Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where

fluid In physics, a fluid is a liquid, gas, or other material that continuously deforms (''flows'') under an applied shear stress, or external force. They have zero shear modulus, or, in simpler terms, are substances which cannot resist any shear ...

is aspirated from the

pericardium The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made ...

(the sac enveloping the

heart The heart is a muscular Organ (biology), organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as ca ...

Anatomy and Physiology

The

is a fibrous sac surrounding the heart composed of two layers: an inner visceral pericardium and an outer parietal pericardium. The area between these two layers is known as the pericardial space and normally contains 15 to 50 mL of serous fluid. This fluid protects the heart by serving as a shock absorber and provides lubrication to the heart during contraction. The elastic nature of the pericardium allows it to accommodate a small amount of extra fluid, roughly 80 to 120 mL, in the acute setting. However, once a critical volume is reached, even small amounts of extra fluid can rapidly increase pressure within the pericardium. This pressure can significantly hinder the ability of the heart to contract, leading to

cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstructi ...

. If accumulation of fluid is slow and occurs over weeks to months, the pericardial sac can tolerate several liters of additional fluid without substantially hindering the ability of the heart to pump.

Indications

Indications for performing pericardiocentesis can be divided into those that are therapeutic (i.e. treating tamponade) and those that are

diagnostic Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine "cause and effect". In systems enginee ...

(i.e. pericardial fluid analysis).

Therapeutic pericardiocentesis

Cardiac tamponade

Pericardiocentesis can be used to diagnose and treat

Cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstructi ...

is a

medical emergency A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified ...

in which excessive accumulation of fluid within the pericardium (

pericardial effusion A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of t ...

) creates increased pressure. This prevents the heart from filling normally with blood. This can critically decrease the amount of blood that is pumped from the heart, causing

obstructive shock Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and te ...

, which can be lethal. The removal of the excess fluid reverses this dangerous process, and is often the first treatment for cardiac tamponade due to its speed.

Pericarditis

Pericardiocentesis can relieve the symptoms of

pericarditis Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sit ...

. There may be a normal amount of pericardial fluid, but

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

still causes compression of the heart. Removal of some of this fluid reduces pressure on the heart.

Diagnostic pericardiocentesis

Analysis of pericardial fluid

Pericardiocentesis can also be used to analyze the fluid surrounding the heart. Fluid may be analyzed to differentiate a number of conditions, including: *

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable di ...

* spread of

cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

autoimmune In immunology, autoimmunity is the system of immune responses of an organism against its own healthy cells, tissues and other normal body constituents. Any disease resulting from this type of immune response is termed an "autoimmune disease". ...

conditions, such as

lupus Lupus, technically known as systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Commo ...

and

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are inv ...

Contraindications

Absolute contraindications

There are no absolute contraindications to pericardiocentesis in emergency situations where a patient is hemodynamically unstable.

Relative contraindications

Long-term drainage

Pericardiocentesis is a one-off procedure, which may not be appropriate for long-term drainage. In cases where longer term drainage is needed, the cardiothoracic surgeon can create a pericardial window. This involves the removal of a section of the pericardium, and the placement of a

chest tube A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...

Aortic dissection

Pericardiocentesis is not appropriate if cardiac tamponade is associated with

aortic dissection Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. In most cases, this is associated with a sudden onset of severe chest or ...

. In this case, there is a high risk of the procedure worsening this aortic dissection by causing

haemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...

Diagnosis of minor pericardial effusion

Pericardiocentesis is not usually useful for diagnosis of more minor

Other

Other relative contraindications include coagulopathies,

thrombocytopenia Thrombocytopenia is a condition characterized by abnormally low levels of platelets, also known as thrombocytes, in the blood. It is the most common coagulation disorder among intensive care patients and is seen in a fifth of medical patients a ...

myocardial rupture Myocardial rupture is a laceration of the ventricles or atria of the heart, of the interatrial or interventricular septum, or of the papillary muscles. It is most commonly seen as a serious sequela of an acute myocardial infarction (heart at ...

, severe pulmonary hypertension, prior thoracoabdominal surgery, prosthetic heart valves, pacemakers and other cardiac devices, inadequate visualization of the effusion on ultrasound during the procedure, and situations in which more appropriate treatment options are available.

Procedure

Overview

The patient undergoing pericardiocentesis is positioned supine with the head of the bed raised between a 30 and 60 degree angle. This places the heart in proximity to the

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bony skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 layers, namely (from sup ...

for easier insertion of the needle into the pericardial sac. For patients that are awake, a

local anaesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general a ...

is applied. A large needle is inserted through the skin of the chest into the pericardium, and the practitioner aspirates the

into a

syringe A syringe is a simple reciprocating pump consisting of a plunger (though in modern syringes, it is actually a piston) that fits tightly within a cylindrical tube called a barrel. The plunger can be linearly pulled and pushed along the inside ...

