Pericardial puncture, pericardiocentesis: methods of implementation, complications

Pericardiocentesis is an invasive procedure for removing fluid from the pericardial sac to immediately relieve cardiac compression due to tamponade and to obtain sample for analysis in cases of significant effusion. In modern practice, it is performed primarily under ultrasound guidance as a life-saving measure and as a diagnostic step when the cause of the effusion is unclear. [1]

The procedure's role has grown due to standardized imaging and improved instrumentation. A high success rate and low incidence of serious complications have been noted when performed by experienced operators using echocardiographic navigation and step-by-step safety algorithms. [2]

Pericardiocentesis also allows for rapid improvement of hemodynamics, reduction of the need for vasopressors and provision of the possibility of specific therapy of the underlying disease, including infectious and neoplastic processes, where analysis of pericardial fluid guides treatment. [3]

In recent years, consensus documents from leading cardiology societies have been published that have reinforced the priority of ultrasound guidance, clarified the indications, and described optimal postoperative steps, including drainage management and criteria for its removal. [4]

When is pericardiocentesis indicated and when should it be avoided?

The absolute indication is cardiac tamponade, confirmed clinically and by imaging, when fluid evacuation is necessary to save life. Emergency puncture is also indicated in cases of increasing effusion with the risk of tamponade or in cases of severe symptoms with hemodynamic compromise. [5]

Diagnostic indications include large effusions of unknown etiology, suspected bacterial, tuberculous, or fungal pericarditis, and suspected pericardial neoplasms, in which case fluid analysis and cytology change the approach. In systemic autoimmune diseases, pericardiocentesis is considered if there is evidence of tamponade or recurrent symptomatic effusions. [6]

Relative contraindications include suspected free wall rupture after myocardial infarction, dissecting aortic aneurysm, and severe coagulation disorders. In the presence of imminent life-threatening tamponade, most contraindications are no longer valid; however, the method and approach chosen are as gentle as possible, and the team is augmented by a surgeon. [7]

In clinical practice, some asymptomatic small idiopathic effusions can be observed dynamically without intervention. The decision to perform a puncture is always individualized based on the rate of fluid accumulation, the clinical picture, and the availability of specialists. [8]

Table 1. Indications for pericardiocentesis and clinical purpose

Situation	Purpose of intervention
Cardiac tamponade	Immediate decompression, life saving
Rapidly increasing effusion with hemodynamic impairment	Stabilization and prevention of tamponade
Large effusion of unclear origin	Diagnosis of the cause by fluid analysis
Suspected infectious or tumor process	Selection of etiotropic therapy based on the results of the analysis
Source: practical reviews and guides. [9]

Preparation, monitoring and command

Even in emergency procedures, a brief risk assessment and preparedness for complications are required. Continuous monitoring of the electrocardiogram, oxygen saturation, and blood pressure is essential, as is readiness for resuscitation and the availability of transfusions. Reliable venous access is ensured, sedation medications are available as indicated, and drainage equipment is prepared. [10]

The standard is an ultrasound assessment prior to the intervention to determine the safest approach, assess the volume and location of the fluid, the thickness of the "window," and the distance to the heart. For difficult-to-find landmarks, a short pre-marking is advisable. Some hospitals use fluoroscopy or computed tomography for complex anatomy. [11]

If time permits, hemostasis parameters and drug-related risk factors are checked; however, in the case of acute tamponade, waiting for the laboratory is unacceptable. Intravenous crystalloid infusion can temporarily improve preload and allow several minutes for operator and equipment preparation. [12]

The key to safety is a clear division of roles: operator, assistant, imaging specialist, and a nurse supervising sterility and preparation. This "micro-team" approach reduces time to puncture and the frequency of errors. [13]

Table 2. Monitoring and equipment before pericardiocentesis

Component	Minimum requirements	Comment
Monitoring	Electrocardiogram, oxygen saturation, blood pressure	Constantly, with trend tracking
Visualization	Ultrasound diagnostics of the heart	Pre-marking and real-time navigation
Accesses	At least 1 reliable venous catheter	Infusion and medications
Tools	Needle, guidewire, catheter, drainage set	Preferably a Seldinger type set
Reserve	Resuscitation and transfusion kit	Preparedness for complications
Source: guidelines and clinical practice instructions. [14]

