What happens before this procedure?

After a provider diagnoses you with either a pericardial effusion or cardiac tamponade, they’ll determine how severe your condition is and the best way to treat it. Local anesthesia is part of the process and happens at the very beginning of the procedure (see the “What happens during the procedure?” heading below).

The preparation for this procedure depends on whether or not it’s an emergency. In cases where it’s not an emergency — such as when you have an effusion that’s slow-growing — your healthcare provider can schedule the procedure. In most cases, except in the direst emergencies, you’ll receive local anesthesia.

On the day of the procedure, you’ll need to fast (not eat) starting eight hours before the procedure (you can have clear liquids up to two hours before the procedure starts).

They’ll also do the following:

• Start an intravenous (IV) line. This is a way providers can give you medications or fluids directly through one of your veins.
• Prepare your skin. A provider will remove any hair you have at the spot where the clinician performing the procedure will insert the needle. The provider will also clean the same area with antiseptic to help prevent infections. In many cases, they’ll prepare multiple areas, saving time if the provider needs to direct the needle at a different angle at the last minute.
• Set up vital sign monitoring. This involves attaching sensors to monitor your blood pressure, breathing, heart rate and blood oxygen levels. They may also attach electrodes, which are sensors that detect the electrical activity in your heart, for an electrocardiogram (ECG or EKG). Changes in your heart’s electrical activity can help providers adjust needle placement.
• Provide additional oxygen. People who have low blood oxygen levels or who might develop this can also receive supplemental oxygen, either through a mask or a tube that runs beneath the nose.

What happens during this procedure?

Pericardiocentesis is a procedure that involves several healthcare providers from different backgrounds. It will likely involve one or more doctors, nurses, imaging technicians and more.

Imaging guidance

Before inserting the needle, the healthcare provider performing this procedure will work with an imaging technician to find the safest, simplest way to reach the pericardium. The most common type of imaging is ultrasound (echocardiogram), which is safe and easy to perform at the time of the procedure. Imaging is especially important because it helps the provider insert the needle right where it needs to go.

• Note: A provider can do this procedure without imaging help in extreme emergencies. However, this is extremely rare and has a higher risk of complications. It’s usually not an option unless there’s no other choice.

Needle placement

Unless you are in immediate danger of your heart stopping, your provider will use a local anesthetic to numb the area just before they insert the needle. They may also use a scalpel to make a small cut on your skin to make it easier to insert the needle.

Depending on where the fluid is in your pericardium, there are several places to insert the needle. The most common location is:

• Substernal (under your sternum, also known as your breastbone). This approach is most common and usually gives easy, direct access to your pericardium.

Less common entry points are:

• Parasternal (above your breastbone). This is just off-center at the front of your chest. This approach lets providers access your heart by going between your ribs from your front.
• Apical. This approach goes between your ribs but from the side of your body. It gets its name because it aims for part of the pericardium near the apex (pointed end near the bottom) of your heart.

Once they insert the needle, they’ll angle it so that it enters your pericardium, but not your heart. Once the tip of the needle is in the pericardium, the provider can start drawing out the extra fluid inside.

Depending on how much fluid is inside your pericardium, it may take only minutes to remove enough fluid. If there’s a lot of fluid, they may insert a catheter tube to drain fluid out more slowly.

Once they’ve drawn out enough fluid, your provider can pull the needle (or catheter) out, or they can leave a drainage catheter in place for a day or two to remove more fluid. When removing the needle or drain, they’ll finish the procedure by bandaging the spot.

What happens after this procedure?

After the procedure, your healthcare provider may want to have the fluid taken from inside the pericardium tested. That can help figure out why you had fluid buildup in the first place. They will also repeat an ultrasound (echocardiogram) to confirm the fluid is all gone. If a drain is left in place, they will repeat an ultrasound daily to confirm the fluid is gone prior to pulling the drainage tube out.

What are the advantages of this procedure?

Pericardiocentesis is a life-saving procedure when your heart is under pressure from fluid around it. It can also help collect fluid samples that will show why it happened in the first place, which can help healthcare providers treat the underlying problem. This procedure is also useful because it’s faster and less invasive than surgery. That means it’s usually a better, faster option when you have severe symptoms from cardiac tamponade and you’re at risk for your heart to stop.

What are the risks or complications of this procedure?

Complications related to pericardiocentesis happen in about 5% to 40% of cases. The risk of complications is lowest when imaging like echocardiogram or fluoroscopy helps the provider “see” where to direct the needle. In extreme emergencies, it’s possible to do this procedure without imaging help. However, this is very rare and should only happen when there’s no other option.

Even with imaging, the procedure involves inserting a needle very close to several of your vital organs and major blood vessels. That means there’s a risk of injuring any of the following:

• Heart. This can cause a heart attack, bleeding or disrupt your heart’s electrical system, causing an irregular heart rhythm (arrhythmia). Both can be severe — or even life-threatening — and bleeding may need emergency heart surgery to repair.
• Lungs. Injuries and punctures can cause lung collapse, a potentially life-threatening condition.
• Pericardium. This can cause fluid to leak into your chest or let the pericardium fill with air.
• Liver.
• Stomach.
• Major blood vessels near the heart.

Any kind of medical procedure that needs to pass through your skin also creates the risk of infection. When these infections spread, it can lead to an overwhelming reaction by your immune system. That overreaction, known as sepsis, is a life-threatening medical emergency.