Pericardial Effusion | Cedars-Sinai

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What is pericardial effusion?

Pericardial effusion is the buildup of extra fluid in the space around the heart.
If too much fluid builds up, it can put pressure on the heart. This can prevent it
from pumping normally.

A fibrous sac called the
pericardium surrounds the heart. This sac consists of two thin layers. Normally, there
is a small amount of fluid between them. The fluid reduces friction between the two
layers as they rub against each other during each heartbeat. In some cases, extra
fluid
can build up between these two layers leading to a pericardial effusion.

A little fluid won’t cause much of
a problem. But if too much fluid builds up, it can make it hard for the heart to expand
normally. This condition is called cardiac tamponade. It usually requires emergency
treatment. Because the heart can’t expand normally, less blood can enter the heart
from
the body. This can reduce the amount of oxygenated blood going out to the body. But
not
all pericardial effusions cause cardiac tamponade.

In some cases, pericardial effusion
develops quickly. This is known as acute pericardial effusion. Other times, the fluid
builds up slowly. This is known as subacute pericardial effusion. Chronic pericardial
effusion occurs when cardiac effusion happens more than once over time.

What causes pericardial effusion?

A number of conditions can cause excess fluid and inflammation in the pericardial
sac, such as:

• Cancer (spread from another part of the body or from the heart tissue itself)
• Infection of the pericardial sac, such
  as from viral or bacterial infections
• Inflammation of the pericardial sac
  (for example, because of a heart attack)
• Injury (including those from medical
  procedures on the heart)
• Immune system problems
• Metabolic causes, like kidney failure with uremia
• Reactions to certain medicines
• Radiation

Sometimes the cause of fluid buildup is unknown.

What are the symptoms of pericardial effusion?

You may not have any symptoms. This
is more often the case with a mild effusion. You might be more likely to have symptoms
from whatever is causing the pericardial effusion. For example, you might have fever
if
you have an infection of the pericardial sac.

When effusion is more severe, you may have symptoms such as:

• Chest pain or discomfort
• Enlargement of the veins of the neck
• Fainting
• Fast breathing
• Increased heart rate
• Nausea
• Pain in the right upper abdomen
• Shortness of breath
• Swelling in the arms and legs

If the effusion is very severe, it
can also lead to very low blood pressure. This can cause symptoms of shock. These
include:

• Lightheadedness or dizziness
• Cool arms and legs
• Clammy skin
• Weakness
• Rapid breathing
• Nausea or vomiting
• Pale skin
• Less urine output

Shock is a medical emergency.

Many of these symptoms can be
caused by other health problems. Always see your healthcare provider for a
diagnosis.

How is pericardial effusion diagnosed?

The process starts with a health
history and a physical exam. Your healthcare provider will ask about your symptoms
and
past medical conditions. For symptoms of shock, it’s important to find the cause
quickly.

Tests may also be done, such as:

• Chest X-ray to see the heart anatomy
• Imaging of the chest or heart with a
  CT scan or MRI
• Echocardiogram (echo) to look at fluid
  around the heart and heart motion
• Electrocardiogram (ECG) to analyze the
  heart’s electrical rhythm

If a pericardial effusion is found,
healthcare providers must try to diagnose the cause. They may use tests such as:

• Analysis of the fluid removed from around the heart to check for cancer or infection
• Different blood tests to diagnose infection, immune system, and metabolic problems

How is pericardial effusion treated?

Treatment will depend on your
symptoms, age, and general health. It will also depend on how severe the condition
is
and what caused it. Chronic and acute pericardial effusions may require different
treatment.

If a pericardial effusion is not severe, treatment may include:

• Careful monitoring with repeated
  echocardiograms
• Therapy aimed at the cause of the
  effusion, such as antibiotics for a bacterial infection or medicines, such as
  ibuprofen, for inflammation
• Treatment of pain with aspirin or another medicine

A severe pericardial effusion may need to be drained. The fluid is drained with a
procedure called pericardiocentesis. This procedure uses a needle and a thin, flexible
tube (catheter) to drain the fluid.

In some cases, the pericardial sac
may be drained during surgery. The surgeon may remove a piece of the pericardium.
This
is done to help diagnose the cause of the effusion. It can also prevent the fluid
from
building up again. Your provider might be more likely to do this if you’ve had chronic
pericardial effusion.

