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

fluid In physics, a fluid is a liquid, gas, or other material that may continuously motion, move and Deformation (physics), deform (''flow'') under an applied shear stress, or external force. They have zero shear modulus, or, in simpler terms, are M ...

is aspirated from the

pericardium The pericardium (: pericardia), 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 inelastic connective tissue (fibrous pericardium), ...

(the sac enveloping the

heart The heart is a muscular Organ (biology), organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrie ...

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. 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 (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...

(i.e.

pericardial fluid Pericardial fluid is the serous fluid secreted by the Serous membrane, serous layer of the pericardium into the pericardial cavity. The pericardium consists of two layers, an outer fibrous layer and the inner serous layer. This serous layer has t ...

analysis).

Therapeutic pericardiocentesis

Cardiac tamponade

Pericardiocentesis can be used to diagnose and treat cardiac tamponade. Cardiac tamponade 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 tissue, connective membrane and an inner two-layered serous membrane ...

) 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, 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 whe ...

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

inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...

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 tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...

* spread of

cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...

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, formally called 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. Common ...

and

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

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 drain (surgery), surgical drain that is inserted through the chest wall and into the pleural space or the Mediastinum. The insertion of the tube is som ...

Aortic dissection

Pericardiocentesis is not appropriate if cardiac tamponade is associated with aortic dissection. In this case, there is a high risk of the procedure worsening this aortic dissection by causing haemorrhage.

Diagnosis of minor pericardial effusion

Pericardiocentesis is not usually useful for diagnosis of more minor

Other

Other relative contraindications include coagulopathies,

thrombocytopenia In hematology, thrombocytopenia is a condition characterized by abnormally low levels of platelets (also known as thrombocytes) in the blood. Low levels of platelets in turn may lead to prolonged or excessive bleeding. It is the most common coag ...

, myocardial rupture, severe

pulmonary hypertension Pulmonary hypertension (PH or PHTN) is a condition of increased blood pressure in the pulmonary artery, arteries of the lungs. Symptoms include dypsnea, shortness of breath, Syncope (medicine), fainting, tiredness, chest pain, pedal edema, swell ...

, 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 ...

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 all sense, sensation (including pain) in a specific body part without loss of consciousness, providing local anesthesia, as opposed to a general anesthetic, which eliminates all sen ...

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 organ (anatomy), organs. It is eponym, named after Sven Ivar Seldinger (1921–1998), a Sweden, Swedish ...

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

angle In Euclidean geometry, an angle can refer to a number of concepts relating to the intersection of two straight Line (geometry), lines at a Point (geometry), point. Formally, an angle is a figure lying in a Euclidean plane, plane formed by two R ...

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 with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

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

to avoid the neurovascular bundle 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 A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(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 Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity through repeated cardiac cycles. It is an electrogram of the heart which is a graph of voltage versus time of t ...

(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 or myocardium) is one of three types of vertebrate muscle tissues, the others being skeletal muscle and smooth muscle. It is an involuntary, striated muscle that constitutes the main tissue of the wall o ...

Risks

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

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

, and puncture of the left ventricle (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, urethr ...

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