ORIGINAL RESEARCH

Aspecte imagistice în sindroamele compresive pericardice – tamponada cardiacă în patologia oncologică

 Imaging of pericardial compressive syndromes – cardiac tamponade in oncologic patients

First published: 24 aprilie 2021

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/OnHe.55.2.2021.5015

Abstract

Cardiac tamponade is a state of hemodynamic compromise that results from heart compression by a variety of fac­tors and conditions, including tumoral pericarditis or tumor cardiac compression. The aim of this article is to evaluate and discuss the added value of CT imaging find­ings of impending cardiac tamponade in patients with tho­ra­cic and hematologic malignancies. We reviewed our data­base for a period of six years, between January 2015 and April 2021, and we selected five patients with cli­ni­cal, he­mo­dynamic state and CT imaging features of car­diac tam­po­nade in oncologic pathology, four of them diag­nosed with he­ma­to­logic malignancies. We included post­ra­dio­­­the­rapy pericardial complications in the case of one patient. Although echocardiography represents the modality of choice to diag­nose patients with suspected cardiac tam­po­na­de, com­pu­ted tomography can provide valuable and sup­ple­men­tary information regarding the extension of the tu­mo­ral peri­car­dial involvement or the type of pericardial effusion. Con­si­de­ring that the early diagnosis of an impending car­diac tam­po­nade and the treatment are crucial in preventing mor­ta­lity and poor outcomes, radiologists have an impor­tant role in recognizing this entity.

Keywords
cardiac tamponade, CT, tumoral pericarditis, cardiac compression

Rezumat

Tamponada cardiacă reprezintă alterarea statusului hemo­di­na­mic, produsă prin compresia cardiacă determinată de o varietate de factori şi afecţiuni, inclusiv pericardita tumorală şi compresia tumorală cardiacă. Obiectivul acestui articol este de a evalua şi discuta aportul examenului CT în tamponada cardiacă iminentă în cazul patologiei tumorale intratoracice şi hematologice. Am revizuit baza noastră de date pe o perioadă de şase ani, între ianuarie 2015 şi aprilie 2021, şi am selectat cinci pacienţi cu tablou clinic, status hemodinamic şi imagistică CT sugestive pentru tamponadă cardiacă în patologia onco­lo­gică, patru dintre pacienţi prezentând patologie tumorală he­ma­to­logică. Am inclus un pacient cu patologie pericardică se­cun­dară radioterapiei. Deşi ecocardiografia reprezintă metoda de elecţie în cazul pacienţilor cu suspiciune de tamponadă car­dia­că, examinarea computer-tomografică oferă informaţii importante şi suplimentare legate de extensia pericardică a proceselor tumorale sau de tipul epanşamentului pericardic. Luând în considerare că diagnosticul şi tratamentul cât mai rapid ale unei iminente tamponade cardiace sunt extrem de importante în reducerea mortalităţii şi în îmbunătăţirea prog­nos­ti­cului bolii, radiologii au un rol major în recunoaşterea acestei entităţi.

Introduction

Cardiac tamponade represents a life-threatening condition characterized by impaired ventricular filling with decreased cardiac output and hemodynamic instability caused by fluid accumulation in the pericardial sac or cardiac tumor compression(1,2,3). It can occur as initial presentation of an unknown malignancy or in patients with established tumoral pathology(4). Pericardial effusion in oncologic patients can be secondary to tumor extension/metastases(5,6), may develop as a complication to radiation and chemotherapy(4), or in case of opportunistic infections(5). CT imaging features of cardiac tamponade in oncologic patients include: anterior heart compression by a mediastinal tumor or loculated/large pericardial effusion(5), angulation and bowing of the interventricular septum(2), enlargement of SVC and IVC (with diameter larger than the one of thoracic aorta)(6), reflux of contrast material into the IVC or azygos vein, periportal edema(1), compression of the coronary sinus(7). CT evaluation can provide valuable information regarding the tumoral pericardial involvement and extension, and the type of pericardial effusion(2).

Materials and method

We made a retrospective study for a period of six years (between January 2015 and April 2021), and we selected 119 oncologic patients with signs of pericardial disease, five patients with clinical, hemodynamic and CT imaging findings suggestive for cardiac tamponade. CT imaging was performed on 16 or 64 multidetector (MD) CT scanners in all cases, with one non-enhanced CT phase (NECT), to measure attenuation values of the pericardial colection and two phases in arterial (25 seconds) and delayed phase (100 seconds) post iodinated contrast material injection, at the injection ratio of 2-3 ml/s, in a quantity of approximately 1-1.5 ml/kg b.w., to evaluate pericardial thickness and enhancement, neoplastic pericardial involvement and heart structural anomalities. The physical parameters used for CT consisted in axial thickness slices of 5 mm, with 1.25 or 1.5 mm reconstruction interval. Different planes reconstructions (coronal, sagittal, oblique views) have been performed in order to have an optimal visualization of the cardiovascular structures.