Symptoms often improve greatly
after the excess fluid is drained. The outcome of treatment may depend on the cause
and
severity of the condition, how quickly treatment is started, and your overall
health.

What are possible complications of pericardial effusion?

Many times, there are no
complications of pericardial effusion. The most serious possible complication is cardiac
tamponade. If untreated, it can lead to shock, which can cause serious complications.
For example, reduced blood flow to the kidneys during shock can cause the kidneys
to
fail. If left untreated, shock can lead multiple organs to fail, causing death. In
rare
cases, the pericardium can become scarred and prevent the heart from filling correctly.

What can I do to prevent pericardial effusion?

You can reduce your risk of some of
the medical problems that can lead to pericardial effusion. For example, take care
of
your heart by:

• Limiting alcohol.
• Eating a heart-healthy diet.
• Getting enough exercise
• Staying at a healthy weight.
• Seeing a healthcare provider regularly
  to treat your medical problems.

Many cases of pericardial effusion
are not preventable.

When should I call my healthcare provider?

If you have any symptoms of
pericardial effusion, call your healthcare provider right away. Call
911 if you
have trouble breathing, chest pain, or symptoms of shock.

Key points about pericardial effusion

• A pericardial effusion is when excess fluid builds up in the pericardial sac around
  the heart. This can happen for a variety of reasons.
• Some pericardial effusions are small. These are unlikely to cause symptoms or major
  problems themselves.
• A large pericardial effusion can
  prevent the heart from pumping normally. This is a medical emergency.
• Healthcare providers can monitor small
  pericardial effusions and treat the underlying causes.
• A person with a large pericardial effusion might need a procedure to remove fluid
  from around the heart.
• Seek medical attention right away if
  you have symptoms like severe chest pain or trouble breathing.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask
  questions and remember what your provider tells you.
• At the visit, write down the name of a
  new diagnosis and any new medicines, treatments, or tests. Also write down any new
  instructions your provider gives you.
• Know why a new medicine or treatment
  is prescribed, and how it’ll help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you don’t take
  the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that
  visit.
• Know how you can contact your provider
  if you have questions.

Medical Reviewer: Steven Kang MD

Medical Reviewer: Stacey Wojcik MBA BSN RN

Medical Reviewer: Stacey Wojcik MBA BSN RN

© 2000-2022 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

Pericardial Effusion: Causes, Symptoms, and Treatment

Written by Matthew Hoffman, MD

• Causes
• Symptoms
• Diagnosis
• Treatment

A pericardial effusion is excess fluid between the heart and the sac surrounding the heart, known as the pericardium. Many are not harmful, but they sometimes can make the heart work poorly.

The pericardium is a tough and layered sac. When your heart beats, it slides easily within it. Normally, 2 to 3 tablespoons of clear, yellow pericardial fluid are between the sac’s two layers. That fluid helps your heart move easier within the sac.

If you have a pericardial effusion, much more fluid sits there. Small ones may contain 100 milliliters of fluid. Very large ones may have more than 2 liters.

In most cases, inflammation of the sac, a condition called pericarditis, leads to the effusion. As it becomes inflamed, more fluid is produced.

Viral infections are one of the main causes of the inflammation and the effusions it leads to. These infections include:

• Cytomegalovirus
• Coxsackieviruses
• Echoviruses
• HIV Infection
• Lupus
• Tuberculosis

In these cases, treating the underlying medical condition will often help treat the effusion.

Other conditions that can cause these effusions include:

• Cancer
• Injury to the sac or heart from a medical procedure
• Heart attack
• Severe kidney failure, also called uremia
• Autoimmune disease (lupus, rheumatoid arthritis, and others)
• Bacterial infections, including tuberculosis

In many cases, no cause can be found. Your doctor may call these idiopathic pericardial effusions.

When inflammation of the sac causes a pericardial effusion, the main symptom is chest pain. It may get worse when you breathe deeply and better when you lean forward.

Other symptoms may include:

• Fever
• Fatigue
• Muscle aches
• Shortness of breath
• Nausea, vomiting, and diarrhea (if you have a virus)

When there’s no inflammation of the sac, there are often no symptoms.

