Cardiac or pericardial tamponade: Manifestations and Causes

Cardiac tamponade, or pericardial tamponade, are names that denote an urgent condition that requires immediate treatment. It is manifested by the failure of the heart's function as a pump, which is life-threatening and may cause death.

It arises acutely, but also over a longer period of time, when it i bse the causative agent of a complication of oncological heart disease or bacterial infections and other diseases.

The cause of cardiac tamponade is excessive pressure in the pericardial space, which oppresses the heart. The cavities of the heart cannot dilate properly, thereby causing insufficient filling of the heart's compartments with blood.

Consequently,...

The blood is not adequately supplied to the body.

The heart's function as a pump fails.
The heart is unable to supply the necessary amount of blood to the body and vital organs. 

A life-threatening condition that ends in death due to lack of time for treatment or its late detection.

The geart and the pericardium

The heart is a muscular pump that draws blood into its cavities. It expels it into the aorta and the body.

The blood flowing from the body back to the heart does not contain enough oxygen. It is re-oxygenated in the lungs. It is then returned to the heart, from which it is expelled under pressure into the aorta and throughout the body.

The cavities of the heart are referred to as:

1. right atrium - into which deoxygenated blood from the body is drawn and conducted
2. right ventricle - expels blood through the pulmonary artery into the lungs
3. left atrium - draws blood from the lungs
4. left ventricle - ejects blood under pressure into the aorta and thus into the whole body

The heart muscle of each heart compartment relaxes (diastole) and contracts (systole) rhythmically to ensure the continuous circulation of blood through the small and large circulations.

Pulmonary circulation between the heart and lungs.
Systemic circulation between heart and body. 

The heart is located in the chest, more precisely in the mediastinum, which is the interstitium.

It is surrounded by the lungs, anteriorly by the sternum and rib cage, posteriorly by the diaphragm, and posteriorly by the vertebral column.

Its position is approximately in the midline of the sternum.
Part of the heart is also located to the right of the sternum.
However, the larger part and tip of the heart points to the left of the sternum, forward and downward.

The weight of the heart in an adult is approximately:
In men 300 - 350 grams, 
in women 250 - 300 grams. 

The wall of the heart itself is made up of three layers.
The endocardium is the inner layer, it also forms the heart valves.
The myocardium is the heart muscle. It is the widest layer of the heart, and the left ventricle has the thickest musculature.
The epicardium is the outer membrane.

The heart is housed in a sac, which is referred to as the pericardium, also called pericardial sac.

The pericardium

The pericardial sac, or the pericardium, is a ligamentous sac in which the heart is housed. The pericardium encases the heart and, in part, the blood vessels going in and out of the heart.

The pericardium literally envelops the heart and is formed by two laminae.

1. serous pericardium - pericardium serosum viscerale / lamina visceralis
   • forms the lining of the pericardial cavity
   • fits directly onto the heart muscle
     • it is thus the epicardium - the third and outer layer of the heart
2. fibrous pericardium - pericardium serosum parietale / lamina parietalis
   • pericardium "own pericardium"
   • thin and shiny layer

Between these two layers is a narrow cavity that contains a very small amount of fluid. This fluid reduces the friction between the layers (epicardium and pericardium) during cardiac activity.

pericardial space  = cavitas pericarditis. 
pericardial fluid= liquor pericardii. 

There is approximately 20-50 ml of fluid in the pericardial cavity.

The pericardium is an inflexible membrane that cannot be stretched. Therefore, when the amount of fluid in the narrow cavity increases, a problem arises.

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Pericardial, or cardiac tamponade

It is defined as: 

Circulatory failure, which is caused by impaired filling of the heart compartments, on the basis of increased filling of the pericardium.

Another one is...

Cardiac tamponade is a life-threatening condition, the basis of which is the oppression of the heart by accumulated fluid/gas in the pericardium.

And...

It is a compression of the heart in the pericardial envelope.

An increase in intrapericardial pressure that causes a buildup of fluid or air in the pericardial cavity, leading to tamponade. It is characterized by an increase in pressure within the cavities of the heart, restriction of filling of the cardiac cavities, reduction in pulse volume and cardiac output.

It is necessary to say a few words on pericardial effusion.

Pericardial effusion 

The disease process that involves the pericardium is almost always behind the inflammatory response. It involves an increase in the amount of fluid in the cavity between the heart and the pericardium.

This mechanism produces exudate.

Then, another mechanism is the accumulation of fluid in case of heart failure. In that case, it is a transudate. Fluid excessively permeates the cavity or is inadequately absorbed.

Pericardial effusion is evaluated on the basis of several characteristics:

• time of occurrence
  • acute, if it arises suddenly within hours
  • sub-acute
  • chronic, long-lasting
• size
  • up to 10 mm - minor
  • 10 - 20 mm - average
  • above 20 mm - major
• composition
  • transudate
  • exudate

It arises in a variety of health problems. It is reported that up to 50% of cases of pericardial effusion accumulation in developed countries have an unknown cause.

Approximately 10-25% of cases have a basis in cancer.
15 - 20% as a result of medical intervention - iatrogenic.
About 5 - 15% due to connective tissue diseases.

In developing countries, more than 60% of cases are due to infectious causes and TB - tuberculosis.

In pericardial effusion, symptoms are manifested on the basis of several features. As mentioned above, the time over which the amount and size of the effusion increases influences the course. Plus other factors.

Mostly, shortness of breath, a feeling of difficulty breathing, up to a feeling of suffocation is at the forefront. For example, a feeling of fullness, swallowing disorders or hoarseness are also associated with oppression of the laryngeal nerves. And other general discomforts, such as fatigue and inefficiency.

