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ABSTRACT: Pericardial effusion is the abnormal accumulation of fluid in the pericardial space. As
the fluid volume and intrapericardial pressure increase, cardiac tamponade can develop.The most
common causes of pericardial effusion include cardiac hemangiosarcoma, idiopathic pericardial
effusion, and chemodectoma. Understanding the underlying cause is important in providing
treatment recommendations and an accurate prognosis.
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COMPENDIUM
PATHOPHYSIOLOGY
Normal intrapericardial pressure approximates intrapleural pressure (varying by 4 mm
Hg with respiration).13 In pathologic states, as
fluid accumulates in the pericardial space, the
ability of the pericardium to stretch is eventually exceeded, and further fluid accumulation
subsequently results in increases in intrapericardial pressure. When the intrapericardial pressure increases to the pressure of the right
atrium and ventricle (normally 4 to 8 mm Hg),
cardiac tamponade develops13 (Figure 2). Cardiac tamponade results in decreases in venous
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AN IN-DEPTH LOOK
Visceral
pericardium
Fibrous
Myocardium
pericardium
Neoplastic
Hemangiosarcoma
Aortic body tumor (chemodectoma)
Heart-base tumor
Mesothelioma
Thyroid carcinoma
Lymphosarcoma
Connective tissue tumor
Other metastatic tumors
5 mm Hg
Pericardial space
Congenital
Peritoneopericardial diaphragmatic
hernia
Pericardial cyst
4 mm Hg
Other
04 mm Hg
Idiopathic
14/14
return, ventricular filling, stroke volume, and
mm Hg
cardiac output.13,14 Increases in heart rate
and peripheral vascular resistance can ini15
mm Hg
tially compensate for these changes, thereby
30/12
mm Hg
maintaining normal blood pressure. As the
intrapericardial pressure rises further, left
atrial and left ventricular filling are also
compromised. L eft-sided dysfunction
results in cardiogenic shock with a significant fall in cardiac output and peripheral
blood pressure.4
The pericardium normally has minimal
elasticity due to its fibrous nature. However,
the pericardium can stretch when pressure is
slowly placed on it. The volume of fluid Figure 2. Changes in the intrapericardial pressure (diastolic/systolic)
required to cause cardiac tamponade varies due to pericardial effusion, resulting in cardiac tamponade.
greatly, depending on the speed with which
the fluid accumulates. In experimental canine
models,13 as little as 25 to 100 ml of fluid rapidly injected
CAUSES
into the pericardial space can raise intrapericardial presCongenital
sure high enough to cause tamponade. In contrast, periPeritoneopericardial diaphragmatic hernia (PPDH) is
cardial effusion that slowly increases in volume can result
the most common congenital pericardial defect in dogs
in a volume as high as 2 L in a large-breed dog before
and cats.3 PPDH occurs when the septum transversum
cardiac tamponade manifests.
improperly fuses with the pleuroperitoneal folds during
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402
embryonic development, resulting in incomplete separation of the abdominal and thoracic cavities.15 PPDH is
frequently asymptomatic and identified incidentally
when radiography is conducted for other reasons (Figure 3). If clinical signs occur, they are usually referable to
the gastrointestinal tract (vomiting, diarrhea, anorexia,
weight loss). Only a small volume of fluid is typically
associated with PPDH. Respiratory signs, including
cough, tachypnea, and dyspnea, are less common.15
Pericardial cysts result from entrapment of the omentum or falciform ligament in the pericardium during
embryonic development.9 They are rare and usually
asymptomatic but can occasionally result in clinically
significant pericardial effusion.
Acquired
Acquired pericardial effusion in dogs is most frequently
due to neoplastic and idiopathic causes. In one study,1 these
causes represented 58% and 19%, respectively, of cases of
pericardial effusion. The three most common neoplasms
resulting in pericardial effusion are hemangiosarcoma, aortic body tumors, and mesothelioma. Hemangiosarcoma
represents 60% to 75% of all neoplasms resulting in pericardial effusion.1,16 Hemangiosarcoma commonly arises
from the right atrial appendage, resulting in pericardial
effusion from hemorrhage into the pericardial space; however, hemangiosarcoma may also arise from the wall of the
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AN IN-DEPTH LOOK
Key Points
Cardiac tamponade develops when intrapericardial
pressure exceeds right atrial pressure.
Hemangiosarcoma and idiopathic pericardial effusion
are the most common causes of pericardial effusion in
dogs.
The prognosis for dogs with pericardial effusion
varies greatly, depending on the cause.
CONCLUSION
Clinical signs of pericardial effusion result from a
combination of the volume of effusion, speed with
which it accumulated, and underlying cause. The interJuly 2007
play among these factors determines when, in the clinical course, intrapericardial pressure rises high enough to
cause cardiac tamponade. Pericardial effusion can result
from multiple causes. Neoplasia and idiopathic pericardial effusion are the most common causes.
