Pericardial effusionI31.3

In 1888, Hasebrock described pericardial effusion for the first time in his publication "Analysis of a Cyclic Pericardial Fluid" in the journal Physiologische Chemie (Kawano 2012).

A pericardial effusion is the accumulation of fluid between the two pericardial sheets that exceeds the normally occurring amount of fluid of approximately 10-50 ml (Pinger 2019).

According to Pinger (Pinger 2019), pericardial effusion is differentiated between:

• exudate
• Transsudate
• Hydropericardium
• Hematopericardium
• Pyopericardium

and chronologically between

• < 1 week (acute effusion)
• 1 week to 3 months (subacute effusion)
• > 3 months (chronic effusion)

According to Horowitz, a pericardial effusion is divided into the following types according to the movement patterns of the two pericardial sheets in the time-motion echocardiogram according to Maisch (Maisch 2008):

• Type A: no effusion detectable
• Type B: an exclusively systolic separation between the pericardium and epicardium, which results in systolic movement of the pericardium (so-called wet pericardium)
• Type C: also an exclusively systolic separation between pericardium and epicardium, but there is no systolic movement of the pericardium
• Type D: this leads to a systolic and diastolic separation of the pericardium (corresponds to the classic effusion)
• Type E: after the effusion has healed, there is a thickening or fibrosis of the pericardium, which shows a movement in the systole
• Type F: this is an effusion that has been healed and where the pericardium is still moving along with the systole
  

A malignant pericardial effusion can be detected in autopsies in the Anglo-Saxon region in about 5% - 10% of tumor patients (Kasper 2015).

All diseases of the pericardium can cause pericardial effusion:

• infectious or non-infectious pericarditis (especially tuberculosis)
• tumorous diseases (both secondary metastatic tumours and primary tumours)
• iatrogenically caused by e.g. pacemaker implantation, catheter interventions etc.
• Heart failure
• Cirrhosis of the liver
• nephrotic syndrome
• rheumatological disorders
• Myxoedema
• Gravidity (occurs in otherwise healthy women)

- amongst other things

In developing countries, tuberculosis is the main cause of pericardial effusion. In our latitudes the cause often remains unexplained (idiopathic). Large effusions are typically found in patients with malignancies, tuberculosis, uremia, myxedema and parasitosis (Pinger 2019).

A large proportion of patients are completely asymptomatic. The effusion is diagnosed as a random finding.

Otherwise the following symptoms may occur:

• Dyspnea, initially on exertion, later also at rest
• Hoarseness (by pressure on the N. recurrens)
• Singultus (also by pressure on the N. recurrens)
• Cough
• Chest pain
• Dysphagia with compression of the esophagus

In addition, there may also be symptoms of the underlying disease, such as

• loss of appetite
• Fever
• general weakness etc.

(pingers 2019)

In earlier times, tuberculosis was found to be the most common cause of a pericardial effusion; nowadays, the first consideration in any chronic effusion - until proven otherwise - should be malignancy.

In younger patients with a corresponding risk profile (homosexuals, occupational handling of blood products, hemophilia patients, drug addicts, etc.), HIV infection should be excluded in any case (Kunert 2006).

Auscultation: The heart sounds are usually attenuated.

Laboratory diagnostics: Depending on the clinical constellation, the following laboratory values should be determined (Pinger 2019):

• Blood count including a diff. BB (in case of tuberculosis detection of specific T-lymphocytes by Elispot technology)
• Establishment of a bacterial culture

optional:

• Determine tumor markers (e.g., AFP, CA125, CA72-4, CA15-3, CA19-9, CEA, CD30, CD25, cytology).
• Tuberculosis diagnostics (e.g. culture or BACTEC detection, lysozyme or IFN-gamma, ADA, PCR)
• Viral diagnostics (e.g. PCR diagnostics for cardiotropic viruses to differentiate a viral effusion from an autoreactive effusion)

ECG

• peripheral low voltage
• in case of a large pericardial effusion (swinging heart), an electrical alternans may occur due to the rhythmic amplitude change
• non-specific T-wave changes

X-ray image

• typically, a so-called Bocksbeutel heart, also called "water-bottle silhouette" is found (this is detectable from approx. 250 -300 ml effusion volume)
• There may be native radiological findings (e.g. round focus, lymphangiosis carcinomatosa, etc.).

Echocardiography: Echocardiography is the most sensitive and at the same time the easiest method to detect or exclude a pericardial effusion. In addition, the hemodynamics of the effusion can be assessed. An effusion is echocardiographically detectable from about 15 ml and, moreover, diastolic touch of the pericardial leaflets is absent in the presence of an effusion (van Aken 2007).

According to Maisch (Maisch 2008), the extent of effusion is echocardiographically divided into:

• small effusion (the anechoic diastolic separation of peri- and epicardium is < 10 mm)
• moderate effusion (diastolic separation is between 10mm - 20 mm)
• large effusion (diastolic separation is more than 20 mm)
• very large effusion (diastolic separation is more than 20 mm and there are additional signs of compression).

Note: It is always advisable to perform ultrasound examinations from both the parasternal and subcostal sides, as this makes it possible to differentiate between a pericardial effusion and a pleural effusion. If there is both pleural and pericardial effusion, both can be differentiated by observing the descending aorta located below the left atrium in parasternal longitudinal section: In the case of the aorta, it is possible that it is separated from the left atrium by fluid in the pericardium. This is not possible with pleural effusion (Kunert 2006).

