- Alan C Heffner, MD
Alan C Heffner, MD
- Director of Critical Care
- Director of ECMO Services
- Pulmonary and Critical Care Consultants
- Department of Internal Medicine
- Department of Emergency Medicine
- Carolinas Medical Center
- Associate Clinical Professor
- University of North Carolina School of Medicine
- Section Editors
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Pericardial effusion and cardiac tamponade represent a spectrum of disease with wide variation in clinical presentation [1,2]. While all significant pericardial effusions are of clinical importance, emergency drainage is needed only for patients with hemodynamic compromise. Cardiac tamponade with hemodynamic collapse is an absolute indication for emergent pericardial drainage via pericardiocentesis or surgical pericardiotomy.
The lethality of pericardial effusions has been recognized for centuries. Riolanus suggested sternal trephination to release pericardial fluid in 1653 and the Spanish physician Romero described intercostal surgical drainage in the early 19th century . The Viennese thoracic surgeon Franz Schuh performed the first successful blind pericardial aspiration in 1840 via a left parasternal approach . Marfan later described the subxiphoid technique in 1911 . Despite significant complications and safety concerns, this remained the standard approach for blind pericardiocentesis through the late 20th century. Experience with echocardiography-directed pericardiocentesis paralleled technical advances in ultrasound during the 1970s, and has evolved as the procedure of choice due to its improved safety and efficacy [6-9]. Nonetheless, blind subcostal or parasternal pericardiocentesis remains a standard procedure for emergency pericardial drainage when ultrasound guidance is unavailable.
The indications, contraindications, preparation, equipment, and techniques of emergency pericardiocentesis will be reviewed here. Cardiac tamponade and its related diseases and non-emergent pericardiocentesis are discussed separately. (See "Cardiac tamponade" and "Cardiac injury from blunt trauma" and "Constrictive pericarditis" and "Pericardial disease associated with malignancy" and "Diagnosis and treatment of pericardial effusion", section on 'Pericardial fluid drainage'.)
ANATOMY AND PHYSIOLOGY
The parietal pericardium is a fibrous sac that encloses the heart and the roots of the great vessels (figure 1). The cone-shaped sac rests on the diaphragm and fuses superiorly with the adventitia of the great vessels. The pericardium and heart lie between the pleural sacs. The pericardium is fixed within the thorax by attachments to the anterior diaphragm, the sternum, and the fourth and fifth left costal cartilages. The phrenic nerve innervates the pericardium as its runs between the mediastinal pleura and fibrous pericardium.
In health, the pericardium envelops the heart loosely, but is rigid enough to provide stability within the thoracic cavity and to limit cardiac distention (pericardial constraint). The normal pericardial space contains <50 mL of thin serous lubricating fluid that is an ultrafiltrate of plasma. Lymphatic drainage of the pericardium to mediastinal and tracheobronchial lymph nodes provides the anatomic basis for pericardial involvement in the pathology of these regions.
- Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol 1990; 66:1487.
- Spodick DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.
- Loukas M, Walters A, Boon JM, et al. Pericardiocentesis: a clinical anatomy review. Clin Anat 2012; 25:872.
- Wong B, Murphy J, Chang CJ, et al. The risk of pericardiocentesis. Am J Cardiol 1979; 44:1110.
- Kilpatrick ZM, Chapman CB. On pericardiocentesis. Am J Cardiol 1965; 16:722.
- Goldberg BB, Pollack HM. Ultrasonically guided pericardiocentesis. Am J Cardiol 1973; 31:490.
- Callahan JA, Seward JB. Pericardiocentesis Guided by Two-Dimensional Echocardiography. Echocardiography 1997; 14:497.
- Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clin Proc 1998; 73:647.
- Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
- Spodick DH. Pathophysiology of cardiac tamponade. Chest 1998; 113:1372.
- Harper, Richard, J.. Pericardiocentesis. In: Clinical Procedures in Emergency Medicine, 5, Roberts, JR, Hedges, JR (Eds), Saunders Elsevier, Philadelphia 2010. p.287.
- Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful? Circulation 1994; 90:2375.
- Silvestry FE, Kerber RE, Brook MM, et al. Echocardiography-guided interventions. J Am Soc Echocardiogr 2009; 22:213.
- Hayashi T, Tsukube T, Yamashita T, et al. Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection. Circulation 2012; 126:S97.
- Cruz I, Stuart B, Caldeira D, et al. Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery. Eur Heart J Acute Cardiovasc Care 2015; 4:124.
- Mackersie RC. Pitfalls in the evaluation and resuscitation of the trauma patient. Emerg Med Clin North Am 2010; 28:1.
- Ho AM, Graham CA, Ng CS, et al. Timing of tracheal intubation in traumatic cardiac tamponade: a word of caution. Resuscitation 2009; 80:272.
- BISHOP LH Jr, ESTES EH Jr, MCINTOSH HD. The electrocardiogram as a safeguard in pericardiocentesis. J Am Med Assoc 1956; 162:264.
- Kerber RE, Ridges JD, Harrison DC. Electrocardiographic indications of atrial puncture during pericardiocentesis. N Engl J Med 1970; 282:1142.
- Sobol SM, Thomas HM Jr, Evans RW. Myocardial laceration not demonstrated by continuous electrocardiographic monitoring occurring during pericardiocentesis. N Engl J Med 1975; 292:1222.
- Park SC, Pahl E, Ettedgui JA, et al. Experience with a newly developed pericardiocentesis set. Am J Cardiol 1990; 66:1529.
- Porter JM, Ivatury RR. Unwillingness to lie supine? a sign of pericardial tamponade. Am Surg 1997; 63:365.
- Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA 2007; 297:1810.
- Callahan JA, Seward JB, Tajik AJ. Cardiac tamponade: pericardiocentesis directed by two-dimensional echocardiography. Mayo Clin Proc 1985; 60:344.
- Guven H, Bakiler AR, Ulger Z, et al. Evaluation of children with a large pericardial effusion and cardiac tamponade. Acta Cardiol 2007; 62:129.
- Fitch MT, Nicks BA, Pariyadath M, et al. Videos in clinical medicine. Emergency pericardiocentesis. N Engl J Med 2012; 366:e17.
- Cooper JP, Oliver RM, Currie P, et al. How do the clinical findings in patients with pericardial effusions influence the success of aspiration? Br Heart J 1995; 73:351.
- Tsang TS, Barnes ME, Hayes SN, et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998. Chest 1999; 116:322.
- Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002; 77:429.
- Cho BC, Kang SM, Kim DH, et al. Clinical and echocardiographic characteristics of pericardial effusion in patients who underwent echocardiographically guided pericardiocentesis: Yonsei Cardiovascular Center experience, 1993-2003. Yonsei Med J 2004; 45:462.
- Hanaki Y, Kamiya H, Todoroki H, et al. New two-dimensional, echocardiographically directed pericardiocentesis in cardiac tamponade. Crit Care Med 1990; 18:750.
- Ellis H. The clinical anatomy of pericardiocentesis. Br J Hosp Med (Lond) 2010; 71:M100.
- John RM, Treasure T. How to aspirate the pericardium. Br J Hosp Med 1990; 43:221.
- Brown CG, Gurley HT, Hutchins GM, et al. Injuries associated with percutaneous placement of transthoracic pacemakers. Ann Emerg Med 1985; 14:223.
- Krikorian JG, Hancock EW. Pericardiocentesis. Am J Med 1978; 65:808.
- Guberman BA, Fowler NO, Engel PJ, et al. Cardiac tamponade in medical patients. Circulation 1981; 64:633.
- Kwasnik EM, Koster K, Lazarus JM, et al. Conservative management of uremic pericardial effusions. J Thorac Cardiovasc Surg 1978; 76:629.
- Lindenberger M, Kjellberg M, Karlsson E, Wranne B. Pericardiocentesis guided by 2-D echocardiography: the method of choice for treatment of pericardial effusion. J Intern Med 2003; 253:411.
- Kil UH, Jung HO, Koh YS, et al. Prognosis of large, symptomatic pericardial effusion treated by echo-guided percutaneous pericardiocentesis. Clin Cardiol 2008; 31:531.
- Degirmencioglu A, Karakus G, Güvenc TS, et al. Echocardiography-guided or "sided" pericardiocentesis. Echocardiography 2013; 30:997.
- Nagdev A, Mantuani D. A novel in-plane technique for ultrasound-guided pericardiocentesis. Am J Emerg Med 2013; 31:1424.e5.
- Osman A, Wan Chuan T, Ab Rahman J, et al. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J Emerg Med 2017.
- Maggiolini S, Bozzano A, Russo P, et al. Echocardiography-guided pericardiocentesis with probe-mounted needle: report of 53 cases. J Am Soc Echocardiogr 2001; 14:821.
- Spodick DH. The technique of pericardiocentesis. When to perform it and how to minimize complications. J Crit Illn 1995; 10:807.
- Iskandrian AS. Practical considerations in pericardiocentesis. Cathet Cardiovasc Diagn 1989; 16:24.
- Vayre F, Lardoux H, Pezzano M, et al. Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients. Eur J Echocardiogr 2000; 1:66.
- Chandraratna PA, Reid CL, Nimalasuriya A, et al. Application of 2-dimensional contrast studies during pericardiocentesis. Am J Cardiol 1983; 52:1120.
- Weisse AB, Desai RR, Rajihah G, Lopez S. Contrast echocardiography as an adjunct in hemorrhagic or complicated pericardiocentesis. Am Heart J 1996; 131:822.
- Chiang HT, Lin M. Pericardiocentesis guided by two-dimensional contrast echocardiography. Echocardiography 1993; 10:465.
- Ainsworth CD, Salehian O. Echo-guided pericardiocentesis: let the bubbles show the way. Circulation 2011; 123:e210.
- Armstrong WF, Feigenbaum H, Dillon JC. Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis for relief of cardiac tamponade. Am Heart J 1984; 107:1266.
- Bastian A, Meissner A, Lins M, et al. Pericardiocentesis: differential aspects of a common procedure. Intensive Care Med 2000; 26:572.
- Tsang TS, Freeman WK, Barnes ME, et al. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol 1998; 32:1345.
- Glasser F, Fein AM, Feinsilver SH, et al. Non-cardiogenic pulmonary edema after pericardial drainage for cardiac tamponade. Chest 1988; 94:869.
- Wolfe MW, Edelman ER. Transient systolic dysfunction after relief of cardiac tamponade. Ann Intern Med 1993; 119:42.
- Vandyke WH Jr, Cure J, Chakko CS, Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade. N Engl J Med 1983; 309:595.
- ANATOMY AND PHYSIOLOGY
- MONITORING AND PREPARATION
- TECHNIQUE OVERVIEW
- General preparation
- Selecting the approach for pericardiocentesis
- - Subcostal (subxiphoid)
- - Parasternal
- - Apical
- Ultrasound-guided pericardiocentesis technique
- Pericardiocentesis technique without ultrasound guidance
- Intrapericardial needle confirmation
- Drain placement
- Catheter drainage and care
- SUMMARY AND RECOMMENDATIONS