Results

We selected five cases of oncologic patients (two females and three males), with ages between 14 and 50 years old, all patients with clinical, hemodynamic and CT imaging findings suggestive for cardiac tamponade. Among our patients, one female patient was diagnosed with breast cancer and the other four patients were diagnosed with hematologic malignancies (one case with acute myeloid leukemia, one case with acute lymphoblastic leukemia, one case with Hodgkin lymphoma, and one case with non-Hodgkin lymphoma). Large pericardial effusion with attenuation values between 12 and 24 UH caused cardiac compression and consecutive cardiac tamponade in three patients, and in one case pericardiocentesis revealed hemopericardium – Case 1, Figure 1. Structural heart compression by a large mediastinal tumor was found in two patients (Case 2, Figure 2, and Case 3, Figure 3), with anterior heart compression, deformity and concave appearance of the anterior cardiac wall (Case 2, Figure 2, curved arrow – a, b) and small heart sign (Case 3, Figure 3). Indirect signs of cardiac tamponade with the enlargement of SVC and IVC (with diameter larger than the one of thoracic aorta) were found in all cases. In three cases, reflux of contrast material into the IVC or hepatic veins was noted (Case 2, Figure 2, arrowhead – c). Bowing of the interventricular septum and marked coronary sinus compression, although considered important imaging signs in cardiac tamponade, were not seen in our patients. In one case, we found associated the superior vena cava syndrome.
 

Figure 1. Inflammatory pericarditis with fast rate of fluid accumulation and consecutive cardiac tamponade in a 14-year-old female patient diagnosed with acute mye­loid leukemia – first non-enhanced CT examination (a, b) re­vealed small pericardial effusion, difference in CT at­te­nua­tion value between miocardium and blood-sign of ane­mia; one week after a second CT examination (c, d) it was re­vealed quantitative progression of the pericardial effusion (arrow – d), with cardiac compression – small heart sign, and also pleural effusion was found (arrowhead – c, d). Urgent pe­ri­car­diocentesis was performed and hematic pericardial effusion was found. The patient died four days later
Figure 1. Inflammatory pericarditis with fast rate of fluid accumulation and consecutive cardiac tamponade in a 14-year-old female patient diagnosed with acute mye­loid leukemia – first non-enhanced CT examination (a, b) re­vealed small pericardial effusion, difference in CT at­te­nua­tion value between miocardium and blood-sign of ane­mia; one week after a second CT examination (c, d) it was re­vealed quantitative progression of the pericardial effusion (arrow – d), with cardiac compression – small heart sign, and also pleural effusion was found (arrowhead – c, d). Urgent pe­ri­car­diocentesis was performed and hematic pericardial effusion was found. The patient died four days later
Figure 2. Pericardial compression syndrome with impen­ding cardiac tamponade in a 29-year-old male patient diag­nosed with non-Hodgkin lymphoma, with marked dyspnea and tachycardia. Axial enhanced CT examination (a, b, c) revealed large anterior mediastinal tumoral mass (star – d), with abnormal concave deformity of the anterior cardiac wall (curved arrow – a, b) by neoplastic lesion, en­larged IVC and reflux of the contrast media into the IVC and hepatic veins (arrowhead – c). Multiple collateral ves­sels in the thoracic wall (arrow – d) secondary to com­pres­sion of SVC by the tumoral mass
Figure 2. Pericardial compression syndrome with impen­ding cardiac tamponade in a 29-year-old male patient diag­nosed with non-Hodgkin lymphoma, with marked dyspnea and tachycardia. Axial enhanced CT examination (a, b, c) revealed large anterior mediastinal tumoral mass (star – d), with abnormal concave deformity of the anterior cardiac wall (curved arrow – a, b) by neoplastic lesion, en­larged IVC and reflux of the contrast media into the IVC and hepatic veins (arrowhead – c). Multiple collateral ves­sels in the thoracic wall (arrow – d) secondary to com­pres­sion of SVC by the tumoral mass
Figure 3. A 24-year-old male patient, recently diagnosed with acute lymphoblastic leukemia, severe rest dyspnea, ortho­pnea and US signs of cardiac tamponade. Axial NE CT (a) shows dense pericardial effusion; axial enhanced CT (b and c) shows large circumferential tumoral mass (star – a, b) with compression of the right cardiac chambers, distension and contrast reflux into IVC (arrow – b), and bilateral pleural effusion. Pericardial drainage wasn’t possible. The cytology of the pleural effusion revealed tumoral infiltration
Figure 3. A 24-year-old male patient, recently diagnosed with acute lymphoblastic leukemia, severe rest dyspnea, ortho­pnea and US signs of cardiac tamponade. Axial NE CT (a) shows dense pericardial effusion; axial enhanced CT (b and c) shows large circumferential tumoral mass (star – a, b) with compression of the right cardiac chambers, distension and contrast reflux into IVC (arrow – b), and bilateral pleural effusion. Pericardial drainage wasn’t possible. The cytology of the pleural effusion revealed tumoral infiltration