. If needed, a drain can be placed using the

Seldinger technique The Seldinger technique, also known as Seldinger wire technique, is a medical procedure to obtain safe access to blood vessels and other hollow organs. It is named after Sven Ivar Seldinger (1921–1998), a Swedish radiologist who introduced ...

for continuous access.

Approaches

There are multiple locations that pericardiocentesis can be performed without puncturing the lungs. * In the past, the standard location was through the

infrasternal angle The lower opening of the thorax is formed by the twelfth thoracic vertebra behind, by the eleventh and twelfth ribs at the sides, and in front by the cartilages of the tenth, ninth, eighth, and seventh ribs, which ascend on either side and form an ...

and is also called subxiphoid approach. The needle is inserted at an

angle In Euclidean geometry, an angle is the figure formed by two rays, called the '' sides'' of the angle, sharing a common endpoint, called the ''vertex'' of the angle. Angles formed by two rays lie in the plane that contains the rays. Angles ...

between 30 and 45 degrees to the chest 1 cm inferior to the left xiphocostal angle. * Another location is through the 5th or 6th intercostal space at the left sternal border at the cardiac notch of the left lung, and is also called as parasternal approach. The needle is inserted at an angle of 90 degrees to the chest. Some evidence suggests that this poses lower risk of vascular damage in adults. * With the routine use of

ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...

guidance, the apical approach is becoming more widely used. The needle is inserted at the level of the cardiac apex, usually between the 5th-7th intercostal space. The needle is advanced directly over the superior aspect of the

rib In vertebrate anatomy, ribs ( la, costae) are the long curved bones which form the rib cage, part of the axial skeleton. In most tetrapods, ribs surround the chest, enabling the lungs to expand and thus facilitate breathing by expanding the ches ...

to avoid the

neurovascular bundle A neurovascular bundle is a structure that binds nerves and veins (and in some cases arteries and lymphatics) with connective tissue so that they travel in tandem through the body. Structure There are two types of neurovascular bundles: superficia ...

and aimed toward the right shoulder.

Ultrasound guidance

Pericardiocentesis should be performed with ultrasound guidance whenever possible to prevent complications. This allows practitioners to assess the location of the

and identify adjacent structures. With ultrasound guidance, an apical approach is most often used, but parasternal and subxiphoid approaches can also be used. Agitated saline is injected and visualized sonographically to confirm the needle placement in the pericardium. Pericardiocentesis can be performed using computed tomography (CT) imaging in cases of complex or loculated effusions or when ultrasound has failed to provide proper visualization.

Blind pericardiocentesis

Blind pericardiocentesis can be performed in emergency settings when ultrasound is not available and typically utilizes a subxiphoid approach. As the needle is advanced, aspiration is performed to assess for advancement of the needle into the pericardial space. To prevent perforation of the heart, electrocardiographic (ECG) monitoring might be used. This involves using an alligator clip to attach an ECG lead to the needle. Changes in ECG waves, such as ST segment elevations or PR depressions, are indicative of contact with the

myocardium Cardiac muscle (also called heart muscle, myocardium, cardiomyocytes and cardiac myocytes) is one of three types of vertebrate muscle tissues, with the other two being skeletal muscle and smooth muscle. It is an involuntary, striated muscle tha ...

Risks

Fewer than 1.5% of patients experience complications from pericardiocentesis. The most common complications are

lacerations A wound is a rapid onset of injury that involves lacerated or punctured skin (an ''open'' wound), or a contusion (a ''closed'' wound) from blunt force trauma or compression. In pathology, a ''wound'' is an acute injury that damages the epider ...

coronary arteries The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ ...

, and puncture of the

left ventricle A ventricle is one of two large chambers toward the bottom of the heart that collect and expel blood towards the peripheral beds within the body and lungs. The blood pumped by a ventricle is supplied by an atrium, an adjacent chamber in the uppe ...

(with associated

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

from both). Echocardiograms can help to identify complications. Blind approaches are typically only advised in emergencies, and a guided approach is typically preferred (using echocardiography).

References

External links

* *
Trauma Man: Images of pericardiocentesis being performed on a simulator

Cardiac Surgery in the Adult: Pericardial disease
{{Cardiac surgery and other cardiovascular procedures Diagnostic cardiology Diagnostic intensive care medicine Medical diagnosis