between different techniques. Choice of modality, therefore, depends on the surgeon’s preferred technique and the underlying aetiology.

The traditional surgical approach involves a small subxiphoid incision, direct visualisation of the pericardium, and incising the parietal pericardium. Drainage through video-assisted thoracoscopy with the creation of a pericardial window is another approach that creates a communication between the pleura and the pericardium, allowing the pericardium to decompress.[54] One small retrospective study found an association with increased operative time and periprocedural morbidity, but a lower recurrence of effusion and tamponade.[55]​ Balloon pericardiotomy is a percutaneous, minimally invasive approach that has good short-term success rates and a low incidence of recurrent effusion or tamponade.[15]

Management of patients with pericarditis

In patients with cardiac tamponade secondary to non-purulent pericarditis (i.e., viral or idiopathic), treatment with a non-steroidal anti-inflammatory drug (NSAID) and colchicine should be given alongside the intervention.[56] This is to prevent pericardial fluid re-accumulation. Where pericarditis is refractory to initial medical treatment, or recurs after initial response, the addition of a corticosteroid or interleukin-1 inhibitor should be considered. The AIRTRIP trial, a randomised trial of anakinra versus placebo for refractory pericarditis in 21 patients, showed that anakinra was significantly associated with reduction in the occurrence of recurrent pericarditis and led to the discontinuation of corticosteroids in all patients compared with placebo.​[57]​ In the RHAPSODY trial, rilonacept monotherapy significantly reduced the recurrent of pericarditis.

Purulent pericarditis is a rare occurrence with the advent of antibiotics, although it is a strong risk factor for tamponade.[32]​ Where it is suspected, intravenous antibiotic therapy must be started immediately.

See Pericarditis.

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