Large, serious pericardial effusions, or smaller ones that develop quickly, may cause symptoms that include:

• Shortness of breath
• Palpitations (sensation that the heart is pounding or beating fast)
• Light-headedness or passing out
• Cool, clammy skin

A pericardial effusion with these symptoms is a medical emergency and may be life-threatening.

Because these often cause no symptoms, they’re frequently discovered after the results of routine tests are abnormal. These tests can include:

Physical examination: A doctor may hear abnormal sounds over the heart that can suggest inflammation. However, pericardial effusions usually can’t be found through a physical.

Electrocardiogram (EKG): Electrodes placed on your chest trace the heart’s electrical activity. Certain patterns on an EKG can signal a pericardial effusion or the inflammation that leads to it.

Chest X-ray film: The heart’s silhouette on one may be enlarged. That’s a sign of a pericardial effusion.

If one is suspected, the best test to confirm it is an echocardiogram (ultrasound of the heart) because your doctor would easily see any excess fluid.

Once the effusion is identified, its size and severity are figured out. Most times, it’s small and causes no serious problems. If it’s large, it can compress your heart and hamper its ability to pump blood. This condition, called cardiac tamponade, is potentially life-threatening.

To find the cause of a pericardial effusion, your doctor may take a sample of the pericardial fluid. In this procedure, called pericardiocentesis, a doctor inserts a needle through your chest, into your pericardial effusion, and takes some fluid.

It depends on its severity and cause. Small ones that don’t have symptoms and are due to known causes (for example, kidney failure) require no special treatment.

For pericardial effusions due to inflammation of the sac, treating the inflammation also treats the effusion.

In that case, you may be given:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), like Aleve, Indocin, and Motrin
• Corticosteroids, like prednisone and Solu-Medrol
• Colchicine (Colcrys)

If a severe infection or heart impairment (cardiac tamponade) exists, the extra fluid must be drained immediately. Drainage is done in two ways:

Pericardiocentesis: A doctor inserts a needle through the chest into the pericardial effusion. A catheter is put into the fluid, and it’s suctioned out.

Pericardiectomy or pericardial window: A surgeon makes an incision in the chest, reaches in, and cuts away part of the pericardium. This drains the pericardial effusion and usually prevents it from coming back. The procedure requires general anesthesia.

Pericardial effusions that are 3 months old or older are called chronic. Often, no cause is known. They’re sometimes monitored without treatment. If there are symptoms or your heart is being harmed, drainage is usually done.

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Hydropericardium in cancer – description and causes

General information about the problem

Hydropericardium (another name is dropsy of the heart) – the appearance of excess fluid between the layers of the pericardium. For adequate functioning of the heart, there is 20-40 ml of transudate in the pericardial cavity (non-inflammatory effusion).

The reason for the occurrence of hydropericardium is the increased permeability of the vascular walls of the pericardial sac or venous congestion.

An increase in the volume of transudate up to 100 ml does not manifest itself clinically. If the amount of fluid exceeds 150-200 ml, you should think about the addition of inflammation.

The following signs of hydropericardium are distinguished:

• Periodic pain in the chest, aggravated by a change in body position (leaning forward).
• Lack of strength, pale skin.
• Increased perspiration.
• Rapid heartbeat, which may not be felt due to weak heart activity.
• Decrease in systolic (“upper”) pressure.
• Rapid and shallow breathing.
• Severe pastosity (swelling) of legs and feet.

How to treat hydropericardium

The accumulation of transudate is a symptom or complication of the underlying pathology, and therefore the underlying disease must be treated.

Therapy begins with the appointment of heart drugs, thyroid hormones, as well as mixtures that restore protein metabolism in the body.

With a slight excess of fluid between the sheets of the pericardium, there is no need for special preparations.

The recommendations of specialists for hydropericardium include the following appointments: potassium and magnesium preparations in combination with potassium-sparing or thiazide diuretics (diuretics). The absence of a long-term result or the detection of a significant amount of effusion may indicate the addition of an inflammatory process (formation of exudate). This is a direct indication for a therapeutic puncture (puncture with a special needle) of the pericardium.