Choice of access: subxiphoid, apical, parasternal

The optimal approach is determined by ultrasound. The subxiphoid approach is traditionally used for circumferential effusions and provides a long, safe "window" to the right chambers, bypassing the lungs. The apical approach is convenient for localized apical effusions and allows for short-distance access. The parasternal approach is useful for parietal anterior effusions. [15]

Comparative data indicate that with modern echo monitoring, the differences in effectiveness and safety between echo monitoring and fluoroscopy are minimal, with operator experience and navigation quality becoming key factors. Real-time ultrasound reduces the incidence of technical errors. [16]

In an emergency, if ultrasound is not possible, an approach that best matches the patient's anatomy based on clinical signs and percussion data is preferred. However, such an approach is only permissible in the absence of equipment and an immediate life-threatening emergency. In routine practice, a "blind" procedure is not recommended. [17]

In cases of severe obesity, chest deformities and after surgery, ultrasound navigation is especially valuable: it allows one to select an alternative intercostal space and control the passage of the needle into the desired fluid pocket. [18]

Table 3. Comparison of approaches for pericardiocentesis

Access	When is it preferable?	Advantages	Restrictions
Subxiphoid	Circumferential effusion	Long safe window	Long needle travel may cause liver injury
Apical	Local apical pocket	Short distance	Risk of contact with the myocardium
Parasternal	Anterior parietal effusion	Direct access	Risk of injury to the internal mammary artery
Source: Tech guides and reviews. [19]

The role of ultrasound and navigation

Echocardiography before and during puncture increases the first-attempt success rate, reduces the number of traumatic punctures, and lowers the risk of myocardial and vascular damage. The effect is particularly pronounced in obese patients, after surgery, and with localized effusions. [20]

Real-plane navigation allows for visualization of the needle along its entire length, control of its angle and depth, and confirmation of placement in the pericardial cavity by the appearance of free fluid in the syringe and the movement of the needle tip relative to the epicardium. If necessary, a contrast method is used: injection of a small amount of saline containing bubbles and visualization of turbulence in the pericardial cavity. [21]

Publications highlight the importance of ultrasound navigation training programs for the sustainable reduction of complications. In institutions with a well-established program, procedural results are more reproducible and safer. [22]

Fluoroscopy and computed tomography retain a niche in complex anatomy and repeated failures, as well as in planning puncture of localized pockets, but their routine use is inferior to bedside echocardiography. [23]

Table 4. Ultrasound before and during pericardiocentesis: what to note

Stage	What to evaluate	For what
Before puncture	Window thickness, maximum pocket depth	Selecting secure access
During the puncture	Position and trajectory of the needle "in the plane"	Reducing injuries
Confirmation	Appearance of free fluid, bubble test	Exclusion of intracardiac position
After the puncture	Residual effusion, signs of recurrence	Volume and drainage solution
Source: Clinical studies on ultrasound navigation. [24]

Step-by-step echo-guided technique

The procedure is performed under strict aseptic conditions, local anesthesia, and sedation if necessary. After pre-marking, the needle is advanced through the selected access site under continuous ultrasound guidance, with continuous aspiration. The appearance of amber effusion confirms the presence of the needle in the pericardial sac. A drainage catheter is then inserted through the guidewire. [25]

In most cases, fractional evacuation is advisable: the first 100-300 milliliters are drained quickly to relieve critical compression, followed by slower drainage through a catheter, which reduces the risk of pericardial decompression dysfunction. Constant hemodynamic monitoring is mandatory. [26]

During each aspiration, it is important to check for the absence of blood and signs of an intracardiac position. Any suspicions require immediate cessation of advancement, repeated visualization, and trajectory adjustment. In questionable cases, a bubble test and re-evaluation of the echocardiographic image are helpful. [27]

After catheter placement, specimens are collected for microscopy, bacteriological and cytological examination, biochemistry, and specific clinical testing, then the drainage is connected to a closed system. All stages and volumes are documented. [28]

