Circulation, Vol 58, 265-272, Copyright © 1978 by American Heart Association
PS Reddy, EI Curtiss, JD O'Toole and JA Shaver
Hemodynamic studies were performed before and after pericardiocentesis in
19 patients with pericardial effusion. Right atrial pressure decreases
significantly, from 16 +/- 4 mm Hg (mean +/- SD) to 7 +/- 5 mm Hg in 14
patients with cardiac tamponade. This change was accompanied by significant
increases in cardiac output (3.87 +/- 1.77 to 7 +/- 2.2 l/min) and
inspiratory systemic arterial pulse pressure (45 +/- 29 to 81 +/- 23 mm
Hg). The remaining five patients did not demonstrate cardiac tamponade, as
evidenced by lack of significant change in these hemodynamic parameters. In
all patients with tamponade, right ventricular end-diastolic pressure
(RVEDP) was elevated and equal to pericardial pressure; equilibration was
uniformly absent in patients without tamponade. During gradual fluid
withdrawal in the tamponade group, significant hemodynamic improvement was
largely confined to the period when right ventricular filling pressure
remained equilibrated with pericardial pressure. In 10 patients with
tamponade and pulsus paradoxus, pulmonary arterial wedge pressure (PAW) was
equal to pericardial pressure except during early inspiration and
expiration when it was transiently less and greater, respectively; however,
inspiratory right atrial pressure never fell below pericardial pressure. In
these 10 patients, PAW decreased significantly following pericardiocentesis
(P less than 0.001). In the remaining four patients with tamponade but
without pulsus paradoxus, all of whom had chronic renal failure, PAW was
consistently higher than pericardial pressure or RVEDP and did not decrease
after pericardiocentesis. These data tend to confirm the hypothesis that in
patients with tamponade, the venous pressure required to maintain any given
cardiac volume is determined by pericardial rather than ventricular
compliance. When pericardial compliance determines diastolic pressure in
both ventricles, relative filling of the ventricles will be competitive and
determined by their respective venous pressures (pulmonary vs systemic),
which vary with respiration and alternately favor right and left
ventricular filling. This results in pulsus paradoxus. However, if
pulmonary arterial wedge pressure is markedly elevated before the onset of
tamponade, as in patients with chronic renal failure, then pericardial
compliance may only determine right ventricular filling pressure. In such
cases, pulsus paradoxus may be absent.
ARTICLES
Cardiac tamponade: hemodynamic observations in man
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