Pericardiocentesis

What is a pericardiocentesis?

Pericardiocentesis (pronounced “pair-ick-arr-dee-oh-sen-TEE-sis”) is a procedure that drains extra fluid from around your heart. It’s often a treatment for a life-threatening condition that can stop your heart.

This procedure involves inserting a needle into your chest until the tip of the needle is inside your pericardium (the pouch that surrounds your heart). Once there, providers can use the needle to drain fluid directly or place a drain that can remove fluid slowly over time.

A pericardiocentesis procedure treats pericardial effusion, or too much fluid in your pericardium. (A small amount of fluid is normal.) Your pericardium holds your heart in place and cushions it from outside movement.

Pericardial effusions can lead to cardiac tamponade. This is a medical emergency because it can make your heart stop, which can be deadly within minutes to hours.

A provider can use pericardiocentesis as an emergency or non-emergency treatment. In emergencies, pericardiocentesis treats either cardiac tamponade or severe pericardial effusions that will cause cardiac tamponade. In non-emergencies, providers often use it as a diagnostic test to determine what’s causing extra fluid to build up.

Who needs to have this treatment?

People with too much fluid in their pericardium may need a pericardiocentesis. Common causes of this include:

• Advanced cancer.
• Heart attack (especially if your heart wall ruptures).
• Tuberculosis (more common in developing countries).
• Inflammation or infection of the pericardium. This includes bacterial and viral infections, including after COVID-19 infection or in people with human immunodeficiency virus (HIV).
• Chronic immune diseases like lupus, rheumatoid arthritis and scleroderma.
• Heart cancer.
• Heart or kidney failure.
• Hypothyroidism (underactive thyroid gland).
• Treatments like certain drugs or radiation therapy.
• Idiopathic (unknown) cause.

How common is a pericardiocentesis?

Pericardiocentesis is a relatively common procedure. Providers in the United States perform more than 29,000 of these procedures each year.

What happens before a pericardiocentesis?

After a provider diagnoses you with either a pericardial effusion or cardiac tamponade, they'll determine how severe your condition is and the best way to treat it.

On the day of the procedure, you'll need to fast (not eat) starting eight hours before the procedure (you can have clear liquids up to two hours before the procedure starts).

How a provider prepares for a pericardiocentesis procedure depends on whether or not it’s an emergency. With a slow-growing effusion (a non-emergency), your healthcare provider can schedule the procedure. In most cases, except in the most extreme emergencies, you’ll receive local anesthesia right before the procedure.

Your provider will:

• Start an intravenous (IV) line. This is a way providers can give you medications or fluids directly through one of your veins.
• Prepare your skin. A provider will remove any hair you have at the spot where the clinician performing the procedure will insert the needle. The provider will also clean the same area with antiseptic to help prevent infections. In many cases, they’ll prepare multiple areas, saving time if the provider needs to direct the needle at a different angle to better access the fluid.
• Set up vital sign monitoring. This involves attaching sensors to monitor your blood pressure, breathing, heart rate and blood oxygen levels. They may also attach electrodes, which are sensors that detect the electrical activity in your heart, for an electrocardiogram (ECG or EKG). Changes in your heart’s electrical activity can help providers adjust needle placement.
• Provide additional oxygen. People who have low blood oxygen levels or who might develop this can also receive supplemental oxygen. This can come through a mask or a tube that runs under your nose.

What happens during a pericardiocentesis?

Pericardiocentesis is a procedure that involves several healthcare providers from different backgrounds. It will likely involve one or more doctors, nurses, imaging technicians and more.

Imaging guidance

Before inserting the needle, the healthcare provider performing this procedure will work with an imaging technician to find the safest, simplest way to reach your pericardium. The most common type of imaging is ultrasound (echocardiogram), which is safe and easy to perform at the time of the procedure. Fluoroscopy is another imaging option.

Imaging is important because it helps the provider insert the needle right where it needs to go.

A provider can do this procedure without imaging help in extreme emergencies. However, this is extremely rare and has a higher risk of complications. It’s usually not an option unless there’s no other choice.

Needle placement

Unless you’re in immediate danger of your heart stopping, your provider will use a local anesthetic to numb the area just before they insert the needle. They may also use a scalpel to make a small cut on your skin to make it easier to insert the needle.

Depending on where the fluid is in your pericardium, there are several places to insert the needle. The most common location is under your sternum, also known as your breastbone. This substernal approach usually gives easy, direct access to your pericardium.

Less common entry points are:

• Parasternal (above your breastbone). This is just off-center at the front of your chest. This approach lets providers access your heart by going between your ribs from your front.
• Apical. This approach goes between your ribs but from the side of your body. It gets its name because it aims for part of the pericardium near the apex (pointed end near the bottom) of your heart.

