2. Place of Puncture Description Disadvantages Advantages
Apical The needle insertion
site is 1-2 cm lateral
to the apex beat
within the fifth, sixth
or seventh
intercostal space.
Advance the needle
over the superior
border of the rib to
avoid intercostal
nerves and vessels.
Risk of ventricular
puncture due to the
proximity to the left
ventricle.
Increased risk for
pneumothorax for
the proximity to the
left pleural space.
The thicker left
ventricle wall is more
likely to self-seal
after puncture.
Due to ultrasound
not penetrating air,
using
echocardiographic
guidance ensures
avoidance of the
lung.
The path to reach the
pericardium is
shorter.
Parasternal The needle insertion
site is in the fifth left
intercostal space
close to the sternal
margin. Advance the
needle perpendicular
to the skin (at the
level of the cardiac
notch of the left
lung).
Risk of
pneumothorax and
puncture of the
internal thoracic
vessels (if the needle
is inserted more than
1 cm laterally).
Echocardiographic
guidance, also with
phase array probe,
provides a good
visualisation of
pericardial
structures.
Subxiphoid The needle insertion
site is between the
xiphisternum and left
costal margin. Once
beneath the cartilage
cage, lower the
needle to a 15-to-30-
degree angle, with
the abdominal wall
directed towards the
left shoulder.
A steeper angle may
enter the peritoneal
cavity, and a medial
direction increases
the risk of right atrial
puncture. In some
cases, the left liver
lobe may be
transversed
intentionally if an
alternative site is not
available.
The path to reach the
fluid is longer.
Lower risk of
pneumothorax.
Equipment for Echo-Guided Pericardiocentesis
Echocardiography with a cardiac probe
Sterile probe cover and sterile echo gel
16-18 gauge, Teflon-sheathed needle
6 Fr to 8 Fr dilator and introducer sheath
J-tipped guidewire
Drainage catheter: pigtail angiocatheter 6 Fr to 8 Fr or specific pericardial drainage set
Disposable flushing system to maintain patency of the catheter
Equipment for Real-Time Echo-Monitored Procedure
Multi-angle bracket to be mounted on the echo probe
Needle guide sterile kit
18 gauge, 9 cm needle (or 15 cm for subxiphoid approach)
6 Fr to 8 Fr dilator
Cardiac tamponade is a life-threatening slow or rapid compression of the heart due to increasing pericardial fluid. The pericardium can stretch
Clinically, cardiac tamponade is defined as the decompensated phase of cardiac compression, resulting from increased intrapericardial press
Effect of pericardiocentesis
The effect of pericardiocentesis is often immediate: the drainage of a few millilitres of the effusion significantly increases stroke volume, reduc
Indications of pericardiocentesis
In haemodynamically unstable patients, an emergent procedure is mandatory because only the removal of fluid allows a normal ventricular fil
In case of pericardial effusion without haemodynamic compromise, pericardiocentesis is indicated for symptomatic moderate to large effusion
Pericardiocentesis for diagnostic purposes is not justified in cases of mild or moderate effusions (<20 mm) for the following reasons: 1) low di
Contraindications
There are no absolute contraindications to pericardiocentesis when cardiac tamponade and shock occur. Aortic dissection and post-infarction
Approaches
Fluoroscopy-guided technique
The fluoroscopic approach was the first imaging system used for percutaneous pericardiocentesis. It is performed through the subxiphoid app
This procedure is standardised and effective, but it can only be performed in heart catheterisation laboratories and it implies an exposure to ra
Computed tomography-guided technique
In recent years, evidence of the feasibility of pericardiocentesis under computed tomography (CT) guidance has been reported. Through the p
Echo-guided technique
Echocardiography-guided pericardiocentesis is a safe and simple technique, introduced at the Mayo Clinic in 1979 and widely used nowaday
Puncture site
Three main approaches can be used for pericardiocentesis: the apical, the subcostal or the parasternal approach.
Traditionally, a subcostal approach has been preferred, largely because it was considered the safest route without image guidance. However
Table 1. Characteristics of the Different Pericardiocentesis Approaches
Figure 1. Pericardiocentesis: Anatomic Structures and Approaches.
A) Anatomic structures to bear in mind during pericardiocentesis procedure.
B) Three main approaches for pericardiocentesis, parasternal, substernal and apical.
