Pericardiocentesis Health Article

Definition

Pericardiocentesis is a therapeutic and diagnostic procedure in which fluid is removed from the pericardium, the sac that surrounds the heart.

Purpose

The pericardium normally contains only a few milliliters (less than a teaspoon) of fluid to cushion the heart. Many illnesses cause larger volumes of fluid, called pericardial effusions, to develop. Spread of cancer to the pericardium is a frequent cause of pericardial effusions. If an effusion is too large, pressure develops within the sac that can interfere with the normal pumping action of the heart. Should that interference become severe, a life-threatening condition called cardiac tamponade can develop, which can lead to shock or death.

Pericardiocentesis is a procedure to remove that fluid, which allows the heart to pump normally again. The fluid is analyzed for the presence of cancer cells or microorganisms. If cardiac tamponade is present, pericardiocentesis must be done on an urgent basis. If tamponade is not present, an elective surgical pericardial drainage procedure can be scheduled.

Precautions

The presence of tamponade is a medical emergency and requires urgent treatment. The blood pressure can be low and breathing compromised. Fluids and intravenous medications might be needed to raise the blood pressure until the pericardiocentesis can be performed.

Description

When possible, pericardiocentesis is performed in the cardiac catheterization laboratory of the hospital, but it can be done at the bedside or in the emergency department. The patient lies on his or her back with the head elevated at about 45 degrees. The skin is sterilized and local anesthetic given. A long needle attached to a large sterile syringe is inserted under the breastbone into the pericardium. If available, an echocardiogram or cardiac ultrasound is done to guide the physician to the pericardium. Once the needle is in the pericardium, the doctor withdraws the pericardial fluid into the syringe. The fluid can then be tested for cancer cells. If the volume of the fluid is large or likely to reaccumulate, a catheter or drain is placed with one end in the pericardial space and the other outside the chest, attached to a collecting bag. This can stay in place for several days, until there is no more fluid to drain. After withdrawing either the needle or the catheter, the doctor will apply direct pressure to the site.

If a pericardiocentesis is unsuccessful at draining the pericardial effusion, other procedures are available such as percutaneous balloon pericardiotomy, in which a balloon-tipped catheter is inserted through the skin and then used to puncture a hole in the pericardium. This is a painful procedure and should be done under anesthesia. The pericardial fluid is allowed to drain into the chest cavity, into the pleural space, the area between the pleura, the membranes that line the lungs, and the lungs themselves. The pleural space can accommodate more fluid than the pericardium without significant discomfort.

Alternatively, if emergent pericardiocentesis is unsuccessful, the patient can be taken to the operating room for a surgical procedure that will drain the fluid. These elective surgical procedures are similar to pericardiocentesis; however, for open surgical procedures, image guidance is not necessary. These are typically performed under general anesthesia. These procedures present the surgeon with the opportunity to perform a biopsy of the pericardium, to confirm the suspicion that the patient's cancer has metastasized there. The operation can also be performed as a thoracoscopic procedure.

Finally, if necessary, a pericardiectomy, sometimes called a pericardial stripping, can be performed. This is a surgical procedure to remove the pericardium and is reserved for the most refractory cases. Pericardiectomy tends to carry more risk than other procedures.