What is a pericardial effusion?
A pericardial effusion is the accumulation of fluid within the pericardium surrounding the heart.
The volume of fluid within the pericardial sac may increase due to bleeding or effusion (eg due to pericarditis).
Pericardial effusion depends on the amount of fluid that has accumulated, usually from 20 to 50 ml and in extreme cases (eg with tuberculous pericarditis) it can increase up to two liters.
The effusion pericardium is rare.
What happens if there is an increased accumulation of fluid in the pericardial cavity (heart sac)?
Because the outer layer of the pericardium is not very elastic, there is increased pressure on the heart muscle when an effusion occurs.
This restricts the activity of the heart. This prevents the heart chambers from being sufficiently filled with blood.
However, the pressure in the heart chambers continues to rise. As a result, the heart cannot pump enough blood to the body.
Smaller pericardial effusions are often asymptomatic.
In other cases, the following symptoms appear:
- Pain behind the sternum or tightness (especially when lying down and when breathing)
- general weakness
- Pain in the upper abdomen with an enlarged liver and congestive cirrhosis (cardiac cirrhosis)
- Fast breathing and shortness of breath
- Reduction of Blood pressure
- Tachycardia, palpitations
- Dysphagia (esophageal compression)
- Hoarseness (compression on the recurrent laryngeal nerve)
- hiccups (pressure of the phrenic nerve)
- Cough (compression of the trachea or bronchi)
Depending on the cause, there may be additional symptoms, such as fever in the case of infective pericarditis.
After analyzing all cases of pericardial effusion, the following signs were found in case of acute pericardial effusion or cardiac embolism:
- Reduction of Blood pressure
- jugular vein congestion
- pallor (peripheral vasoconstriction)
- Shortness of breath, rapid breathing
- heart attack
- contraction stop
- Associated sympathetic symptoms: sweating, insomnia
Possible causes of all cases of pericardial effusion
Pericardial effusion is a common finding of pericarditis. Pericarditis, which can lead to pericardial effusion, is caused by:
- Infectious infections (mostly caused by viruses)
- Rheumatic infections (due to autoimmune diseases)
- Malignant cause (due to a tumor)
- after a heart attack
- Post-traumatic (post-traumatic)
- after surgery (post-operative)
- uremic medium (as a result of urinary intoxication)
- Iatrogenic (due to medical procedures)
The classic symptoms of right heart failure are blue lips, engorged veins in the neck, enlarged liver, and edema in the arms and legs.
What complications can arise?
Pericardial tamponade or pericardial embolism is a life-threatening complication and pericardial effusion is one of the most serious heart diseases where there is acute heart failure with sudden drop in blood pressure and shock. The buildup of so much fluid occurs in the pericardium that the heart is no longer able to function properly. In addition, the heart muscle is not adequately supplied with oxygen and nutrients through the coronary arteries.
It is an emergency situation that needs immediate attention to treat pericardial effusion. As a rule, the pressure here is relieved by pericardial puncture, with which the pericardial effusion is treated on the amount of fluid absorbed.
How is pericardial effusion diagnosed?
Rapid diagnosis can now be made using ultrasound (echocardiography). Pericardial effusion can also be seen well on a CT scan of the heart. In addition, the fluid in the effusion can be examined cytologically for malignant cells and bacteria after paracentesis. The analysis of puncture fluid includes the following aspects:
- Macroscopic evaluation: such as blood, secretions, lymph
- microbiological examination
- Molecular biological examination (eg polymerase chain reaction (PCR) for viral pericarditis)
- Determine the number of cells
- Malignant cell examination
Laboratory tests may also provide information about the underlying cause of a pericardial effusion, for example:
- Increased CRP in bacterial cause
- Elevated renal parameters in uremic toxicosis
- Antibody diagnosis in autoimmune pericarditis
How is pericardial effusion treated?
Small pericardial effusions don't need treatment.
