An In-Depth Look:

CE Article #1

CANINE PERICARDIAL EFFUSION

Canine Pericardial Effusion:

Pathophysiology and Cause*
Scott P. Shaw, DVM, DACVECC
John E. Rush, DVM, MS, DACVIM (Cardiology), DACVECC
Cummings School of Veterinary Medicine at Tufts University

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.

ericardial effusion is the abnormal accumulation of fluid within the pericardial

space.13 It is the most common disease of
the pericardium in dogs.3,4 Small volumes of
pericardial effusion may not cause clinical signs;
however, as the volume and pressure in the
pericardial space increase, cardiac tamponade
can develop. Cardiac tamponade occurs when
the rise in intrapericardial pressure is sufficient
to cause hemodynamic compromise due to
decreased diastolic filling.3 Cardiac tamponade
can result in a life-threatening clinical condition that may require emergency treatment.
Reported causes of pericardial effusion in dogs
include neoplasia, idiopathic pericardial effusion, right-sided heart failure, and cardiac rupture1,310 (see box on p. 401).

THE NORMAL PERICARDIUM

The normal pericardium is composed of the
outermost fibrous pericardium
and the parietal and visceral
layers of the serous pericardium. The pericardial cav Take CE tests
ity lies between the parietal
See full-text articles

CompendiumVet.com
COMPENDIUM

and visceral layers of the serous pericardium. 4

The pericardial cavity is normally filled with 1
to 15 ml of fluid that is an ultrafiltrate of
plasma11 (Figure 1). The pericardium fixes the
heart in the thorax, preventing excessive motion;
provides a nearly frictionless anatomic barrier;
prevents extension of infection or neoplasia into
the heart; aids in ventricular coupling; and limits acute cardiac dilation.12 However, humans
and animals lacking an intact pericardium can
function normally.

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

*A companion article on diagnosis, treatment, and prognosis begins on p. 405.

400

July 2007

Canine Pericardial Effusion: Pathophysiology and Cause CE

401

AN IN-DEPTH LOOK

Causes of Pericardial Effusion

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

Right-sided heart failure

Left atrial rupture
Traumatic atrial rupture
Anticoagulant rodenticide toxicosis
Uremic pericarditis
Bacterial or fungal infection
Constrictive pericarditis

04 mm Hg

Figure 1. Layers of the normal pericardium as well as the normal

intrapericardial and right-sided heart pressures.

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

July 2007

COMPENDIUM

402

CE Canine Pericardial Effusion: Pathophysiology and Cause

AN IN-DEPTH LOOK

Figure 3. Radiograph of a dog with a congenital

peritoneopericardial hernia showing enlargement of the

cardiac silhouette and an indistinguishable border
between the caudal aspect of the heart and the
diaphragm. In addition, gas-filled loops of the intestine are
cranial to the heart.

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
COMPENDIUM

Figure 4. Heart from a dog with right atrial

hemangiosarcoma. The mass was growing from the

right atrial appendage (circle).

right atrium, especially near or above the atrioventricular

groove (Figure 4). German shepherds and golden retrievers
are reportedly predisposed to right atrial hemangiosarcoma.16,17 Cardiac hemangiosarcoma has virtually a 100%
metastatic rate by the time of diagnosis.16
Aortic body tumors are found in approximately 10%
and mesotheliomas in approximately 5% of dogs with
pericardial effusion secondary to neoplasia.1,16 Aortic
body tumors arise from chemoreceptors in the pulmonary artery and aortic outflow tract. These tumors
are also called chemodectomas. Brachycephalic breeds are
believed to be predisposed to aortic body tumors. This
has been hypothesized to be due to chronic hypoxia
caused by nasopharyngeal conformation in these
breeds.18 These tumors tend to be slow growing and
locally invasive. One report19 found that 81% of dogs
diagnosed with heart-base tumors had pericardial effusion at the time of diagnosis.
Mesotheliomas are diffuse tumors arising from the
pleura, peritoneum, and pericardium. Clinical signs usually result from accumulation of a large volume of
malignant effusion. Pericardial involvement may occur
in isolation or be combined with other mesothelial surfaces. A male predisposition for the development of
mesothelioma has been reported. 1 Other types of
tumors are rarely associated with pericardial effusion.
Infectious pericardial effusion occurs infrequently. It
may result from multiple causes, including bacterial
infection secondary to migrating foreign bodies, particJuly 2007