Possible complications

The development of complications of hydropericardium is associated with the severity of heart failure. An increase in the volume of pathological effusion up to 1-1.5 liters provokes an increase in symptoms: pressure numbers decrease, shortness of breath worsens, swelling becomes more noticeable.

Running dropsy of the heart leads to the development of tamponade, in which the accumulated fluid compresses the heart muscle so much that physiological contractions become impossible. The clinical picture of the condition is accompanied by a pronounced decline in strength, weakness, asthma attacks with frequent shallow breathing, a feeling of rapid heartbeat, episodes of loss of consciousness. In this case, urgent medical attention is required.

What causes hydropericardium in cancer

The causes of hydropericardium are as follows: an increase in the production of transudate or a slowdown in its absorption. A similar pathophysiological mechanism is observed in many diseases:

1. Chronic heart failure – a condition characterized by congestion.
2. Other cardiovascular diseases: pericarditis, cardiomyopathy, congenital heart disease.
3. Intoxication with pesticides (in hazardous industries), decaying cancer cells.
4. Cachexia. With an extreme degree of exhaustion, the heart decreases in size, the organ does not completely fill the pericardial cavity.
5. Chronic kidney disease. With hydronephrosis, renal failure, pyelonephritis, acid-base metabolism and water-salt metabolism are disturbed, which provokes the development of edema of the internal organs.
6. Severe degree of anemia – a violation of the processes of cellular respiration leads to the formation of excess effusion.
7. Trauma is a common cause of cardiac tamponade (compression of the heart muscle by excessive effusion).
8. Radiation therapy in oncopathology.
9. Benign or malignant neoplasms of the mediastinum.

There are special forms of hydropericardium, in which lymph accumulates (a frequent occurrence in a metastatic process) or blood (heart injury, complicated myocardial infarction).

Diagnostic methods in Medscan

The survey begins with a survey and examination of the patient. The results of physical research methods (percussion, auscultation) indicate an enlarged heart.

Specialists resort to laboratory and instrumental studies:

• Clinical and biochemical blood tests, clinical urinalysis. Laboratory studies will assess the general condition of the body, the presence or absence of inflammatory processes.
• Chest x-ray. The method will help to see only a massive increase in effusion.
• X-ray kymography. The procedure registers the pulsation of the atria and ventricles of the heart, as well as the main vessels. With initial changes in the pericardium, a decrease in the voltage of the ventricular and atrial teeth is determined.
• Echocardiography is the leading diagnostic tool for this condition. According to the results of ultrasound, the normal gap between the wall of the heart and the inner leaf of the pericardial sac is up to 5 mm. An increase in this indicator indicates an excess of transudate.
• Diagnostic puncture. The procedure gives an understanding of the properties of the fluid of the cavity of the heart bag.

The diagnostic center at the Medscan clinic is equipped with modern and high-precision state-of-the-art equipment. The center presents a wide range of laboratory, instrumental examinations in combination with comprehensive programs.

Treatment methods in Medscan

The tactics of patient management at the Medscan clinic is based on international protocols. An individual treatment plan is drawn up for each patient. Treatment of hydropericardium depends on the amount of accumulated fluid, as well as echocardioscopy (ultrasound of the heart).

Based on the results of laboratory and instrumental studies, the doctor makes appropriate appointments.

First of all, specialists pay attention to the main pathology (oncological process), which provoked the complication. In parallel with the treatment of cancer, the fight against hydropericardium is being carried out. It begins with the use of diuretics (diuretic drugs), which “unload” the circulatory system and remove excess fluid.

A significant amount of effusion is observed with a combination of transudate and exudate (produced during inflammation), which requires a therapeutic puncture of the pericardium.

Expert opinion

The prognosis of the pathological process is determined by the degree of its intensity, as well as the timeliness of diagnosis. Favorable prospects for the treatment of hydropericardium are possible with the complete elimination of its cause, otherwise, even against the background of stabilization of the general condition, there is a possibility of a recurrent course.

There is no specific primary prevention of hydropericardium. Patients with pathologies that can be complicated by the accumulation of effusion between the sheets of the pericardium should be under the supervision of experienced specialists, regularly undergo examinations and follow all medical recommendations.

