t -
Echocardiographically Guided Pericardiocentesis: Evolution and
State-of-the-Art Technique
TERESA S. M. TSANG, M.D., WILLIAM K. FREEMAN,
AND JAMES B. SEWARD, M.D.
Percutaneous pericardiocentesis was introduced during
the 19th century and became a preferred technique for the
management of pericardial effusion by the early 20th cen-
tury, Until the era of two-dimensional echocardiographi-
cally guided pericardiocentesis, however, the procedure
was essentially "blind," and serious complications were
comparatively common, an outcome that resulted in an
increased preference for surgical solutions. Because two-
dimensional echocardiography facilitates direct visualiza-
tion of cardiac structures and adjacent vital organs, per-
cutaneous pericardiocentesis can be performed with mini-
mal risk. Since its inception in 1979 (19 years ago), the
A safe and simple approach to percutaneous peri-
cardiocentesis has evolved during the past 19 years.
Since its introduction in 1979, this approach, convention-
ally referred to as "echo-guided pericardiocentesis," has
become the preferred initial procedure for the diagnosis
and management of pericardial effusion.
BACKGROUND
Percutaneous pericardiocentesis is not a new procedure.
The "blind" subxiphoid approach was previously used but
was associated with unacceptably high rates of morbidity
and mortality. 1 For this reason, surgical decompres-
sion, although associated with higher morbidity>' and cost,
had been advocated as a "safer" and more "definitive"
procedure.Y
Two-dimensional (2D) phased-array echocardiography
was introduced at the Mayo Clinic in 1977.7 This technol-
ogy revolutionized visualization of cardiac anatomy and
was found to provide superior assessment of the site and
distribution of pericardial fluid. At that time, "blind"
pericardiocentesis was usually performed by a cardio-
thoracic surgeon, who preferentially used a subcostal ap-
proach to the pericardial space. If this was unsuccessful or
if complications developed, a surgical pericardial window
was created. In an attempt to improve safety, blind
From the Division of Cardiovascular Diseases and Internal Medi-
cine, Mayo Clinic Rochester, Rochester, Minnesota.
Address reprint requests to Dr. J. B. Seward, Division of Cardiovas-
cular Diseases; Mayo Clinic Rochester, 200 First Street SW, Roch-
ester, MN 55905.
Mayo Clin Proc 1998;73:647-652
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
M.D., LAWRENCE J. SINAK, M.D.,
echocardiographicaIIy guided pericardiocentesis tech-
nique has continued to evolve. Important procedural ad-
aptations and modifications that optimize safety, simplic-
ity, and patient comfort and minimize the recurrence of
effusion have been defined and incorporated. This tech-
nique has been proved to be safe and effective. A detailed
step-by-step description of the procedure and the neces-
sary precautions to optimize success and safety is pre-
sented herein.
Mayo Clin Proc 1998;73:647-652
I 2D =two-dimensional I
pericardiocentesis was often performed under fluoroscopic
guidance and electrocardiographic needle monitoring.t"
Despite these additional measures, reported complications
included damage to the liver, myocardium, coronary arter-
ies, and lungs. 10,11 Mortality and complication rates associ-
ated with blind pericardiocentesis were as high as 6% and
50%, respectively.t-'v"
In 1979, a postoperative 2D echocardiographic study of
a Mayo Clinic patient with clinical tamponade revealed a
large loculated posterior pericardial effusion compressing
the heart anteriorly (Fig. 1). Multiple attempts by the
attending surgeon to tap the effusion by using blind sub-
costal pericardiocentesis were unsuccessful. Echocardiog-
raphy demonstrated that the effusion was inaccessible by
the subcostal approach but was close to the chest wall. A
cardiologist trained in invasive technique, who was famil-
iar with echocardiography and percutaneous left ventricu-
lar puncture, decided to introduce a short polytef (Teflon)-
sheathed needle directly through the left chest wall into the
fluid space (similar to the then commonly performed Brock
procedure 13). The success of this novel and minimally
invasive technique marked the beginning of the era of
echo-guided pericardiocentesis and the routine approach to
such fluid spaces from a position on the body surface where
the fluid is closest to the transducer, and all vital structures
are avoided. 14
Echocardiographic guidance has reduced the morbidity
and mortality associated with pericardiocentesis to ex-
tremely low rates. This technique has been modified and
refined during the past 19 years and is now considered the
647 © 1998 Mayo Foundation/or Medical Education and Research
648 Echo-Guided Pericardiocentesis Mayo Clin Proc, July 1998, Vol 73