Canine Pericardial Effusion: Pathophysiology and Cause CE

403

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.

ularly grass awns. The most commonly isolated bacteria

associated with the condition are Actinomyces and Nocardia.5 Coccidioides immitis, a soil fungus endemic to the
southwestern United States, has also reportedly resulted
in pericardial effusion.20
Pericardial effusion secondary to right-sided heart
failure is due to passive congestion and decreased
drainage from the pericardial space. It rarely results in
a volume large enough to cause tamponade and
require pericardiocentesis. Left atrial rupture can
occur secondary to myxomatous degeneration of the
mitral valve. It is believed to occur when the jet of
regurgitant blood into the left atrium gradually weakens the left atrial wall, resulting in its perforation.
Traumatic right atrial rupture is well described in the
human literature. There is one case report10 of successful management of a traumatic right atrial rupture in a
dog. Exposure to anticoagulant rodenticides has also
reportedly resulted in pericardial effusion. 6 Uremic
pericarditis can result from serositis and myocarditis
caused by exposure to toxic metabolites normally
eliminated by the kidneys.
Idiopathic pericardial effusion refers to sterile, often
hemorrhagic effusion in the pericardial space.7,8,21 No
evidence of neoplasia, cardiac disease, trauma, infection,
or uremia is found in these cases. Histologic examination of idiopathic pericardial effusion reveals thickening
of the epicardium and pericardium with associated
inflammation.1 German shepherds, golden retrievers,
Great Danes, and Saint Bernards appear to be predisposed to idiopathic pericardial effusion.1,7,8 The age at
the time of diagnosis varies widely, ranging from 1 to 14
years, with a mean of 6 years. 2 Males appear to be
affected more frequently than females.7

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.

COMPENDIUM

404

CE Canine Pericardial Effusion: Pathophysiology and Cause

AN IN-DEPTH LOOK

ARTICLE #1 CE TEST
This article qualifies for 2 contact hours of continuing education credit from the Auburn University College of Veterinary
Medicine. Subscribers may purchase individual CE tests or sign up for our annual CE program. Those who
wish to apply this credit to fulfill state relicensure requirements should consult their respective state authorities regarding the
applicability of this program. CE subscribers can take CE tests online and get real-time scores at CompendiumVet.com.
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.

CE

6. Which statement regarding hemangiosarcoma is

correct?
a. Norfolk terriers are predisposed to hemangiosarcoma resulting in pericardial effusion.
b. The prognosis for dogs with right atrial hemangiosarcoma is generally good.
c. Cardiac hemangiosarcoma most commonly develops
from the right atrial appendage.
d. Hemangiosarcoma is usually associated with a pericardial fluid volume larger than 500 ml.
7. Which statement regarding heart-base tumors is
correct?
a. Dolichocephalic breeds are predisposed.
b. They arise from the smooth muscle cells of the
aorta.
c. They rarely cause pericardial effusion.
d. They are slow growing and locally invasive.
8. Infectious pericardial effusion
a. is frequently caused by migrating foreign bodies.
b. results from extension of infection from the pleural
space.
c. is the most common cause of pericardial effusion.
d. is most commonly caused by C. immitis.

4. Which statement regarding PPDH is correct?

a. It is the most common congenital defect in dogs and
cats.
b. It usually causes pericardial effusion by the end of the
first year of life.
c. The most common clinical signs are referable to cardiac tamponade.
d. The long-term prognosis is generally poor.

9. Which statement regarding pericardial effusion

is correct?
a. Pericardial effusion secondary to right-sided heart
failure commonly results in cardiac tamponade.
b. Uremic pericarditis commonly results in cardiac tamponade.
c. Anticoagulant rodenticide toxicosis may result in
pericardial effusion.
d. Viral infection frequently results in pericardial effusion.

5. Which is the most common cause of acquired

pericardial effusion?
a. mesothelioma
b. hemangiosarcoma
c. idiopathic effusion
d. heart-base tumor

10. Idiopathic pericardial effusion

a. occurs exclusively in young dogs.
b. is characterized by sterile inflammation of the pericardium.
c. is most common in German shepherds.
d. is frequently associated with mitral valvular disease.

COMPENDIUM

July 2007