Teaching Case

A 63-year-old female with a history of locally advanced oesophageal squamous cell carcinoma presented in the emergency department with orthopnoea and dyspnoea. Imaging studies revealed disease relapse with pericardial involvement. Two days later, the patient presented hypotension and increased central venous pressure. Additional studies were performed.

A nodular opacity adjacent to the right cardiac chambers was identified on the chest X-ray, likely secondary to pleural/pericardial involvement. The subsequent chest X-ray performed two days after the onset of symptoms showed mild bilateral pleural effusion. In addition, low voltage was identified on the electrocardiogram. Due to rapid clinical deterioration, a contrast-enhanced computed tomography (CT) was performed to rule out complications. The study revealed a circumferential pericardial effusion that showed high CT attenuation values (>20 HU) and pericardial enhancement. There was also flattening of the anterior cardiac contour, enlargement of the hepatic veins and mottled appearance of the liver (“nutmeg liver”). With the radiological suspicion of cardiac tamponade due to malignant pericardial involvement an echocardiogram was carried out, which confirmed the presence of severe pericardiac effusion that caused significant hemodynamic compromise. With the diagnosis of cardiac tamponade, percutaneous pericardiocentesis was immediately performed. After consecutive cytological analysis with negative results for malignancya pleuropericardial biopsy confirmed malignant involvement of the pericardium (immunhistochemical analysis CK-AE1/AE3 and BerEp4 +).

Cardiac tamponade is a life-threatening condition secondary to increased intrapericardial pressure sufficient to compress the heart and cause impaired cardiac output. It can be produced by the accumulation of fluid, pus, blood, gas or tissue [1, 2].

Prompt diagnosis is essential to reduce the mortality risk of these patients. Beck´s triad refers to increased central venous pressure, hypotension, and muffled heart sounds as the result of the rapid accumulation of pericardial fluid. Clinical signs and symptoms can vary depending on the acuteness and underlying cause of the tamponade [3, 11], being the most common dyspnoea, tachycardia and elevated jugular venous pressure. Other frequent findings are hepatomegaly, paradoxical pulse, and diminished heart sounds [4].

Although cardiac tamponade is a clinical diagnosis, an echocardiogram should always be performed without delay to confirm the suspicion [5]. It usually shows pericardial effusion, cardiac chamber compression with early diastolic collapse of the right ventricular free wall, inferior vena cava (IVC) plethora, Doppler flow-velocity paradoxus, compression of the thoracic IVC and pulmonary trunk, paradoxical motion of the interventricular septum and swinging motion of the heart in the pericardial sac. The electrocardiogram typically shows diffuse low voltage and occasionally electrical alternans [9]. The chest X-ray may reveal an enlarged cardiac silhouette, with a bottle-shaped heart [1, 10].

CT can be extremely helpful in defining the nature of the pericardial effusion. Attenuation values greater than those of the water (0-20 HU) can be seen in malignancy, hemopericardium or purulent exudates. The presence of pericardial thickening or nodular lesions arising from or adjacent to the pericardium suggest malignant pericardial disease. Furthermore, CT also allows to rule out other abnormalities in the mediastinum or lungs.

CT findings in cardiac tamponade include enlargement of the superior vena cava or IVC, reflux of contrast within the IVC or azygos vein, enlargement of hepatic and renal veins and periportal oedema [6-8]. Other findings are the “flattened sign” (flattening of the anterior surface and decreased anteroposterior diameter of the heart), compression of the coronary sinus or bowing of the interventricular septum. Although magnetic resonance imaging (MRI) allows detection of pericardial effusion with high sensitivity [10], it has a limited role in the prompt diagnosis of cardiac tamponade [12].

Emergency pericardiocentesis, preferably by using needle pericardiocentesis with echocardiographic guidance is the treatment of choice. Patients with recurrent tamponade may require pericardial sclerosis or a balloon pericardiotomy [10].