Cardiac Tamponade

This TTE image is a parasternal long axis view. To obtain a parasternal long axis view, place phase array transducer at the left sternal border in the left 3rd-4th intercostal space with the probe indicator directed towards the patient’s right shoulder.

In this image, you have a large circumferential pericardial effusion causing dynamic diastolic collapse of the RA/RV. This is cardiac tamponade.

We can differentiate pleural effusions from pericardial effusions by looking for the location of the anechoic fluid relative to the aorta.

• When the fluid is between the aorta and the LA/LV it is pericardial.

• When the fluid extends behind the aorta (closer to the bottom of the screen), it is pleural.

Normally, there is ~10mL of pericardial fluid to lubricate the space between the heart and the pericardial sac. Cardiac tamponade is not a volume-dependent phenomenon, but can occur at low volumes accumulating over a short amount of time. Therefore, all patients with pericardial effusions should be closely evaluated.

Clinical cardiac tamponade is associated with Beck’s triad (hypotension, muffled heart sounds, and JVD); however, this is fairly uncommon in practice. Echocardiographic cardiac tamponade is TTE features of tamponade physiology in the asymptomatic patient.

In the hypotensive fluid with cardiac tamponade, bolus fluids and emergent pericardiocentesis is recommended. Pericardial window can be performed, but if the underlying etiology off the effusion is not addressed, the effusion will recur as the pericardial sac scars down after window. Definitive treatment is targeting the underlying cause.