Fig. 1. First use of echo-guided pericardiocentesis in 1979. Two-dimensional echocardiographic images

demonstrated a largeloculated posterior pericardial effusion (arrows) withcompression of heartanteriorly.
Effusion was inaccessible from subcostal approach. After multiple blind attempts at pericardiocentesis in
the surgical suite,fluidwasremoved through entrysiteon chestwallby echocardiographic guidance. Fluid
was2 ernfromchestwalland was removed without incidence. A = anterior; I = inferior; L = left; LA = left
atrium; LV = left ventricle; P = posterior; PF = pericardia! fluid; R = right; RV = rightventricle; S = superior.

procedure of choice for safe removal of pericardial
fluid.':":" This article describes the technique for echo-
guided pericardiocentesis and provides a step-by-step
guide to the performance of this procedure.
GENERAL OVERVIEW OF ECHO-GUIDED
PERICARDIOCENTESIS
The equipment and supplies needed for echo-guided
pericardiocentesis (Table 1) can be readily obtained in any
hospital. Special needles or catheters are unnecessary, and
a pericardiocentesis tray can be assembled from standard
supplies. Most 2D echocardiographic ultrasound machines
are suitable for imaging and are portable to the bedside or
procedure room. Physicians with a general understanding
of echocardiography and knowledge of the echo-guided
technique can safely perform the procedure with appropri-
ate patient selection. Greater expertise is needed when the
effusion is small or localized, as in some diagnostic taps or
that associated with cardiac perforation complicating
invasive cardiovascular procedures.
The ideal site of needle entry is the point at which the
largest fluid accumulation is closest to the body surface
and from which a straight needle trajectory avoids vital
structures. Because ultrasound does not penetrate air,
avoidance of the lung is normally ensured. The left chest
wall, instead of the subcostal region, has become the pre-
ferred location for entry under echocardiographic site se-
lection. The subcostal route is not commonly used because
it necessitates a longer path to reach the fluid, passes ante-
rior to the liver capsule, and is directed toward the right
heart chambers.
The specific direction of the ultrasound beam that best
avoids vital structures is the needle trajectory of choice.
The intended needle trajectory should be evaluated by
echocardiography several times to confirm the optimal di-
rection and depth that the needle will be advanced. The use
of a 16-gauge polytef-sheathed intravenous needle
(Deseret) for entry has eliminated the need for electrocar-
diographic monitoring of a steel needle. Once the fluid
space has been entered, only the polytef sheath is advanced.
The steel core is immediately withdrawn. This latter step
ensures safe manipulation after entry into the fluid-filled
space and avoids the potential for sharp needle injury to a
vital structure. In the early years, the transducer was at-
tached to the needle for continuous monitoring during
needle entry. This practice has since been discontinued,
and complication rates have remained low." Critical as-
pects of the procedure are (1) determination of the ideal
entry site and needle trajectory, (2) use of a polytef-
sheathed needle, and (3) advancement of the needle in a
straight line without side-to-side manipulation during
needle entry. At any time during the procedure, the posi-
tion of the polytef sheath can be confirmed by echocardio-
graphic imaging from a remote window while agitated
saline (echo-contrast) is injected.
Introduction of a pigtail catheter into the pericardial sac
provides better control of fluid withdrawal and ensures
continued access to the pericardial space for extended fluid
drainage or instillation of medications, if necessary." The
increasing use of a pericardial catheter for malignant effu-
sions" and for postoperative pediatric effusions'? has been
associated with a reduced recurrence of effusion and de-

