Pericardiocentesis: Guide to Pericardial Fluid Drainage Procedure

What is Pericardiocentesis?

#

Pericardiocentesis is draining fluid accumulated in the pericardial space (the area between the membrane surrounding the heart and the heart itself) using a needle and catheter. Normally, this space contains only 15-50 ml of fluid that allows the heart to move freely.

When the amount of fluid increases (pericardial effusion), the heart can become compressed and pumping function can be impaired. This condition is called cardiac tamponade and requires emergency intervention.

Purposes of Pericardiocentesis:

• Diagnostic: Obtaining a sample for laboratory analysis of the fluid (infection, cancer screening)
• Therapeutic: Draining excess fluid to reduce pressure on the heart
• Emergency: Life-saving intervention in cardiac tamponade

Causes of Pericardial Effusion

#

There are many causes of fluid accumulation in the pericardium:

Infectious Causes

#

• Viral pericarditis: Most common cause (Coxsackie, Echovirus, Adenovirus)
• Bacterial pericarditis: Severe course, requires urgent treatment
• Tuberculous pericarditis: Important especially in developing countries

Non-infectious Causes

#

• Malignancy: Lung cancer, breast cancer, lymphoma, leukemia
• Uremia: Advanced kidney failure
• Autoimmune diseases: Systemic lupus, rheumatoid arthritis
• Hypothyroidism: Underactive thyroid gland
• Post-cardiac injury syndrome: After heart surgery or myocardial infarction
• Trauma: Chest trauma, surgical complication
• Idiopathic: Cases where cause cannot be found

Pericardiocentesis Indications

#

Emergency Indications

#

• Cardiac tamponade: Most urgent indication
• Hemodynamic instability: Low blood pressure, signs of shock
• Respiratory distress: Severe shortness of breath

Elective Indications

#

• Large effusion (over 20 mm)
• Symptomatic effusion (shortness of breath, chest pain)
• Diagnostic purpose (suspicion of malignancy, infection investigation)
• Recurrent effusion

Cardiac Tamponade: Emergency Situation

#

Cardiac tamponade is when pericardial fluid compresses the heart and prevents it from filling during diastole (relaxation phase). It is life-threatening.

Tamponade Signs (Beck’s Triad):

1. Low blood pressure (hypotension)
2. Distended neck veins
3. Muffled heart sounds

Other Findings:

• Pulsus paradoxus (weakening of pulse during inspiration)
• Tachycardia (rapid heartbeat)
• Shortness of breath
• Restlessness, feeling of fear

How is Pericardiocentesis Performed?

#

Pre-procedure Preparation

#

• Echocardiography: Determining the amount and location of fluid
• Coagulation tests: Assessment of bleeding risk
• Intravenous access: IV line for emergency medication
• Monitoring: ECG, blood pressure, oxygen tracking

Procedure Techniques

#

Subxiphoid Approach (Most Common):

• Entry just below the xiphoid process
• Safe entry under echocardiographic guidance
• Lowest complication risk

Apical Approach:

• Entry from the heart apex (left chest lateral wall)
• Preferred when fluid accumulates more in this area

Parasternal Approach:

• Entry from beside the sternum
• Rarely used

Procedure Steps

#

1. Sterile preparation: Sterilization of the chest area
2. Local anesthesia: Anesthetic injection to the entry site
3. Needle entry: Reaching the pericardial space under echocardiographic guidance
4. Fluid aspiration: Withdrawing fluid with a syringe, obtaining samples
5. Catheter placement: If needed for complete drainage
6. Drainage: Complete draining of fluid
7. Catheter removal: At the end of procedure or after a few days

Procedure Duration

#

Total duration: 30-60 minutes

Pericardiocentesis Results

#

Success Rates

#

Fluid Analysis

#

The obtained fluid is sent for the following tests:

• Cytology: Investigation for cancer cells
• Biochemistry: Protein, LDH, glucose levels
• Microbiology: Investigation for bacteria, fungi, tuberculosis
• Cell count: Leukocyte and erythrocyte counts

Results help determine the cause of the effusion.

Possible Complications

#

Pericardiocentesis is a safe procedure in experienced hands, but some risks exist:

• Heart perforation: Rare but serious (1-2%)
• Arrhythmia: Temporary rhythm disturbances during the procedure
• Pneumothorax: Accidental entry into the lung
• Infection: Very rare
• Bleeding: From the entry site

Complication risk is significantly reduced in procedures performed under echocardiographic guidance.

After Pericardiocentesis

#

Follow-up

#

• Echocardiography check: Checking for fluid recurrence (after 24-48 hours)
• Clinical monitoring: Following symptoms
• Treatment of underlying cause: Infection, cancer, etc.

In Case of Recurrent Effusion

#

In some patients, fluid may reaccumulate. In such cases:

• Pericardial window: Surgically creating a permanent opening in the pericardium
• Pericardiectomy: Surgical removal of the pericardium
• Sclerotherapy: Adhesion of pericardial layers

Frequently Asked Questions

#

Consult a cardiology specialist if you have suspected pericardial effusion or complaints such as chest pain and shortness of breath.