From the Guidelines
Pericardiocentesis is indicated primarily for cardiac tamponade, a life-threatening condition where fluid accumulation in the pericardial sac compresses the heart and impairs cardiac filling, as well as for diagnostic purposes in cases of suspected purulent, tuberculous, or malignant pericardial effusions when less invasive methods are inconclusive, and for large pericardial effusions (>20mm in echocardiography) causing symptoms like dyspnea or chest pain, as recommended by the 2015 ESC guidelines 1.
The indications for pericardiocentesis can be summarized as follows:
- Cardiac tamponade, a life-threatening condition where fluid accumulation in the pericardial sac compresses the heart and impairs cardiac filling
- Diagnostic purposes in cases of suspected purulent, tuberculous, or malignant pericardial effusions when less invasive methods are inconclusive
- Large pericardial effusions (>20mm in echocardiography) causing symptoms like dyspnea or chest pain
The procedure involves inserting a needle, typically via the subxiphoid approach under ultrasound guidance, into the pericardial space to remove fluid. Echocardiographic guidance significantly improves safety by reducing the risk of complications such as cardiac puncture, coronary artery laceration, pneumothorax, and arrhythmias, with a reported incidence of major complications of 1.3-1.6% 1.
Following emergency drainage, patients require close monitoring for reaccumulation of fluid and treatment of the underlying cause of the effusion. The 2015 ESC guidelines recommend targeting the therapy of pericardial effusion at the aetiology as much as possible, and considering pericardiocentesis or cardiac surgery for cardiac tamponade or for symptomatic moderate to large pericardial effusions not responsive to medical therapy, and for suspicion of unknown bacterial or neoplastic aetiology 1.
It is essential to note that pericardiocentesis should be performed by experienced operators, and the procedure carries a risk of complications ranging from 4 to 10% depending on the type of monitoring, the skill of the operator, and the setting (emergency vs. urgent vs. elective) 1.
In conclusion, pericardiocentesis is a life-saving procedure for cardiac tamponade and a valuable diagnostic tool for pericardial effusions, with a favorable safety profile when performed under echocardiographic guidance by experienced operators.
From the Research
Indications for Pericardiocentesis
The primary indication for pericardiocentesis is the management of emergent cardiac tamponade 2. Cardiac tamponade is a life-threatening condition characterized by fluid accumulation in the pericardium, which compresses the cardiac chambers, impingements diastolic filling, and can lead to clinical shock 3.
Causes of Cardiac Tamponade
The causes of cardiac tamponade include:
- Malignant disease, which is the primary cause of medical tamponade 4
- Idiopathic diseases 5
- Traumatic cases 5
- Purulent or recurrent effusions 5
- Cardiac perforation during percutaneous coronary intervention (PCI) 6
- Intra-pericardial bleeding due to anti-coagulation treatment 4
Pericardiocentesis Procedure
Pericardiocentesis is performed by inserting a needle into the left xiphocostal angle perpendicular to the skin and advancing it until it reaches the pericardial fluid 2. The procedure can be guided by two-dimensional echocardiography or fluoroscopy 2 and more recently, periprocedural use of ultrasound has emerged as the preferred initial technique for pericardiocentesis 3.
Treatment Options
Treatment options for cardiac tamponade include:
- Echo-guided pericardiocentesis, which is a minimal invasive procedure and should be the first choice, especially in idiopathic cases and in patients with hemodynamic instability 5
- Primary surgical treatment, which may be performed for traumatic cases, purulent, recurrent, or malign effusions 5
- Surgical treatment following pericardiocentesis, which may be required in some cases 5