Overview of Optimal Techniques for Pericardiocentesis in Contemporary Practice

Left internal mammary artery injury and subsequent hypovolemic shock due to a hemothorax after subxiphoid pericardiocentesis in a postoperative cardiac surgery patient

“…An ECG-machine V-lead alligator clip can be attached to the base of the pericardiocentesis needle. 5 The development of PR-segment depression or ST-segment elevation suggests contact with the atrial or ventricular wall. Fluoroscopic-guided pericardiocentesis is also typically performed via a subxiphoid approach and by injection of iodinated contrast through the needle, pooling of contrast inferiorly can be observed when the pericardial space is reached.…”

“…In order to minimize the risk of trauma to adjacent structures and cardiac perforation, pericardiocentesis should be performed at the site with the shortest distance from skin to pericardium and where the pericardial fluid is largest. 5 Moreover, when using the parasternal or apical approach, clear echocardiographic visualization of the pericardial space excludes intervening lung tissue as ultrasound beams are strongly reflected by air, thereby minimizing the risk of pneumothorax. Importantly, in an apical or parasternal approach it is important to puncture at the superior border of the rib, in order to avoid injury to the intercostal nerves running inferior to each rib.…”

“…Echocardiographic confirmation of an intrapericardial position can be performed by injection of 10 mL agitated 0.9% saline through the needle. 1,5 Alternatively, injection of iodinated contrast through the needle can be performed under fluoroscopy as described above.…”

“…Blind pericardiocentesis is typically performed via a subxiphoid approach, and in order to reduce complications, ECG monitoring can be performed to protect against cardiac perforation to identify myocardial contact. An ECG‐machine V‐lead alligator clip can be attached to the base of the pericardiocentesis needle 5 . The development of PR‐segment depression or ST‐segment elevation suggests contact with the atrial or ventricular wall.…”

“…Echocardiographic assessment of all potential pericardial access sites, including those distinct from the traditional subcostal window, allows identification and avoidance of adjacent structures. In order to minimize the risk of trauma to adjacent structures and cardiac perforation, pericardiocentesis should be performed at the site with the shortest distance from skin to pericardium and where the pericardial fluid is largest 5 . Moreover, when using the parasternal or apical approach, clear echocardiographic visualization of the pericardial space excludes intervening lung tissue as ultrasound beams are strongly reflected by air, thereby minimizing the risk of pneumothorax.…”