Definition & Overview
Pericardiocentesis is the aspiration of fluid from the pericardial cavity, a space within the pericardial sac. The pericardial sac or pericardium is a double-walled sac that envelops the heart. It protects the heart and the roots of the vessels that bring blood to the aorta, superior vena cava, pulmonary arteries, and veins, among others.
The pericardial sac has a fluid-filled space called pericardial cavity. This fluid serves as a cushion to protect the heart from a sudden jolt or external shock. The pericardial sac lubricates the heart, anchors the heart to its surrounding areas, and protects it from infections.
Pericardiocentesis becomes necessary when there is pressure buildup around the heart caused by the accumulation of abnormal amounts of fluid in the pericardial cavity. By removing the fluid from this cavity, surgeons will be able to depressurise the area. They can also analyse the contents of the fluid and find out what causes the condition.
Because the heart is almost completely enveloped by the lungs, inserting sharp surgical objects towards it can accidentally puncture the surrounding organs. Some methods used to avoid such are the following:
Subxiphoid approach - In this technique, the syringe pierces through the infrasternal angle located in the lower opening of the thorax or the chest cavity.
Parasternal approach - The syringe penetrates the space between the 5th or 6th intercostal space or the space between the two ribs near the left lung.
Who Should Undergo and Expected Results?
Pericardiocentesis is required for patients suffering from cardiac tamponade. Cardiac tamponade is a condition characterised by an increased or excessive accumulation of fluid in the pericardial sac. The condition, which is often considered an emergency, can be due to:
- Blunt trauma
- Gunshot or stab wounds
- Accidental perforation following the insertion of a pacemaker, cardiac catherisation, or angiography
- Breast or lung cancer that has spread to the pericardial sac
- Inflammation of the pericardium (pericarditis)
- Kidney failure
- Certain types of infections that affect the heart
- Heart attack
- Certain inflammatory disease
- Ruptured aortic aneurysm
Cardiac tamponade patients typically suffer from the following symptoms:
- Chest pains radiating to the shoulders, neck, or back
- Breathing difficulty
- Anxiety and restlessness
- Dizziness or loss of consciousness
- Discomfort that is relieved by leaning forward or sitting
The build up of fluid in this area creates excessive pressure within the heart. The pressure prevents the heart from filling itself with blood to its full capacity. When there is less blood going into the heart, the amount of oxygen the body receives from the oxygenated blood pumped out by the heart also decreases. With decreased oxygen, a gas vital to life, the body cannot function properly and one can suffer from serious hypoxemia (oxygen deficiency) and worst - death.
Removing the excess fluid that accumulates in this area reverses the symptoms of cardiac tamponade. The fluid drawn from the pericardial sac is then analysed in a lab to check for signs of an infection, tumour cells, cancer, or verify the presence of an autoimmune disease.
How is the Procedure Performed?
First, the patient is subjected to cardiac ultrasound or echocardiogram, which allows doctors to check the condition of the heart and assess the location and amount of liquid that has accumulated in the area.
Most pericardiocentesis procedures are done in a special room called cardiac catheterisation laboratory. An intravenous (IV) line is necessary while the procedure is being carried out. It can be used for injecting medicines in case the heartbeat slows down or the blood pressure drops.
Depending on the approach used, which is either subxiphoid or parasternal, the surgeon will either insert the needle just below the left nipple or below the breastbone. This needle will be used to extract the fluid from the pericardial sac.
Surgeons will use echocardiography (ultrasound) during the procedure so they could closely monitor the movement of the needle and identify any fluid drainage. Additionally, x-rays and electrocardiogram (ECG) are also employed to better position the needle.
As soon as the needle reaches the target area, it will be replaced with a catheter that will help drain the fluid into a container, a process that may take hours.
While pericardiocentesis guarantees a high rate of success, it can also fail and the problem may come back. In this case, surgical drainage is suggested and the patient has to go through a more serious open surgery. Open surgery is more invasive and requires general anaesthesia.
Pericardiocentesis is a rather old technique in treating heart diseases. It was first introduced by Frank Schuh and first performed in Vienna in 1840. Due to its success, it became a medical procedure of choice for patients with pericardial effusions.
Possible Risks and Complications
Pericardiocentesis is inherently safe. However, like most invasive medical procedures, it carries with it some risks, which include the following:
- Internal bleeding
- Collapsed lung
- Infection in the treated area
- Heart attack
- Puncture or injury to nearby organs
- Pneumopericardium, a condition characterised by the presence of air in the pericardial cavity
Patients are advised to see their doctor if they experience extreme discomfort, breathlessness, or nagging pain in and around the treated area. Also, scheduled follow-up appointments should not be missed so that doctors can properly monitor and ensure the success of the procedure.
Saltzman AJ, Paz YE, Rene AG, Green P, Hassanin A, Argenziano MG, et al. Comparison of surgical pericardial drainage with percutaneous catheter drainage for pericardial effusion. J Invasive Cardiol. 2012 Nov. 24(11):590-3.
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 Mar. 1(1):66-71.