Table 5. Algorithm for safe pericardiocentesis

Step	Action	Quality control
1	Pre-labeling and access selection	Ultrasound imaging
2	Needle "in plane", constant aspiration	Tip visualization and aspirate
3	Guidewire and catheter placement	Confirmation by echocardiography
4	Fractional evacuation	Continuous monitoring
5	Selection of material and drainage connection	Labeling samples and recording volumes
Source: Video tutorials and how-to guides. [29]

What to examine in pericardial fluid and how to interpret it

The basic kit includes a complete blood count with a cell count, protein, lactate dehydrogenase, glucose, culture and staining, and cytology if a tumor is suspected. If tuberculosis is suspected, microscopy, culture, and molecular tests are performed; if a fungal infection is suspected, specific stains and cultures are performed. Extended panels are prescribed individually. [30]

Interpretation is based on a combination of clinical and laboratory findings of the exudate. Tumor cells in cytology confirm metastatic disease, while very low glucose and high protein are characteristic of bacterial, tuberculous, and neoplastic processes. In autoimmune diseases, the fluid composition is variable and requires comparison with serology. [31]

The very fact of obtaining a large volume of purulent fluid with a rapid improvement in hemodynamics confirms the diagnostic and therapeutic value of the intervention; further tactics are based on the results of microbiology and cytology, as well as on visualization data. [32]

In chronic recurrent effusions in cancer patients, local methods are additionally discussed, including intrapericardial administration of antitumor drugs according to the protocols of specialized centers. The decision is made by a multidisciplinary team. [33]

Table 6. Pericardial fluid analysis: basic and advanced tests

Test group	Examples	When to prescribe
Basic	Cells, protein, lactate dehydrogenase, glucose, seeding	To all patients
Cytology	Tumor cells	Suspected metastases
Tuberculosis	Microscopy, culture, molecular tests	Epidemiological and clinical grounds
Fungus	Special colors, seeding	Immunodeficiency and the corresponding clinical picture
Source: reviews of pericardial diseases. [34]

Drainage management and criteria for its removal

After the initial evacuation, the catheter is left in place until the daily flow rate decreases to low levels and effusion regression is confirmed by echocardiography. A closed system is maintained with regular volume monitoring and patient assessment. Antibiotics are prescribed as indicated, based on microbiological and clinical findings. [35]

Early, aggressive removal of large volumes without monitoring increases the risk of pericardial decompression dysfunction, which is characterized by an acute deterioration in pump function due to a rapid drop in pericardial pressure. Fractionation strategies and monitoring reduce this risk. [36]

In cases of recurrent effusions and unsatisfactory drainage, a pericardial surgical window is considered, especially in cases of localized pockets and postoperative conditions. The choice of intervention depends on the cause of the effusion and the patient's condition. [37]

Documentation should include the date and time, volumes of evacuation, echocardiographic changes, test results, and events during follow-up. Such documentation improves traceability and quality of care. [38]

Table 7. Criteria for removal of pericardial drainage

Criterion	Threshold	Comment
Daily flow rate	Low values within 24-48 hours	In combination with clinical improvement
Echocardiography	There is no significant effusion or signs of compression.	Control before removal
Well-being	Stable hemodynamics, no symptoms	Post-removal follow-up
Microbiology	There is a response to therapy in the infectious process	Decision made in conjunction with an infectious disease specialist
Source: practical reviews. [39]

Complications and their prevention

The most dangerous complications are associated with myocardial and coronary vessel injury, bleeding, arrhythmias, pneumothorax, and infection. The use of ultrasound navigation, continuous aspiration, a visible needle tip, and staged evacuation significantly reduce the incidence of these events. [40]

Pericardial decompression dysfunction is a rare but severe phenomenon characterized by acute deterioration of ventricular function following rapid evacuation of a large volume. Prevention includes fractional drainage, readiness for inotropic support, and close monitoring. [41]

In patients with pulmonary arterial hypertension, pericardiocentesis is associated with an increased risk of adverse outcomes and a higher incidence of decompression dysfunction. In this group, the most gentle evacuation volumes and management are indicated in experienced centers. [42]

