What is pericardiocentesis (pericardial fluid aspiration)?

From the Guidelines

Pericardiocentesis is a lifesaving procedure that involves the aspiration of fluid from the pericardial space surrounding the heart, primarily indicated for cardiac tamponade, and should be performed under echocardiography or fluoroscopy guidance by experienced operators in a facility equipped for radiographic, echocardiographic, haemodynamic, and ECG monitoring. The procedure is used to remove fluid that has accumulated in the pericardial sac, which can compress the heart and impair its ability to fill properly, leading to cardiac tamponade, a life-threatening condition. According to the most recent and highest quality study 1, pericardiocentesis should be guided by either fluoroscopy or echocardiography to minimize the risk of complications, such as laceration of the heart or other organs. Some key points to consider when performing pericardiocentesis include:

• The ideal entry site is the point on the body surface where the effusion is closest to the transducer and the fluid collection is maximal 1
• The needle trajectory should avoid vital structures such as the liver, myocardium, lung, internal mammary artery, and the vascular bundle at the inferior margin of each rib 1
• Local anesthesia with 1-2% lidocaine is administered at the insertion site, usually in the subxiphoid area
• After accessing the pericardial space, a guidewire is placed, followed by a catheter through which the fluid is drained
• The fluid should be sent for laboratory analysis including cell count, protein, glucose, cytology, and cultures to determine the underlying cause
• Potential complications include cardiac puncture, arrhythmias, pneumothorax, and infection, and the procedure should be performed by experienced clinicians in an appropriate setting with cardiac monitoring and resuscitation equipment available 1. Pericardiocentesis works by relieving the pressure on the heart, allowing proper cardiac filling and restoring normal hemodynamics, and it is considered a primary therapy for patients with clinically significant effusions, with a success rate of 97% in relieving tamponade, as reported in a previous study 1.

From the Research

Definition and Purpose of Pericardiocentesis

• Pericardiocentesis, also known as pericardial fluid aspiration, is a medical procedure used to remove fluid that has accumulated in the pericardium, the sac surrounding the heart 2, 3.
• The purpose of pericardiocentesis is to relieve the pressure on the heart caused by the accumulated fluid, which can lead to cardiac tamponade, a life-threatening condition characterized by impaired diastolic filling and clinical shock 2, 4, 5, 3, 6.

Procedure and Techniques

• Pericardiocentesis can be performed using various techniques, including the subxiphoid "blind" approach or under transthoracic echocardiographic guidance 3.
• The procedure typically involves inserting a needle into the pericardial sac to drain the accumulated fluid, which can be done using an indwelling "pigtail" catheter 3.
• The use of ultrasound guidance has emerged as the preferred initial technique for pericardiocentesis, as it allows for the assessment of the pericardial effusion and the safety and feasibility of the procedure from various trajectories to minimize complications 2.

Indications and Contraindications

• Pericardiocentesis is indicated as an emergency procedure in patients with hemodynamic compromise secondary to cardiac tamponade 6.
• Absolute contraindications for pericardiocentesis are few, but knowledge of them is mandatory when assessing patients for the procedure 2.
• Pericardiocentesis may be performed in various settings, including hospitals and even in ambulances or other prehospital settings in emergency situations 6.

Potential Complications

• Pericardiocentesis can be associated with various complications, including laceration of the right ventricle or coronary artery, arrhythmias, viscus perforation, hypotension, pneumothorax, adult respiratory distress syndrome, and death 4.
• Pericardial decompression syndrome (PDS) is a rare but life-threatening complication that can occur after pericardiocentesis, characterized by paradoxical worsening of vital signs after successful decompression of the pericardium 5.