Depending on the cause of the disease, drug therapy can be started. However, in the case of a larger effusion, emergency treatment should be performed by pericardial puncture, in which the effusion is withdrawn through a cannula. The puncture is done under echocardiography so that the doctor always has control and can know where and how the puncture should be done.
Another option is pericardial drainage. Here, the effusion is drained via a catheter. In contrast, in the case of chronic recurrent pericarditis, a percutaneous pericardiotomy is performed, for example. As with the piercing, it is also performed through the chest wall below the sternum. With the help of a catheter and a balloon, compressed air is used to blow a hole in the pericardial wall. The main advantage of this procedure is that the effusion can initially flow over a longer period of time and conventional treatment is possible and depends on the nature of the flow of the pericardial effusion. There is also the option of a pericardial window placement, where a 'window' is cut into the pericardium so that the effusion can flow better. Treatment of a pericardial effusion depends on the amount of fluid drained.
In rare and severe cases of pericardial effusion, acute or chronic, it may be necessary to remove the pericardium. Especially when the scarring of the last effusion is so severe that it severely hampers the heart's activity even if it heals. For example, an armored heart develops as a result of pericarditis. Removal of the pericardium is also known in medicine as Pericardectomy.
Endoscopic pericardial window
A puncture is made in the pericardium via thoracoscopy so that the effusion can be drained or reabsorbed.
What preparations are made?
Before the operation, an attempt is generally made to relieve the effusion by puncturing the pericardium and inserting a tube (drainage). If this is not enough or if the effusion continues to form again, then a pericardial window procedure is used. The operation is performed under general anesthesia with the usual preparations for anesthesia.
How is the process?
For the pericardial openings, the thoracoscope is inserted into the chest cavity through an incision approximately 10 cm in length below the left fifth costal arch. An opening (window) is cut in the pericardium under the guidance of the camera so that fluid can be emptied into the chest cavity. There it is absorbed by the pleura (pleura). After the pericardial window, a drainage tube is usually placed to facilitate drainage. The process takes about an hour. The tube is removed after two to three days. The entire hospital stay generally takes 4 to 5 days.
What is the treatment success rate?
The results are usually very good. The effusion is eliminated with a pericardial window. The "hole" in the pericardium does not affect the heart. For better results, the underlying disease that caused the effusion must be treated.
What are the complications or risks of treatment?
This procedure is low-risk and generally has no complications. However, as with all operations, infection, bleeding or blood clots can occur in rare cases.
What happens after the operation?
After the pericardial window, it is necessary to perform ultrasound examinations the first time after the procedure to check the progress and to ensure that no new effusions form.
Chronic inflammation of the pericardium can cause the pericardium to thicken over time and form a crust that narrows the heart. This phenomenon is also called an armored heart. In this case, surgical treatment consists in partial or complete removal of the pericardium (pericardiectomy).
What preparations are made before pericardectomy?
Pericardectomy is performed under general anaesthesia. Accordingly, the usual clarifications are necessary before the operation, such as blood tests, ECG, measurement of blood pressure. You are admitted to the hospital the day before the operation.
How is pericardectomy performed?
For a pericardiectomy, the chest cavity is opened through a thoracic incision, which is an incision between the ribs. The surgeon then cuts out the pericardium partially or completely, depending on the extent of the blockage of the pericardium. The removed pericardium does not need to be replaced. The heart can move freely in the chest cavity without the pericardium. The procedure is usually possible without the use of a heart-lung machine.
What is the success rate Pericardectomy?
The results are excellent. After a short period of getting used to the new position without the pericardium, the heart is working properly again.
What are the complications or risks of pericardectomy treatment?
Pericardectomy is considered low-risk and generally without complications. However, as with all operations, infection, bleeding or blood clots can occur in rare cases.
What happens after pericardectomy?
As the heart has to get used to the new situation, intensive monitoring is necessary for a few days after the procedure and circulation should be supported with medication. Until the wounds have completely healed, heavy lifting and strenuous physical exertion should be avoided. After the procedure, heart function is checked regularly over a longer period of time.