Discussion

Cardiac tamponade represents a life-threatening con­di­tion, the oncologic patients with cardiac tamponade caused by malignant disease having death rates exceeding 75% within 12 months(8). In oncologic patients, cardiac tamponade can be secondary to heart compression by a large pericardial effusion(4,5) or by an invasive cardiopericardial tumor with no evidence of pericardial ef­fusion(2). Pericardial effusion in oncologic patients can be secondary to tumoral invasion of the pericardium, as side effect to the radiation and chemotherapy, or to opportunistic infections(9). Dyspnea, cough and chest pain are the most frequent symptoms of impending cardiac tamponade(4). Beck’s triad, with increased jugular vein distension, small and silent heart and hypotension, is rarely encountered in case of tumoral pericarditis(9,10). In our patients, moderate to severe dyspnea was the most frequent symptom. Electrocardiography most often reveals ST-T changes and low QRS voltages(4,11); in our patients, three of them presented ST-T changes and tachycardia. CT imaging signs suggestive for an impending cardiac tamponade are: cardiac compression by pericardial effusion, more common with fast fluid accumulation(1) (Case 1, Figure 1), flattened heart – anterior heart compression by a mediastinal tumor (Case 3, Figure 3), deformity with reduction of the anteroposterior cardiac diameter (Case 2, Figure 2) loculated/large pericardial effusion – in three of our patients (Case 1), angulation and bowing of the interventricular septum(2), enlargement of SVC and IVC (with diameter larger than the thoracic aorta)  – seen in all our patients, reflux of contrast material into the IVC or azygos vein (Case 2, Figure 2; Case 3, Figure 3). According to literature, compression of the coronary sinus(7) and bowing of the interventricular septum(2), described as another signs of impending cardiac tamponade, were not seen in our patients’ CT examinations. Based on attenuation measurement, CT provides information about the posible nature of the pericardial effusion(2); high density values and a density greater than that of skeletal muscle suggest haemorragic pericarditis(12). All these imaging findings, in the presence of a large pericardial effusion, can strongly suggest an impending cardiac tamponade(2), therefore timely therapeutic intervention is mandatory in oncologic patients in proper clinical scenarios.

Conclusions

Although a rapid assessment of patients with clinical signs of impending cardiac tamponade is best made with echocardiography, in malignancies CT examinations provide valuable and supplementary information regarding the tumoral pericardial involvement and extension, the type of pericardial effusion and cardiac structural changes, with implications for the therapeutic choice regarding the opportunity of pericardiocentesis or pericardiectomy.  

Bibliografie

  1. Guimaraes M, et al. Imaging acute complications in cancer patients: what should be evaluated in the emergency setting? Cancer Imaging. 2014;14(1):18.

  2. Restrepo CS, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007;27(6):1595-1610.

  3. De Potter B, et al. Imaging of urgencies and emergencies in the lung cancer patient. Insights Imaging. 2018;9(4):463-476. 

  4. Halfdanarson TR, et al. Emergencies in Hematology and Oncology. Mayo Clin Proc. 2017;92(4):609-641.

  5. Kathabathina VS, et al. Nonvascular, nontraumatic mediastinal emergencies in adults: a comprehensive review of imaging findings. RadioGraphics. 2011;31(4):1141-1160.

  6. Maggiolini S, et al. The role of early contrast-enhanced chest computed tomography in the aetiological diagnosis of patients presenting with cardiac tamponade or large pericardial effusion. European Heart Journal – Cardiovascular Imaging. 2016 Apr;17(4):421–428. 

  7. Gold MM, et al. Coronary sinus compression: an early computed tomographic sign of cardiac tamponade. J Comput Assist Tomogr. 2008 Jan-Feb;32(1):72-7. 

  8. Stashko E, Meer JM. Cardiac Tamponade. [Updated 2020 Nov 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/

  9. Shenoy S, et al. Cardiovascular Oncologic Emergencies. Cardiology. 2017;138:147-158

  10. Roy CL, et al. Does this patient with a pericardial effusion has cardiac tampo­nade? JAMA. 2007 Apr 25;297(16):1810-8.

  11. Adler Y, et al. European Society of Cardiology (ESC). 2015 ESC guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-64.

  12. Peebles CR, et al. Pericardial disease – anatomy and function. The British Journal of Radiology. 2011;84 Spec no 3(Spec Iss 3):S324-37.

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