Pericardial Decompression Syndrome

Pericardial decompression syndrome is paradoxical haemodynamic deterioration, with left or right ventricular failure, pulmonary oedema or shock, after drainage of a large pericardial effusion or relief of tamponade or constriction.

Epidemiology. It is uncommon, occurring in about 5% or fewer of patients after pericardiocentesis or pericardial window, with mortality in severe cases. It develops within minutes to 48 hours after drainage.

Risk factors. Large or chronic effusion (over 1 litre), rapid drainage of a large volume, prior left ventricular dysfunction, malignant effusion, uraemia, hypothyroidism, hypertension, and pericardial constriction.

Pathophysiology. Proposed mechanisms are sudden increase in venous return with acute right ventricular dilation and septal shift, left ventricular systolic dysfunction from stunning, sudden afterload mismatch, sympathetic withdrawal, and increased preload to a ventricle that was protected by compression. Pulmonary oedema or ventricular failure follows.

Presentation is breathlessness, hypotension, pulmonary oedema, arrhythmia, cardiogenic shock or arrest, soon after drainage (sometimes after initial improvement). Echocardiography shows new left or right ventricular dysfunction and dilation.

Red flags.

• Hypotension or pulmonary oedema after pericardiocentesis.
• Large effusion drained quickly (over 1 litre).
• New ventricular dilation or reduced ejection fraction.

Echocardiography (ventricular size, ejection fraction, residual effusion, septal motion, valve function), ECG, troponin, natriuretic peptide, chest radiograph, lactate and gas. Exclude bleeding, recurrent tamponade, pneumothorax from the procedure and coronary injury.

Differential diagnosis. Recurrent tamponade, haemopericardium, procedural pneumothorax, coronary laceration, sepsis and arrhythmia.

Prevention.

• Drain slowly: remove up to 500 mL to 1 litre initially, then clamp the catheter and release the remainder over 6 to 24 hours.
• Leave a drain in place and monitor haemodynamics and echocardiography.
• Prepare inotropes before drainage in high risk patients.

Treatment.

• Give the usual acute heart failure care with careful afterload and preload control.
• Oxygen and non-invasive ventilation (or intubation) for pulmonary oedema.
• Diuretic: furosemide 40 mg IV, repeated as needed.
• Vasodilator when blood pressure allows: nitroglycerin 10 to 200 microgram/min.
• Inotrope for low output: dobutamine 2.5 to 10 microgram/kg/min. Vasopressor (noradrenaline 0.05 to 0.5 microgram/kg/min) for hypotension.
• Mechanical support (intra-aortic balloon pump, venoarterial ECMO) for refractory shock.
• Recheck for residual or recurrent effusion and drain again if tamponade recurs.

Underlying cause. Treat malignancy, uraemia, hypothyroidism or infection that caused the effusion.

Monitoring. Haemodynamics, echocardiography at 6, 24 and 48 hours after drainage, drain output and renal function.

Referral and escalation. Cardiology, cardiac surgery (pericardial window) and intensive care.

Special groups. In renal failure, careful diuretic dosing and early dialysis. In malignancy, discuss pericardial window and the goals of care.