Olkin Dmitry Borisovich

Oncologist, chemotherapist

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Hydropericardium

Hydropericardium – what is it?

Hydropericardium is called an abundant accumulation of liquid mass in the heart sac. This bag itself consists of two leaves surrounding the heart. Their task is to protect it and separate it from other organs. Fluid collects in the middle of the sac (called the “pericardium”). Its quantity is insignificant, and it is designed to prevent the walls of the bag from rubbing against each other, as well as the heart. For a normal condition, the sheets are 3-5 millimeters apart, the amount of accumulated liquid is up to 50 milligrams.

If there is too much fluid, it prevents the heart from working properly, which can lead to cardiac tamponade and cardiac arrest.

The disease we are talking about dramatically increases the amount of natural fluid in the heart bag at times. If the natural amount of liquid mass ranges from 15 to 50 milligrams, then in a pathological condition this amount can be over a liter. In addition, with the development of pathology, blood or lymph enters the bag.

Reasons

What causes the disease? Let’s start with a description of the mechanism of normal functioning. So, the fluid is produced by the cells of the pericardium, they also absorb it. That is, there is a natural control of the amount of fluid, as well as its renewal. If one of these processes is disturbed, a hydropericardium occurs.

The causes of the disease are very different:

• Pericarditis;
• Heart failure;
• Chronic renal failure;
• Heart defects;
• Post-infarction condition;
• Hypothyroidism;
• Rheumatoid arthritis;
• Infections;
• Injuries of the chest;
• Allergic reactions;
• Insufficient protein level;
• Cancer and other neoplasms;
• Intoxication, etc.

As a rule, the disease belongs to the category of secondary pathologies, which must be taken into account when diagnosing and prescribing treatment. That is, it is very important to find the true cause that led to the development of the disease.

Classification

The classification is based on the main aspect – the amount and type of accumulated fluid.

Taking into account the amount of fluid in the heart sac and the distance between its leaves, they speak of three stages of the disease:

• Early stage. The amount of accumulated liquid does not exceed 100 ml, the distance between the sheets is from 6 to 10 mm;
• Moderate stage. The accumulated liquid is within 100 – 500 ml, the sheets have diverged by 10-20 mm;
• Pronounced stage. Water weight > 500 ml, sheets spread more than 20 mm.

As you can see, an increase in the amount of accumulated fluid increases not only the manifestation of symptoms, but the risk to health and life.

The moment of quality of the accumulated liquid is also important. It can be of several types, it is important to know for diagnosis:

• Accumulated natural fluid – diagnosis of hydropericardium;
• Accumulation of fluid with blood – “hemopericardium”;
• Accumulation of lymphatic fluid – “chelopericardium”;
• Accumulated pus and inflammation – “pericarditis”.

Symptoms

The volume of accumulated transudate fluid at an early stage of pathology < 100 mils. If the indicator increases, then, most likely, we are talking about the beginning of the inflammatory process.

At an early stage, external symptoms practically do not appear, at the subsequent ones they may be as follows:

• Profuse sweating;
• Pain in the chest, aggravated by stooping forward;
• General weakness;
• Pale skin;
• Manifestations of tachycardia;
• Rapid shallow breathing;
• Swelling in the legs.

Further development of the disease entails the appearance of new symptoms simultaneously with a decrease in blood pressure.

An extreme complication of the pathology is the development of cardiac tamponade. It manifests itself with strong squeezing of the heart by accumulations of fluid, in which normal contractions of the organ are impossible.

Tamponade symptoms:

• Severe weakness;
• Increasing dyspnea;
• Fear of death.

This condition requires an immediate visit to the doctor.

Diagnostic measures

Diagnosis begins with an examination and history taking.

As an instrumental study, the following are applicable:

• Chest X-ray – reveals a significant increase in fluid volume;
• X-ray kymography – registers pulsations of the heart departments and main vessels;
• Echocardiography – is the main technique used to detect pathology;
• Diagnostic pericardial puncture – allows you to determine the type of accumulated fluid.

For a deeper study, blood and urine tests are necessary, ultrasound examinations of the small pelvis, abdominal cavity, and other studies are possible.

Treatment, prognosis, prevention

Treatment tactics depend on several factors, including the volume of accumulated fluid and the condition of the heart.