Overview of Pericardiocentesis

Pericardiocentesis is a medical procedure aimed at removing excess fluid from the sac that surrounds your heart, which is also known as the pericardial sac. This procedure is usually carried out to provide relief from symptoms or for diagnostic reasons. This is typically needed when there is pericardial effusion, either sudden or over a long time, causing serious symptoms. These severe symptoms can often lead to a dangerous condition known as cardiac tamponade.

The procedure might also be needed in cases of acute or chronic pericardial effusions without tamponade, meaning, even if this dangerous condition is not present, to identify the cause of the effusion, relieve symptoms like difficulty in breathing or swelling, or to avoid the condition from progressing into tamponade. The procedure can be done either without any guidance or with the help of real-time imaging such as echocardiography (an ultrasound scan of your heart) or fluoroscopy (a type of medical imaging that shows a continuous X-ray image on a monitor). The choice of performing pericardiocentesis and the method used depend on the cause and nature of the effusion, in addition to the patient’s condition.

The built-up of fluid in the pericardial sac can occur due to increase in fluid production, problems in draining it, or both, which can occur due to several issues such as infections, cancer, autoimmune diseases, syndromes after a heart attack, and irregularities in metabolism such as uremia. Effusions causing symptoms, especially those leading to tamponade, require immediate medical intervention. Pericardiocentesis is the quickest and most efficient method to eliminate this fluid. While it’s a safe procedure when performed by experienced healthcare professionals, it can still be high risk if the person doing it does not have enough knowledge of anatomy or does not use imaging guidance.

Anatomy and Physiology of Pericardiocentesis

The pericardium is a kind of ‘sac’ that surrounds your heart, made up of two layers. The outer layer is a fibrous structure, while the inner layer is split into two – the visceral part, which is attached to the heart, and the parietal part, which is a bit thicker. The space between these inner layers is filled with a small amount of fluid, about the volume of a shot glass. This fluid reduces friction and allows the heart to move smoothly.

Just like a car needs oil to run smoothly, the pericardium needs this fluid. However, sometimes too much fluid can build up in the pericardium, like a car overfilled with oil. This is called pericardial effusion and can occur due to various causes, such as infections, cancers, autoimmune diseases, or as a result of certain medical treatments.

The pericardium acts like a protective jacket for the heart and prevents it from expanding too much when the body takes in a lot of fluids. It also keeps the heart in the right position in your chest. However, the pericardium is not very stretchable, meaning it can only hold a certain amount of fluid – usually up to 50ml.

In certain cases, such as with cancer, the pericardium might be able to stretch a bit more over time and accommodate up to 2 liters of fluid. However, in sudden situations like trauma, the pericardium fills up quickly— usually with 80 to 200 ml fluid— before it exceeds its limit. Once that limit is crossed, internal pressure increases sharply, causing a dangerous condition known as tamponade that can affect the way your heart functions.

When tamponade occurs, the extra fluid in the pericardium first starts squeezing the right side of the heart, which operates at lower pressure. This prevents the right side of the heart from filling up properly. This imbalance between the left and right sides of the heart can cause various complications, including a significant drop in blood pressure when you breathe in. This condition, known as pulsus paradoxus, happens because the right side of the heart can’t fill up properly, affecting the left side’s ability to pump blood out. To treat tamponade and restore normal heart function, doctors perform a procedure called pericardiocentesis which relieves the pressure by draining the excessive fluid from the pericardium.

Why do People Need Pericardiocentesis

Pericardiocentesis is a medical procedure doctors use to remove fluid that has built up in the sac around the heart. This condition is called pericardial effusion. There are several reasons why a person might need this procedure:

– If the fluid is pressing on the heart and causing it to not function correctly, which is known as cardiac tamponade.

– If the amount of extra fluid around the heart is causing symptoms, like chest pain or shortness of breath.

– In case of purulent pericarditis, an accumulation of pus around the heart.

– If you’ve recently had heart surgery and extra fluid has returned (this is known as postpericardiotomy syndrome).

– If fluid builds up around the heart again after being removed once before (i.e., recurrent effusion).

– If there is bleeding into the sac around the heart due to a blunt impact or penetrating injury (referred to as traumatic hemopericardium).

Injuries obtained from any objects or accidents in “the box” area – the front chest area within the boundaries of the collarbone, ribs, and sides of the chest – can potentially injure heart structures and result in cardiac tamponade. If a person has had this type of trauma, pericardiocentesis may be used as an emergency procedure to stabilize them and allow them to be transported to the operating room for more definitive treatment.

Generally, if a person has a traumatic injury and they are either unstable or in cardiac arrest, and there’s no clear reason other than the presence of fluid around the heart, this procedure may be needed to remove that fluid. When pericardiocentesis can’t remove all the fluid, or if it’s unsuccessful, a surgical procedure called a thoracotomy might be done right then and there to drain the fluid.

