Epicardial metastases with effusion

Secondary neoplastic involvement of the heart produced by dissemination of extracardiac primary malignant tumors.

Definition

Secondary neoplastic involvement of the heart produced by dissemination of extracardiac primary malignant tumors, which preferentially settles in pericardium and epicardial surface causing nodular implants, moderate-to-severe serosanguinous or hemorrhagic pericardial effusion, and electrocardiographic voltage attenuation [C10] [G810-10].

Severity criteria

Literal statement from article of Chiles et al. [G810-10, Abstract]:
- «Metastases to the heart and pericardium are much more common than primary cardiac tumors and are generally associated with a poor prognosis»
- «shortness of breath, which may be out of proportion to radiographic findings in patients with pericardial effusion»
Pericardial effusion volume: Accumulation of hemorrhagic pericardial fluid usually moderate (200–500 mL) [C10] [G810-10].
Electrocardiographic voltage: Low voltage criteria on surface ECG (sum QRS < 0.5 mV in limb leads or < 1.0 mV in precordial leads) [G810-10] [E1].

Findings by layer

Hemodynamics

Cardiac output slightly reduced or at lower limit (cardiac output 3.8–4.8 L/min) [C10].
Mean right atrial pressure and pulmonary capillary wedge pressure moderately increased (10–14 mmHg) due to elastic compression of pericardial fluid [C10] [G810-10].

Rhythm

Sinus tachycardia (sinus tachycardia, 100–115 bpm) reactive to inflammation and subacute compression, with alternative of atrial fibrillation from irritation of atrial epicardial wall [C10] [G810-10].

ECG

Diffuse low voltage of QRS complexes (low voltage) in all leads due to interposition of pericardial fluid layer and possible non-specific ST-segment and T-wave abnormalities [G810-10] [E1].

Heart sounds and murmurs

Heart sounds: S1 and S2 heart sounds muffled or attenuated by pericardial effusion [C10] [B1].
Murmurs: Absence of intrinsic pathological valvular murmurs [C10].

Arterial pulse

Regular, rapid pulse with slightly decreased amplitude; pulsus paradoxus usually not significant (< 10 mmHg) unless progressing to tension tamponade [B4] [B5].

Jugular venous pulse

Mild to moderate elevation of mean jugular venous pressure with preserved or slightly dampened 'y' descent [B3].

Maneuvers

Habitual physiological responses [B1].

Simulator severity grades

Simulator severity grades: Single grade

Baseline rhythm: Sinus Tachycardia

Also known as: Epicardial metastases with effusion · Pericardial metastases · Cardiac metastases · Epicardial metastases

Other pathologies in this group

Sources

[B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
[B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
[B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
[B5] Pulsus paradoxus . Eur Respir J (2013) . DOI: 10.1183/09031936.00138912 PubMed: 23222878
[C10] Primary Cardiac Tumors: JACC: CardioOncology State-of-the-Art Review . JACC CardioOncol (2020) . DOI: 10.1016/j.jaccao.2020.05.009 PubMed: 34396236
[E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
[G810-10] Metastatic involvement of the heart and pericardium: CT and MR imaging . Radiographics (2001) . DOI: 10.1148/radiographics.21.2.g01mr15439 PubMed: 11259706