REFERENCES
1. Berg R, Wingfield W: Pericardial effusion in the dog: A review of 42 cases.
JAAHA 20:721730, 1984.
2. Dunning D, Monnet E, Orton C, Salman M: Analysis of prognostic indicators for dogs with pericardial effusion: 46 cases (19851996). JAVMA
212:12791280, 1998.
3. Smith F, Rush J: Diagnosis and treatment of pericardial effusion, in Kirk R,
Bonagura J (eds): Current Veterinary Therapy XIII. Philadelphia, WB Saunders, 1999, pp 772777.
4. Bouvy B, Bjorling D: Pericardial effusion in dogs and cats, part I: Normal
pericardium and causes and pathophysiology of pericardial effusion. Compend
Contin Educ Pract Vet 13:417424, 1991.
5. Aronson L, Gregory C: Infectious pericardial effusion in 5 dogs. Vet Surg
24:402407, 1995.
6. Petrus D, Henik R: Pericardial effusion and cardiac tamponade secondary to
brodifacoum toxicosis in a dog. JAVMA 215:647648, 1999.
7. Gibbs C, Gaskell C, Darke P, Wotton P: Idiopathic pericardial haemorrhage
in dogs: A review of fourteen cases. J Small Anim Pract 23:483500, 1982.
8. Stephien R, Whitley N, Dubielzig R: Idiopathic or mesothelioma-related
pericardial effusion: Clinical findings and survival in 17 dogs studied retrospectively. J Small Anim Pract 41:342347, 2000.
9. Sisson D, Thomas W: Pericardial disease, in Fox PR, Moise NS (eds): Textbook of Canine and Feline Cardiology: Principles and Clinical Practice, ed 2.
Philadelphia, WB Saunders, 1999, pp 668669.
10. Witt A, Mathews K: Successful management of traumatic right atrial rupture. J Vet Emerg Crit Care 10:8589, 2000.
11. Wingfield W: Pericardial disease, in Bojrab J (ed): Pathophysiology in Small
Animal Surgery. Philadelphia, Lea & Febiger, 1981, pp 214217.
12. Martin M: Pericardial disease in the dog. J Small Anim Pract 53:381385,
1999.
13. Reed J, Thomas WP: Hemodynamics of progressive pneumopericardium in
the dog. Am J Vet Res 45:301307, 1984.
14. Shoemaker W: Pericardial tamponade, in Grenvik A (ed): Textbook of Critical
Care. Philadelphia, WB Saunders, 2000, pp 10971101.
15. Evans S, Bierry D: Congenital peritoneopericardial diaphragmatic hernia in
the dog and cat: A literature review and 17 additional case histories. J Am Vet
Radiol Soc 21:108116, 1980.
16. Ware W, Hopper D: Cardiac tumors in dogs: 19821995. J Vet Intern Med
12:95103, 1999.
17. Brown N, Patnaik A, MacEwen E: Canine hemangiosarcoma: Retrospective
analysis of 104 cases. JAVMA 186:5658, 1985.
18. Hayes HJ: A hypothesis for the aetiology of canine chemoreceptor system
neoplasms, based upon epidemiological study of 73 cases among hospital
patients. J Small Anim Pract 16:337343, 1975.
19. Vicari E, Brown D, Holt D, Brockman D: Survival times of and prognostic
indicators for dogs with heart-base masses: 25 cases (19861999). JAVMA
219:485487, 2001.
20. Shubitz L, Matz M, Noon T, et al: Constrictive pericarditis secondary to Coccidioides immitis infection in a dog. JAVMA 218:537540, 2001.
21. Aronsohn M, Carpenter J: Surgical treatment of idiopathic pericardial effusion in the dog: 25 cases (19781993). JAAHA 35(6):521525, 1999.
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ARTICLE #1 CE TEST
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Medicine. Subscribers may purchase individual CE tests or sign up for our annual CE program. Those who
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1. The normal pericardium
a. is filled with 1 to 15 ml of blood.
b. is essential to normal cardiac function.
c. contains a cavity between the parietal and visceral
pericardium.
d. ensures the normal orientation of the lungs in the
thoracic cavity.
2. Which statement regarding the normal pericardium is correct?
a. Normal intrapericardial pressure is 4 mm Hg or less.
b. The pericardium is inelastic.
c. Intrapleural pressure normally exceeds intrapericardial pressure.
d. The pericardium may rupture due to the development of pericardial effusion.
3. Which statement regarding cardiac tamponade
is correct?
a. A minimum of 500 ml of fluid is required to cause
cardiac tamponade in most dogs.
b. The volume of pericardial fluid is directly related to
the severity of the cardiac tamponade.
c. Cardiac tamponade results in decreased venous
return and cardiac output.
d. Cardiac tamponade is typically characterized by
bradycardia.
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