The cause of cardiac tamponade is the accumulation of fluid or air in the pericardial cavity. In the cavity between the pericardium and the heart - the epicardium.

The pericardium is a rigid sac and is not elastic. When there is excessive formation, or accumulation of fluid, in the pericardial cavity, the muscle of the heart is compressed, as in a corset. The heart is unable to stretch properly and the cardiac cavities do not fill with the necessary amount of blood.

The liquid literally squeezes the heart.

External pressure on the heart is rising,
and,
the internal pressure in the cavities of the heart increases.

Tamponade = the pressure in the pericardium exceeds the pressure in the right atrium. 
The right chamber does not fill with blood = collapsing.

The heart rate increases, and due to the lack of blood, the systemic blood pressure decreases. Blood is supplied in insufficient quantities to the body and vital organs.

The heart is failing like a pump. A shock state develops.

The pericardium can accumulate:

• blood, blood clot - hemopericardium
  • in heart muscle infarction
  • in aortic dissection
  • injury or complication of surgery
• pus - pyoperikard
  • exudate
  • yellow and cloudy
  • product of inflammatory secretion
  • purulent nature
  • for example, in pericarditis, bacterial and viral infection, tuberculosis
  • myocardial, epicardial and pericardial swelling in infection
• transudate - hydropericardium
  • for example, fluid accumulating in cardiac insufficiency
    • cit is a non-inflammatory effusion of blood fluid into the body cavitiesvýpotok
    • clear, colourless or slightly yellowish
• air - pneumoperikardium
• lymph - chylopericardium

The causes of tamponade are, for example:

• heart - due to the functioning of the heart
  • myocardial infarction
  • type A aortic dissection
  • pericarditis
  • heart failure
  • cardiomyopathy
• mechanic
  • iatrogenic, due to medical procedures
    • catheterization, PCI
    • pacemaker implant 
    • defective pericardial puncture
    • cardiac surgery, other
  • trauma, injury
    • serious mechanism of injury, traffic accidents, falls from great heights and others,
    • blunt chest trauma, cardiac contusion
    • penetrating, i.e. piercing through the chest wall, stab wounds
• general diseases
  • infections
  • oncological diseases, heart tumours, primary or secondary metastases
  • uremia
  • diabetes mellitus - diabetes
  • autoimmune diseases
    • rheumatoid arthritis
    • systemic lupus erythematosus
    • scleroderma
• post-radiation issues

Symptoms depend on the length of time it takes, plus the size of the pericardial effusion.

Acute rapid-onset tamponade is manifested by characteristic symptoms. These have been described and defined as the Beck's triad.

Beck's triad:

1. low blood pressure - reduction of arterial pressure
2. high venous pressure - observed as increased filling of the jugular veins = dilation of the jugular veins
3. weakening of heart echoes and absent heartbeat at the apex of the heart + low QRS on ECG

 Generally, with tamponade, symptoms are described as:

• shortness of breath, difficulty breathing in up to 85% of cases
• chest pain - pain aggravated on inspiration
• tachycardia - accelerated heart rate
• hypotension- low blood pressure
  • and pressure drop on inspiration
    • inhalation and enlargement of the lungs additionally increases the pressure on the oppressed heart
    • a fall in BP of more than 10% or more than 10 mmHg during inspiration
• paradoxical pulse - a non-palpable pulse on inspiration
• weakening and disappearance of heart echoes
• heart murmur - pericardial friction murmur
• rapid breathing - tachypnea, over 20 breaths per minute
• state of shock
  • blood pressure BPs below 90 mmHg
  • tachycardia over 100/minute
  • increased venous filling
  • damp cold skin
  • pale skin to cyanosis - blue discoloration of the skin, lips
• and non-specific symptoms such as:
  • feeling of fullness
  • fatigue and weakness
  • anxiety
  • dizziness - vertigo
  • swelling, swelling of the lower limbs
  • cough
  • sweating
  • weight loss
  • enlarged liver
• confusion, unconsciousness
• cardiac arrest up to death

Non-specific difficulties are mostly manifested in longer-lasting forms.

The diagnosis focuses on the medical history and, therefore, the symptoms reported by the sufferer. Those that can be examined. Suspicion is supported by the presence of characteristic symptoms - Beck's triad.

Blood pressure, pulse, heart auscultation are examined. Symptoms of heart failure are assessed.

Imaging methods rely mainly on:

• echocardiogram - the greatest benefit in diagnosis, but is not always available due to the time factor
• X-ray
• ECG - low ORS voltage
• CT
• MRI

There is not always enough time for a thorough diagnosis and rapid progression of the condition. Rapidly developing health problems and symptoms, the presence of characteristic symptoms forces the doctor to urgent treatment.

The death of the affected person is imminent.
And that's for lack of time, in emergent form.
Alternatively, when tamponade of the heart is not detected.

The course and triggering of discomfort in pericardial effusion depends on the time over which it occurs and the size of the contents that confine the heart.

Basically, even a small amount of fluid accumulated over a short period of time will cause tamponade of the pericardium.

An acute tamponade is created by as little as 200 ml of fluid. 
In the chronic form of pericardial effusion, 1000 to 2000 ml of contents can be collected.

Acute tamponade occurs, for example, in trauma, myocardial infarction or aortic dissection.

The subacute type arises, for example, in oncological disease.

Chronic forms occur in uraemia or tuberculosis.

In terms of time, it is assessed as:

• emergent cardiac tamponade - minutes to hours
• acute - hours
• subacute - days to weeks
• chronic - months