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clio Proc, July 1998, Vol 73
creased use of pericardial operations. If a catheter is to be
used, it is introduced before any substantial amount of fluid
has been withdrawn. Initially, the effusion is completely
drained through the catheter. Any additional fluid that
accumulates is aspirated intermittently rather than con-
tinuously. In our early experience, continuous catheter
drainage was associated with a high incidence of catheter
obstruction. This problem has been eliminated with the
adoption of intermittent drainage, typically performed ev-
ery 4 to 6 hours or as clinically indicated. After each
withdrawal, the catheter is flushed with sterile saline
to maintain catheter patency. The catheter is left in
the pericardial space until net fluid output is less than
30 mL per 24 hours." Standard indwelling catheter care,
with a complete change of dressing every 72 hours, is
recommended.
Noninvasive Doppler hemodynamic assessment has re-
duced the use of cardiac catheterization for the detection
and characterization of tamponade, constriction, and re-
striction." Pericardial pressure can be determined by using
a simple manometer attached to the introducing polytef
sheath. Both diagnostic and therapeutic advantages are
associated with this technique. Neither surgical explora-
tion nor biopsy of the pericardium has enhanced diagnosis
of the underlying cause of a pericardial effusion.t-" In our
experience, the use of sclerotherapy for malignant ef-
fusions has also largely been eliminated with adequate
catheter drainage." Morbidity and patient discomfort are
minimal.P-" The patient is allowed to be ambulatory im-
mediately after the procedure. With a thorough under-
standing of the procedure and appropriate patient selection,
physicians have successfully performed echo-guided peri-
cardiocentesis in outpatients."
The contraindications to echo-guided pericardiocentesis
are few. Theoretically, pericardiocentesis is contraindi-
cated in the setting of myocardial rupture or aortic dissec-
tion because of the risk of extending the rupture or dissec-
tion with decompression." In critically ill patients, any
procedural complication may become a more serious situa-
tion. Management must be individualized.
TECHNIQUE OF ECHO-GUIDED
PERICARDIOCENTESIS
The following is a step-by-step approach to echo-guided
pericardiocentesis." The hemodynamics of pericardial
effusion, specific indications, and results of the proce-
dure have been previously reported7,26,30 and are not a
part of this descriptive article. Any echocardiographic
system equipped with a 2.5- to 5-MHz transducer can be
used. A sterile pericardiocentesis tray (Table 1) can be
assembled from standard medical supplies found in most
hospitals.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Echo-Guided Pericardioceotesis 649
Table I.-Equipment and Supplies for
Echo-Guided Pericardiocentesis
Pericardiocentesis tray
Povidone-iodine solution (skin antiseptic)
Sterile transparent plasticdrape (1030Drape, Baxter)
One 20- to 25-gauge needlefor local anesthetic infiltration
1 to 2%lidocaine (localanesthetic)
Multiple 16-to 18-gauge (5,1-to 8.3-cm) polytef-sheathed
venous "intracath" needles (Deseret)
Syringes (10 to 20 mL and one 60 mL)
Specimen-collecting tubesfor fluid analyses and cultures
Plastic tubing(30 em) and three-way stopcock
Scalpel (No. II blade)
4 by 4 in. gauze dressing
Othersupplies
Sheath introducer set (Cordis)
Fine-gauge (0.035-mm) polytef-coated, floppy-tipped
guidewire
Dilatorand introducer sheath(6 F to 8 F)
A 65-cmstandard pigtailangiocatheter (6 F to 8 F) with
multiple side holes (Cordis)
Fluidreceptacle (I L vacuum bottle)
Manometer (for pericardial pressure measurement)
Dressings and antiseptic ointment
Sterileisotonic saline(for flushing catheter)
Sterilegloves, mask,and gown
1. Two-Dimensional Echocardiographic and Doppler
Examination
If the clinical situation allows, both 20 and Doppler
studies are performed to assess the size, distribution, and
hemodynamic effect of the effusion." In an emergency,
the essential information can be obtained by performing an
abbreviated 20 examination to localize the effusion and
identify the ideal entry site and needle trajectory for
pericardiocentesis.
2. Echocardiographic Selection of the Ideal Entry Site
The ideal entry site is the point on the body surface
where the effusion is closest to the transducer and the fluid
accumulation is maximal. The distance from the skin to the
pericardial space is assessed. The needle trajectory is
defined by the angulation of the handheld transducer. A
straight trajectory that best avoids vital structures, includ-
ing the liver, myocardium, and lung, is chosen. Be-
cause ultrasound does not penetrate air-filled spaces, the
lung is effectively avoided. The operator should select a
site that avoids the internal mammary artery (3 to 5 em
from the parasternal border) and the vascular bundle at
the inferior margin of each rib. The intended point of
entry is marked on the skin with an indelible pen, and
the direction of the ultrasound beam is carefully and re-
peatedly noted. This optimal needle trajectory should
be transfixed in the operator's mind. Any repositioning of
650 Echo-Guided Pericardiocentesis Mayo Clin Proc, July 1998, Vol 73