Some complications are related to technical errors and are trainable: adequate operator training and teamwork have been proven to improve safety. In institutions with formal training programs, results are reproducible and better than in places without systematic training. [43]

Table 8. Complications of pericardiocentesis and prevention

Complication	How to prevent	First steps
Myocardial and vascular injury	Ultrasound, visible needle, gentle angle	Stop immediately, evaluate by echocardiography
Bleeding	Coagulation control if possible, gentle technique	Pressure, infusions, surgeon consultation
Arrhythmias	Avoid intracardiac position, monitoring	Cardiostrategy according to the protocol
Pericardial decompression dysfunction	Fractional evacuation	Inotropes, intensive monitoring
Infection	Strict asepsis and closed system	Antibiotics as indicated
Source: clinical reviews and observations. [44]

Special clinical situations

Postoperative and localized effusions. After cardiac surgery, accumulations are often localized and difficult to access with standard approaches. The choice is made based on visualization; sometimes, early discussion of the surgical window is warranted. [45]

Oncologic effusions. In cases of pericardial tumor involvement, pericardiocentesis relieves pressure, while cytology and subsequent management determine the long-term strategy. In recurrent cases, local antitumor approaches are discussed in specialized centers. [46]

Infectious effusions. If tuberculosis or a purulent process is suspected, extensive microbiological testing and early specific treatment are required. Rapid evacuation of a significant volume improves the condition and facilitates diagnosis. [47]

Antithrombotic therapy and coagulopathy. In planned situations, discontinuation intervals are considered and hemostasis is adjusted according to specialized recommendations. In life-threatening tamponade situations, the decision to puncture is made immediately, choosing the least traumatic approach under echo guidance. [48]

Table 9. Tactics in special situations

Situation	The main goal	Tactical accents
Postoperative localized effusion	Relieving pressure	Navigation and early discussion of surgery
Tumor effusion	Symptomatic improvement and diagnosis	Cytology and oncology strategy
Tuberculous or purulent effusion	Decompression and verification	Advanced Microbiology
Coagulopathy and anticoagulants	Minimizing bleeding	Individualization, echo control
Source: Guides and Reviews. [49]

What has changed in guides and reviews in recent years?

A key shift is the universalization of ultrasound guidance as a basic standard and an emphasis on training. Current guidelines update the indications for puncture in conjunction with imaging data and recommend structured drainage management to reduce recurrence. [50]

In parallel, published data show that with an experienced team and navigation, the differences between echocardiography and fluoroscopy in terms of safety and effectiveness are eliminated, facilitating bedside implementation without patient transport. [51]

Some reviews highlight high-risk groups, including patients with pulmonary arterial hypertension and malignant effusions, where the strategy should be as gentle and multi-stage as possible. This requires close interdisciplinary coordination. [52]

Finally, pericardial decompression dysfunction is actively discussed as a rare but fundamentally important cause of deterioration after rapid evacuation of a large volume - preventive measures have already been included in algorithms. [53]

Table 10. Short operator checklist

Checkpoint	Yes or no
Tamponade or other clear indication confirmed
Ultrasound pre-marking was performed and safe access was selected.
The resuscitation and transfusion kit is ready.
The fractional evacuation plan has been agreed upon
Laboratory and ultrasound support is provided after the procedure.
Source: Practice guidelines and consensus documents. [54]

Frequently asked questions

Is it possible to perform pericardiocentesis without ultrasound?
Only in cases of immediate life-threatening emergency and unavailability of equipment. In routine practice, "blind" access is significantly more dangerous and is not recommended. [55]

How quickly should fluid be evacuated?
First, quickly relieve critical pressure, then continue drainage more slowly. This fractional approach reduces the risk of pericardial decompression dysfunction. [56]

Do all patients require a surgical window?
No. For most, catheter drainage with follow-up is sufficient. A surgical window is considered for recurrences, localized pockets, and postoperatively. [57]

What are the most important tests for pericardial fluid?
A minimum of a complete blood count (CBC) with differential, protein, lactate dehydrogenase, glucose, culture, and cytology are included, as indicated. Further testing is determined by the clinical need. [58]