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Hypoechoic Material in the Pericardial Effusion
A middle aged patient presented to ED, periarrest.
This was his echo:
What do you see on the bedside echo which is worrying?
FEATURES OF ECHOGENIC PERICARDIAL EFFUSIONS BY CAUSE
FAT PAD
epicardial fat pad. Mainly anechoic with echogenic dots and linear structures. No evidence of tamponade (annotated below)
MALIGNANCY
Pericardial mets with surrounding anechoic fluid (annotated below)
Pericardial mets with surrounding anechoic fluid (annotated below)
Pericardial lymphoma: uniform hypoechoic material
INFECTIVE
Purulent effusion: Fibrin strands and anechoic effusion
CAUSE OF THE HYPOECHOIC MATERIAL IN THIS PATIENT
This patient had a pericardial effusion and haematoma secondary to type A aortic dissection. His RV was collapsed and IVC non collapsing.
He had a SBP 60 and barely responded to fluid resuscitation. Cardiothoracics discouraged pericardiocentesis in ED and the patient went from CT to theatre.
PERICARDIAL HAEMATOMA
Common causes of pericardial haematoma are trauma, myocardial rupture and aortic dissection. So always look for:
1. features of dissection
- ascending aorta >3cm
- undulating dissection flap
2. Myocardial contusion or infarction
- regional wall motion abnormality
- MV regurgitation due to pap muscle rupture
MANAGEMENT
Traditional teaching for management of pericardial haematoma due to the above conditions is surgical, rather than pericardiocentesis. The reasons for this is multifold:
1. The fear of rebound hypertension post pericardiocentesis causing more profuse bleeding/ dissection.
2. Surgical management is the definitive treatment
3. haematoma may be difficult to aspirate
Isselbacher et al published a report in 1994 describing the catastrophic effect of pericardiocentesis in ascending aortic dissection (1) and from that, the adage has been to exclusively manage pericardial tamponade from dissection surgically.
However, more recent studies have shown that controlled pericardiocentesis where only a small volume of fluid (30-50ml) is removed: ie just enough to improve output and perfusion, has good patient outcomes, especially when surgery may be delayed (2,3,).
For features of tamponade on echo click on the buttons below
For how to perform pericardiocentesis click on the button below
REFERENCES
1. Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful? Circulation. 1994;90:2375-2378.
2. HayashiT,TsukubeT,YamashitaT,etal.Impactofcontrolled pericardial drainage on critical cardiac tamponade with acute type-A aortic dissection. Circulation. 2012;126:S97-S101.
3. Cruz I, Stuart B, Caldeira D, et al. Controlled pericardiocent- esis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic sur- gery. Eur Heart J Acute Cardiovasc Care. 2015;4:124-128.