Fig. 2. Use of agitated saline contrast medium for confirmation of sheath position in pericardial space.
Pericardial effusion was visualized by imaging from subcostal position remote from entry site on chest wall,
before injection of agitated saline contrast medium (Left). Injection of agitated saline contrast medium
provides dense opacification of pericardial space, confirming sheath position (Right). LA = left atrium;
LV = left ventricle; RA = right atrium; RV = right ventricle; VS = ventricular septum; * = pericardial space.

the patient should prompt reassessment ot entry site and
trajectory.
3. Sterile Preparation
Povidone-iodine is used as skin antiseptic. A transpar-
ent plastic sheet (1030 Drape, Baxter) allows both visual-
ization of the sterile field and echocardiographic imaging,
if needed.
4. Local Anesthetic Administration
A 20- to 25-gauge needle is used for lidocaine injection
(I to 2%) at the selected site. On the chest wall, the
superior margin of a rib is used as a landmark.
5. Insertion of Polytef-Sheathed Needle
The polytef-sheathed "intracath" (16- to l8-gauge, 5.1-
to 8.3-cm) Deseret needle with an attached saline-filled
syringe is positioned at the predetermined entry site and
angulation. In the predetermined trajectory and with gentle
aspiration, the sheathed needle is advanced in the direction
of the fluid space. On entering the fluid, the needle is
advanced approximately 2 mm further. The polytef sheath
is advanced over the needle, and the steel core is with-
drawn. Only the polytef sheath remains in the fluid space.
aspirated or if the position of the sheath is questionable.
The echo-contrast effect is monitored by 2D echocardiog-
raphy, from a position outside the sterile field or through
the underside of the transparent sheet. Saline echo-contrast
medium is prepared by using two syringes (one contains 5
mL of saline, and the other is empty), each connected to a
three-way stopcock. The saline is aerated by rapid injec-
tion back and forth between the two syringes. The agitated
saline (echo-contrast) is then quickly injected into the poly-
tef sheath, and the contrast effect is observed by 2D echo-
cardiography (Fig. 2). If contrast appears in the pericardial
sac, the procedure can be continued. If the sheath is not in
the pericardial space, it should be repositioned by with-
drawal, or passage of another needle should be attempted.
7. Intrapericardial Pressure Measurement
Intrapericardial pressure (measured in centimeters of
water) may be obtained by attaching a manometer directly
to the polytef sheath. This procedure is optional.
8. Diagnostic Tap
Fluid is aspirated directly into a syringe or through a
three-way stopcock with extended flexible tubing. The
fluid is sent for selected diagnostic tests.

6. Saline Echo-Contrast Medium for Confirmation of 9. Catheter Drainage

Position (a) A guidewire is advanced through the polytef sheath
If necessary, the position of the sheath is confirmed by before any appreciable amount of pericardial fluid has been
injecting 5 mL of agitated saline through the sheath. Saline withdrawn. The polytef sheath is removed over the
should be injected particularly if bloody fluid has been guidewire.