Look for signs of a so-called swinging heart and distinguish it from mitral or tricuspid prolapse or a SAM (Systolic Anterior Movement) phenomenon of the mitral valve, which may be feigned by the sweeping movements of the heart (Engberding 2013).

Rule out any signs of tamponade or tumor infiltration (Pinger 2019).

To assess the development of pericardial effusion, Herold (Herold 2018) recommends:

• close-meshed blood pressure checks (if the effusion increases, the blood pressure drops)
• regular CVD measurements (and the CVD increases)
• Echocardiography checks

Computed tomography / cardiac magnetic resonance imaging: Computed tomography can accurately quantify the pericardial effusion. Particularly localized effusions can be better assessed here than in sonography, since the echo-free space behind the heart and, in the case of large effusions, also in front of the heart can be better visualized (Herold 2018). In addition, CT can differentiate between hemorrhagic and serous effusion based on the different density values, which may be important for further diagnosis. In cases of unclear effusions, CT or cardiac magnetic resonance imaging should always be performed, as these two types of examinations are the best imaging methods for excluding or detecting space occupying lesions in the mediastinum, lungs, or pericardium (Maisch 2008). However, the EACVI 2015 (European Association of Cardiovascular Imaging) recommends CT only in cases of moderate or large effusion with v. a. aortic dissection or in cases of Z. n. trauma (Cosyns 2015).

Puncture: If the effusion is first detected and uncomplicated, routine puncture can be expected to yield only a low diagnostic yield (pericardiocentesis of 32 patients yielded a confirmed diagnosis in only 2 cases [Pinger 2019]).

However, puncture is always indicated in cases of purulent pericarditis or malignant effusion (Pinger 2019). Prolonged drainage for a few days should be inserted during this procedure, as this can reduce the recurrence rate (Adler 2015).

The pericardial effusion should then be examined molecularly, immunologically, and cytologically for further diagnosis to allow rapid initiation of etiopathogenetic therapy (Maisch 2008).

The causative underlying disease should be treated immediately - if it was detectable at diagnosis.

Drug therapy: A proven drug therapy option that would lead to a reduction of the amount of effusion is not known. If there are signs of systemic infection and in cases of pericarditis, NSAIDs / ASS plus colchicine should be used. However, this drug treatment is not promising in the absence of signs of inflammation (Pinger 2019).

Suggested therapy (Herold 2018):

• e.g. Ibuprofen 600mg every 8 h
• as stomach protection cimetidine 200mg - 400mg / d
• Colchicine 0,5 mg/d

Pericardial puncture/pericardiocentesis: A pericardial effusion does not always have to be punctured. If the effusion proves to be haemodynamically stable, further follow-ups can be waited for. According to ESC 2015 (European Society of Cardiology), the indications for therapeutic pericardiocentesis for tamponade prophylaxis are as follows:

• a large subacute effusion (after about 4-6 weeks) with collapse of the right atrium and right ventricle
• a large, chronic effusion that lasts longer than 3 months (Adler 2015)

Particularities and special aspects of individual causative factors of pericardial effusion:

Chronic idiopathic effusion: This is defined as an effusion that persists for > 3 months without a detectable cause. In this case, the further procedure should be decided on a case-by-case basis. In case of stable hemodynamics and depending on the size of the effusion, it is possible to wait and see. Otherwise a pericardiocentesis should be performed.

In the case of autoreactive genesis of pericardial effusion, instillation with 300 mg triamcinolone (Pinger 2019) for 24 hours is recommended.

Malignant pericardial effusion: A malignant pericardial effusion is usually a secondary metastatic infection, more rarely a primary tumor of the pericardium. The effusion is predominantly hemorrhagic. However, since the effusion is not caused by the malignant event in up to two thirds (!) of cases, despite the presence of the tumour, the biopsy with cytological analysis is essential for the diagnosis of "malignant effusion" (Pinger 2019). Therapeutically, depending on the histology, staging and grading, a tumor-targeted treatment should be performed.

According to Pingert (Pinger 2019) there are several options with regard to the effusion:

• Performance of a pericardiocentesis
• Installation of a prolonged drainage system
• intrapericardial instillation treatment for sclerotherapy (e.g.
  • Tetracycline 1 - 8 x 0.5 g - 1.0 g; the treatment is inexpensive, but often causes fever and pain
  • Bleomycin 1- 2 x 5 mg - 30 mg in 20 ml NaCl; the treatment has fewer side effects but is more expensive)

Pericardial effusion in the gravidity: This type of effusion is often clinically inapparent. There are no signs of existing or past pericarditis. Possible pregnancy-associated ECG changes are not related to the effusion. A therapeutic measure is not necessary.

The prognosis of pericardial effusion depends on the genesis.

Effusions occurring during pregnancy heal without complications without therapeutic measures (Pinger 2019).

The situation is different for malignant effusions. After pericardiocentesis a recurrence occurs in about 38 %. With prolonged drainage the recurrence rate is 12 % and with intrapericardial instillation therapy it is 11 %.

The median survival time for malignant pericardial effusions is about 2 months, 25% of patients survive up to 11 months (Pinger 2019).

In the case of a chronic, idiopathic effusion, tamponade is to be expected in about 29% of cases. Patients should therefore be informed about the possible symptoms. If the effusion has been treated by pericardiocentesis, 42% of the patients show a sustained therapeutic success (Pinger 2019).

In the case of effusion caused by autoreactive pericarditis, 82% of patients are expected to be free of recurrence in the first year (Pinger 2019).

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