What Is Pericardiocentesis?

Pericardiocentesis is a procedure to drain excess fluid from the heart's protective sack (pericardium).

Pericardiocentesis is an invasive procedure to remove fluid from the protective sac (pericardium) around the heart. Pericardium is a thin, two-layered sac with a small amount of fluid. Pericardiocentesis is a procedure by which excessive pericardial fluid (pericardial effusion) is drained. Fluid removed is then tested for causes.

Pericardiocentesis may be performed with three main approaches. 

• Subxiphoid or subcostal: This is the most common angle for the needle insertion, from just below the breastbone.
• Parasternal: The needle is inserted in the fifth left intercostal space (space between the ribs), close to the edge of the sternum.
• Apical: The needle is inserted 1-2 cm lateral to the apex of the left ventricle.

Traditionally, the subcostal approach was considered the safest. This may not always be practical, as the fluid may not be present evenly in the pericardial space. The advent of imaging guidance has made it possible for doctors to use other approaches more safely, depending on where the fluid is accumulated.

Pericardiocentesis is performed to remove fluid from the pericardial space for either diagnosis or treatment. It may be performed

• As an emergency procedure for cardiac tamponade, a life-threatening accumulation of fluid affecting heart function
• To relieve symptoms of pericardial effusion such as
  • shortness of breath
  • rapid breathing
• To extract samples for diagnosing the cause of pericardial effusion

Pericardial effusion may be caused by

• Chest injury from stabbing or gunshot
• Trauma to the chest from an accident
• Heart attack and heart failure
• Rupture of aortic aneurysm
• Cardiac and other surgeries in the chest region
• Accidental perforation due to procedures like placement of pacemaker or catheter, and angiography
• Anticoagulant treatment like blood thinners
• Certain drugs which cause fluid to accumulate
• Final stages of lung and other cancers
• Radiation treatment to the chest and radiofrequency ablation
• Inflammation of the pericardium (pericarditis) caused by viral or bacterial infections
• High level of urea in the blood (uremia) due to kidney disease/failure
• Still disease
• Hypothyroidism
• Connective tissue diseases such as
• Lupus
• Rheumatoid arthritis
• Dermatomyositis
• Genetic muscle degeneration disease (Duchenne muscular dystrophy)
• Human immunodeficiency virus (HIV) infection

Pericardiocentesis is usually performed by a cardiac surgeon. The actual procedure may take up to an hour, but drainage may go on for a few hours as required. The surgeon uses one of the following guiding techniques:

• Fluoroscopy-guided: This is performed in heart catheterization labs using a contrast medium in the needle which indicates the correct position for needle insertion.
• Echo-guided technique: The surgeon inserts the needle guided by images in the echocardiography monitor.
• CT-guided: This technique is not widely available and not useful in emergencies. It is used to decide the needle position and does not allow continuous visualization. A final scan is useful in diagnosing the underlying disease.

Preparation

• The patient undergoes blood and imaging tests.
• The patient may need to avoid eating or drinking for 6 hours prior.
• The patient must check with the doctor before taking any regular medication and inform them about allergies.

Procedure

• The patient lies in a semi-reclining position at 30- to 45-degree angle.
• The doctor may give a mild sedative.
• The doctor will attach an IV line for medications.
• The patient will receive supplemental oxygen.
• The patient’s blood pressure, pulse, and heart rate will be continuously monitored.
• The doctor will choose the puncture site guided by the imaging monitor.
• The doctor will administer a local anesthetic to numb the area.
• The doctor will insert a hollow needle with a syringe into the pericardium.
• The doctor will draw fluid for testing and attach a catheter to the needle to drain the excess fluid.
• The catheter may stay attached for a few hours.
• After excess fluid is drained the doctor will remove the catheter and needle and apply a bandage on the puncture site.
• The doctor will monitor the patient’s vital functions until they stabilize.
• Recovery time depends on the underlying cause for the pericardial effusion.

The pericardial drain may be left in place for as long as a day, but is typically removed as soon as possible to reduce chances of infection.

Pericardiocentesis is a major invasive procedure on a vital organ. It is potentially life-saving, but risky, and the severity of complications may depend on the underlying condition. The risks include:

• Irregular heartbeat
• Heart attack
• Cardiac arrest
• Injury to major blood vessels
• Puncture of the heart, lung, liver or stomach
• Infection
• Unsuccessful procedure requiring more invasive surgery