Once they insert the needle, they’ll angle it so it enters your pericardium, but not your heart. Once the tip of the needle is in your pericardium, the provider can start drawing out the extra fluid inside.

Depending on how much fluid is inside your pericardium, it may take only minutes to remove enough fluid. It takes about 10 to 20 minutes to perform a pericardiocentesis procedure. If there’s a lot of fluid, they may insert a catheter tube to drain fluid out more slowly.

Once they’ve drawn out enough fluid, your provider can pull the needle (or catheter) out, or they can leave a drainage catheter in place for a day or two to remove more fluid. When removing the needle or drain, they’ll finish the procedure by bandaging the spot.

What happens after a pericardiocentesis?

After the procedure, your healthcare provider may:

• Test the fluid they took from inside your pericardium. That can help them figure out why you had fluid buildup in the first place.
• Repeat an ultrasound (echocardiogram) to confirm the fluid is all gone. They’ll perform an ultrasound daily if you have a drain left in place.
• Pull the drainage tube out after confirming that the fluid is gone.

What are the benefits of a pericardiocentesis?

Besides being a life-saving procedure when your heart is under pressure from fluid around it, a pericardiocentesis:

• Can help collect fluid samples that will show why it happened in the first place, which can help healthcare providers treat the underlying problem.
• Can take place in your hospital room, an operating room or in a cardiac catheterization lab.
• Is faster and less invasive than surgery. That means it’s usually a better, faster option when you have severe symptoms from cardiac tamponade and you’re at risk of your heart stopping.

How successful is a pericardiocentesis?

Studies have found success rates higher than 90% (with some as high as 100%) for a pericardiocentesis procedure.

Depending on the cause and treatment options, fluid can continue to build up after the initial drainage. If this happens, your provider might recommend you see a surgeon to discuss a more permanent procedure called a pericardial window.

What are the risks or complications of a pericardiocentesis?

Pericardiocentesis complications happen in about 5% to 40% of cases. The risk of complications is lowest when imaging like an echocardiogram or fluoroscopy helps the provider “see” where to direct the needle.

In extreme emergencies, it’s possible to do this procedure without imaging help. But this is very rare and should only happen when there’s no other option.

Even with imaging, a pericardiocentesis procedure involves inserting a needle very close to several of your vital organs and major blood vessels. That means there’s a risk of injuring any of the following:

• Heart. This can cause a heart attack, bleeding or disruption of your heart’s electrical system, causing an irregular heart rhythm (arrhythmia). These can be severe — or even life-threatening — and may need emergency heart surgery to repair.
• Lungs. Injuries and punctures can cause lung collapse, a potentially life-threatening condition.
• Diaphragm.
• Pericardium. This can cause fluid to leak into your chest or let the pericardium fill with air.
• Liver.
• Stomach.
• Major blood vessels near your heart.

Any kind of medical procedure that needs to pass through your skin also creates the risk of infection. When these infections spread, it can lead to an overwhelming reaction from your immune system. That overreaction, known as sepsis, is a life-threatening medical emergency.

What is the recovery time?

Most people will start to feel better quickly when a provider drains the fluid or immediately afterward. You’ll need to rest for 12 to 24 hours afterward while providers keep an eye on your condition. The overall pericardiocentesis recovery time depends on:

• The severity of your case.
• What caused it (especially if it happened because of an injury).
• Any other medications or treatments you received for it.

Your healthcare provider is the best person to tell you what to expect when it comes to your recovery and when you can resume your normal activities.

When should I call my healthcare provider?

Your healthcare provider will schedule follow-up visits to ensure you don’t have any complications or additional need for treatment. Some people will need more than one procedure because pericardial effusions can happen more than once. This is especially the case for certain cancers, infections, like tuberculosis, or other conditions.

When should I go to the hospital?

Several symptoms or other indications mean you need medical attention if you’ve recently had this procedure.

Symptoms of cardiac tamponade

The symptoms of cardiac tamponade include:

• Chest pain.
• Trouble breathing or breathing unusually fast.
• Fainting, dizziness or feeling lightheaded.
• Heart palpitations or rapid heartbeat.

Symptoms of infection and sepsis

You should also go to the hospital immediately if you have any infection symptoms. These can be a sign of sepsis, a life-threatening condition that’s as serious as a heart attack or stroke. The symptoms of sepsis include:

• Swelling or redness around the needle entry point.
• Skin that’s unusually warm to the touch around the needle entry point.
• Fever or chills.
• Confusion or disorientation (especially when a person isn’t acting like usual).

How painful is pericardiocentesis?

It may sting when a provider injects a local anesthetic into your skin. But the anesthetic will keep you from feeling pain in that area. Instead, you may feel pressure when a needle goes into your pericardial sac.

Is a pericardiocentesis the same as a pericardial tap?

Yes, they are different names for the same procedure.