3. Place of Puncture Description Disadvantages Advantages
Apical The needle insertion
site is 1-2 cm lateral
to the apex beat
within the fifth, sixth
or seventh
intercostal space.
Advance the needle
over the superior
border of the rib to
avoid intercostal
nerves and vessels.
Risk of ventricular
puncture due to the
proximity to the left
ventricle.
Increased risk for
pneumothorax for
the proximity to the
left pleural space.
The thicker left
ventricle wall is more
likely to self-seal
after puncture.
Due to ultrasound
not penetrating air,
using
echocardiographic
guidance ensures
avoidance of the
lung.
The path to reach the
pericardium is
shorter.
Parasternal The needle insertion
site is in the fifth left
intercostal space
close to the sternal
margin. Advance the
needle perpendicular
to the skin (at the
level of the cardiac
notch of the left
lung).
Risk of
pneumothorax and
puncture of the
internal thoracic
vessels (if the needle
is inserted more than
1 cm laterally).
Echocardiographic
guidance, also with
phase array probe,
provides a good
visualisation of
pericardial
structures.
Subxiphoid The needle insertion
site is between the
xiphisternum and left
costal margin. Once
beneath the cartilage
cage, lower the
needle to a 15-to-30-
degree angle, with
the abdominal wall
directed towards the
left shoulder.
A steeper angle may
enter the peritoneal
cavity, and a medial
direction increases
the risk of right atrial
puncture. In some
cases, the left liver
lobe may be
transversed
intentionally if an
alternative site is not
available.
The path to reach the
fluid is longer.
Lower risk of
pneumothorax.
Equipment for Echo-Guided Pericardiocentesis
Echocardiography with a cardiac probe
Sterile probe cover and sterile echo gel
16-18 gauge, Teflon-sheathed needle
6 Fr to 8 Fr dilator and introducer sheath
J-tipped guidewire
Drainage catheter: pigtail angiocatheter 6 Fr to 8 Fr or specific pericardial drainage set
Disposable flushing system to maintain patency of the catheter
Equipment for Real-Time Echo-Monitored Procedure
Multi-angle bracket to be mounted on the echo probe
Needle guide sterile kit
18 gauge, 9 cm needle (or 15 cm for subxiphoid approach)
6 Fr to 8 Fr dilator
Cardiac tamponade is a life-threatening slow or rapid compression of the heart due to increasing pericardial fluid. The pericardium can stretch
Clinically, cardiac tamponade is defined as the decompensated phase of cardiac compression, resulting from increased intrapericardial press
Effect of pericardiocentesis
The effect of pericardiocentesis is often immediate: the drainage of a few millilitres of the effusion significantly increases stroke volume, reduc
Indications of pericardiocentesis
In haemodynamically unstable patients, an emergent procedure is mandatory because only the removal of fluid allows a normal ventricular fil
In case of pericardial effusion without haemodynamic compromise, pericardiocentesis is indicated for symptomatic moderate to large effusion
Pericardiocentesis for diagnostic purposes is not justified in cases of mild or moderate effusions (<20 mm) for the following reasons: 1) low di
Contraindications
There are no absolute contraindications to pericardiocentesis when cardiac tamponade and shock occur. Aortic dissection and post-infarction
Approaches
Fluoroscopy-guided technique
The fluoroscopic approach was the first imaging system used for percutaneous pericardiocentesis. It is performed through the subxiphoid app
This procedure is standardised and effective, but it can only be performed in heart catheterisation laboratories and it implies an exposure to ra
Computed tomography-guided technique
In recent years, evidence of the feasibility of pericardiocentesis under computed tomography (CT) guidance has been reported. Through the p
Echo-guided technique
Echocardiography-guided pericardiocentesis is a safe and simple technique, introduced at the Mayo Clinic in 1979 and widely used nowaday
Puncture site
Three main approaches can be used for pericardiocentesis: the apical, the subcostal or the parasternal approach.
Traditionally, a subcostal approach has been preferred, largely because it was considered the safest route without image guidance. However
Table 1. Characteristics of the Different Pericardiocentesis Approaches
Figure 1. Pericardiocentesis: Anatomic Structures and Approaches.
A) Anatomic structures to bear in mind during pericardiocentesis procedure.
B) Three main approaches for pericardiocentesis, parasternal, substernal and apical.
