Pericardial effusion: diagnosis and treatment

The pericardial effusion is a problem that is found in a Relatively frequent in medical practice. Sometimes it is related to an already known disease and other times it requires a specific evaluation and follow-up to establish its cause.

In some cases, it is impossible to determine the cause of the pericardial effusion. Even this condition it can remain unchanged for years, becoming chronic and without producing any hemodynamic commitment.

At first, the treatment focuses on solving the problem which gives rise to the pericardial effusion and in managing its symptoms. However, when the cause is unknown, the clinical management that is given is the same as a pericarditis.

What is the pericardial effusion

The pericardial effusion is defined as a abnormal accumulation of fluid in the pericardial cavity. Remember that the pericardium is formed by two layers: one visceral (internal) and another parietal (external).

The space between these two layers is the pericardial cavity or pericardial sac. Under normal conditions, it contains up to 50 ml of serous fluid. When there is an inflammatory or infectious process, fluid production increases and the pericardial effusion occurs.

Likewise, this can originate because of the decreased reabsorption of the liquid. This occurs due to the increase in systemic venous pressure. In turn, the increase in pressure usually occurs due to congestive heart failure or pulmonary hypertension.

Diagnosis

The clinical presentation of the pericardial effusion depends on the speed with which the liquid accumulates. Typical symptoms are shortness of breath and pain in the chest. Nausea, dysphagia, hoarseness and hiccups are also common.

When there is suspicion of pericardial effusion, the usual thing is that one or several of these exams are carried out:

• Echocardiogram. It allows to detect the magnitude of the effusion and the state of cardiac function. The post-esophageal echocardiogram offers more detailed images, and therefore more reliable, than the antithrombotic echocardiogram.
• Electrocardiogram. This test allows detecting patterns of possible tamponade.
• Thoracic radiography. It provides an indicator to establish the magnitude of the pericardial effusion globally.

Although the most used diagnostic test is the echocardiogram, Computed tomography (CT) and magnetic resonance imaging (CMR) offer a wider field of vision. However, due to availability and costs, only those tests are used on a few occasions.

In any case, the echocardiographic evaluation allows the determination of five fundamental variables: size, time of evolution, distribution, composition and hemodynamic effects. The next clinical challenge is that of establish the cause of the pericardial effusion to proceed to define the line of treatment.

Treatment for pericardial effusion

The treatment of pericardial effusion depends directly on the amount of fluid accumulated, the existence or not of cardiac tamponade and the cause that gives rise to this anomaly. In general, treating the cause solves the problem.

The first step in the management of a pericardial effusion is to evaluate the size of the pericardial effusion, define its hemodynamic importance and establish possibly associated diseases. In about 60% of cases, there is an underlying disease.

If there is no blockage or a considerable risk of it occurring, it is usual to order bed rest and an anti-inflammatory treatment. Conchycin and corticosteroids are also used.

If there is tamponade or a high risk that the effusion progresses, the indicated thing is to carry out a pericardiocentesis. When it is not possible to perform it, or this fails, it is appropriate to carry out an open surgical drainage. This should include biopsy and the creation of a pericardial window.

Monitoring and forecast

In general, the Idiopathic pericardial effusion and pericarditis have a good prognosis. The risk of complications is very low. Cases of chronic idiopathic effusion have a 30% to 35% chance of escalating to cardiac tamponade.

In the other type of spill, the prognosis depends mainly on the cause that produces it and the size of the spill. Those that are greater than 10 mm worsen and progress to tamponade in up to a third of the total cases.

In moderate idiopathic effusions, it is advisable to follow up that includes an echocardiogram every six months. If these are severe, it should be done every three months. And in the case of non-idiopathic patients, the follow-up will depend on the disease that gives rise to this anomaly.