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clio Proc, July 1998, Vol 73
(b) A small "stab" incision of the skin is made at the
entry site, followed by introduction of a dilator (6 to 8 F,
Cordis) over the guidewire. Predilatation of the chest wall
passage facilitates subsequent insertion of the introducer
sheath-dilator (6 to 8 F, Cordis) and minimizes burring of
the sheath tip.
(c) The guidewire and dilator are removed, and only the
sheath is left in the pericardial sac. (The introducer sheath
technique is used rather than direct catheter passage over
the guidewire because the catheter tip occasionally pulls
the wire out of the pericardial sac. The sheath is particu-
larly helpful for traversing longer distances or passing
through a sclerotic pericardial sac.)
(d) The pigtail angiocatheter (65 cm, Cordis) is inserted
through the introducer sheath, and fluid is aspirated to
ensure good return.
(e) After the pigtail catheter has been inserted, the intro-
ducer sheath is removed, and only the smooth-walled pig-
tail catheter is left in the pericardial space. The potential
complication caused by a frayed sheath tip (which hap-
pened in one patient) can be eliminated by withdrawing the
sheath after the pigtail catheter has been secured in the
pericardial sac.
(f) Injection of agitated saline echo-contrast medium is
repeated as necessary to confirm the position of the catheter
or sheath.
(g) The pericardial fluid is drained completely by sy-
ringe suction, with echocardiographic assessment of re-
sidual fluid and Doppler hemodynamics as needed.
Manual syringe aspiration is preferred to vacuum suction
because the former provides better control, and collapse of
the tubing is effectively avoided.
10. Dressing
The pericardial catheter is secured to the chest wall by
suture or appropriate dressing or both. Antiseptic ointment
is applied to the entry site, and aseptic dressings are used.
11. Subsequent Catheter Drainage and Maintenance
Education for nursing staff is crucial to ensure appropri-
ate care and maintenance of the pericardial catheter.
(a) Pericardial fluid is aspirated intermittently through a
three-way stopcock with aseptic technique (usually every 4
to 6 hours or as clinically indicated). In order to avoid
catheter plugging, continuous drainage is not used.
(b) At the end of each fluid withdrawal, the catheter is
flushed with sterile isotonic saline to maintain patency.
Aspirations and flushing inputs are charted, and net vol-
umes are recorded.
(c) The site should be re-dressed periodically (usually
every 72 hours), and guidelines for appropriate care of the
site should be analogous to those for any central line.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Echo-Guided Pericardioceotesis 651
(d) The attending physician should be notified if there is
a sudden increase in the volume of aspirated fluid; a change
in the appearance of the fluid, especially if the fluid be-
comes bloody or purulent; acute chest pain; or a change in
vital signs-for example, development of tachycardia,
hypotension, tachypnea, or fever.
(e) The catheter is removed once the drainage has de-
creased to less than 25 to 30 mL in 24 hours and follow-up
echocardiography reveals no significant residual pericar-
dial effusion.
While the pericardial catheter is in place, the patient
may be ambulatory as tolerated without restriction of upper
body movement. Continuous electrocardiographic moni-
toring has been found to be unnecessary. Minor discomfort
can be managed with simple analgesics. Underlying condi-
tions should be treated as clinically indicated.
OTHER PERICARDIAL DRAINAGE TECHNIQUES
Surgical techniques, including subxiphoid pericardiotomy
and partial or complete pericardiectomy, have historically
been described as "definitive" because of low rates of fluid
reaccumulation." Surgical approaches were associated
with high mortality and morbidity." In three reviews of
surgical management of pericardial effusion, 30-day mor-
tality rates ranged from 20 to 50%.2,4,32 Sclerotherapy has
also been used for malignant effusions.v-" In a recent
review of malignant pericardial effusion, catheter drainage,
surgical decompression, and sclerotherapy were associated
with similar rates of recurrence." At the Mayo Clinic,
echo-guided placement of a pericardial catheter for ex-
tended drainage is now preferred. Balloon pericardiotomy
has been reported to have a high rate of initial success;
however, complications necessitating further interventions
have occurred in up to 18% of cases." This technique is
not used at the Mayo Clinic.
Echo-guided pericardiocentesis is simple, safe,19,26 ef-
fective, humane, and relatively inexpensive." It is pre-
ferred to more complex and invasive procedures. Echo-
guided pericardiocentesis is considered the primary
therapy for patients with a clinically significant effusion,
and for most patients, it is also the definitive therapy.
CONCLUSION
Percutaneous echo-guided pericardiocentesis has an excellent
profile in terms of simplicity, safety, and efficacy. The use of
a pericardial catheter is associated with significant reduction
of recurrence of effusion. The technology is widely accessible
without the need for specialized facilities and personnel. As
described in this step-by-step presentation, echo-guided
pericardiocentesis with extended catheter drainage can now
supplant more invasive procedures as the initial, and usually
definitive, strategy for management of pericardial effusion.
652 Echo-Guided Pericardiocentesis
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