When a Person Should Avoid Pericardiocentesis

There aren’t any solid reasons to suggest a person in an unstable health state shouldn’t undergo pericardiocentesis, a procedure which involves removing fluid from the sac around the heart. This operation can quickly improve the body’s circulation or “hemodynamics”, especially if the patient has a condition named tamponade, a life-threatening condition where fluid accumulates around the heart and puts pressure on it.

However, there are a few situations where pericardiocentesis may not be the best choice:

  • If the person has uncorrected coagulopathy, which means that their blood doesn’t clot well.
  • If a person has a low platelet count, which makes it difficult for their blood to clot which can cause extreme bleeding during or after surgery.
  • If the specifics of a patient’s chest anatomy aren’t clear or the diagnosis is uncertain, the operation carries more risks. For instance, if a fluid build-up around the heart (pericardial effusion) is believed to be due to a tear in the aorta (known as aortic dissection), accidentally poking the aorta during the procedure can have serious consequences.
  • If the patient is unlikely to cooperate during the process, perhaps due to mental health difficulties or fear of procedures.
  • If there is an ongoing infection at the site where the doctor would insert the needle into the body. This could spread the infection.

Equipment used for Pericardiocentesis

If your doctor needs to perform a procedure called a pericardiocentesis, which is used to drain excess fluid from around your heart, they will need specific types of equipment. Here’s what they typically use:

– An ultrasound machine or a fluoroscopy suite: These tools help your doctor see the area around your heart better during the procedure.

– Continuous hemodynamic and electrocardiographic monitoring: These monitors help keep track of your heart’s health and activity during the procedure.

– Sterile drapes and gloves: These are used to keep the procedure area clean and prevent infections.

– Local anesthetic: This is a medication used to numb the area where the doctor will be working, so you don’t feel any pain.

– Needles: long, thin needles are used to access the space around your heart.

– Catheter: This is a small tube, usually about 6 to 8 French in size (that’s a measurement system used for tubes like this) that is used for draining the fluid.

– Guidewire: This is a flexible wire that helps guide the catheter to the correct location.

– Dilators: These are used to slowly increase the size of the path for the catheter.

– Syringes: These are used to draw out fluid during the initial needle insertion.

– Three-way stopcock: This is a device used to control the flow of fluids.

– Extension tubing: This is additional tubing used to help direct the fluid to a collection bag.

– Accessories: These may include a scalpel (a small, sharp knife used in surgery), a bag to collect the fluid, sutures (stitches) to close any incisions, and adhesive dressing to cover the wound and help it heal.

Who is needed to perform Pericardiocentesis?

When a patient needs a pericardiocentesis procedure, which is a medical procedure to remove fluid from the sac around the heart, a team of different medical specialists comes together to make sure everything goes smoothly. One of the main people involved is a heart doctor known as a cardiologist. This doctor has a lot of skill with this type of treatment and really understands how the heart works.

Often, a medical imaging expert will be a part of the team as well. They might be a radiologist or a sonographer, and their job is to create clear, detailed pictures of the inside of the body using medical technology. This helps to make sure the procedure goes well and reduces the risk of any problems.

Nurses play a key role in getting the patient ready for the procedure, keeping an eye on them during it, and taking care of them afterward. The person who makes sure the patient is relaxed and pain-free during the procedure is often an anesthesiologist or a sedation specialist.

Lastly, it’s crucial to have an emergency surgery team on standby. If there are any complications, or if not all the fluid can be drained from the pericardiocentesis, they can perform another procedure, either a pericardiotomy or a pericardial window. All of these professionals working together helps to ensure the safety of the procedure and successful treatment of the buildup of fluid around the heart, known as pericardial effusions.

Preparing for Pericardiocentesis

Getting ready for a pericardiotomy, a surgery to open the sac around the heart, involves several crucial steps to make sure the patient is safe and the procedure goes smoothly. The process involves different medical professionals and includes:

* Checking the patient’s condition
* Doctors first check for any symptoms of cardiac tamponade (pressure on the heart that can cause heart problems), any visible chest abnormalities, and make sure the heart is stable.
* If necessary, they will provide support for breathing or additional oxygen.
* Taking images of the heart
* Using a method called echocardiography, doctors can see whether there is too much fluid around the heart, where it’s located, and how it’s affecting the heart.
* Running blood tests
* Doctors will take some blood tests to get a baseline record of the patient’s complete blood count, clotting ability, and kidney function, especially if they plan to use sedation or anesthesia during the procedure.
* Getting equipment ready

All necessary tools, such as an ultrasound machine for guiding the procedure and monitors for tracking the heart’s activity and how stable the patient is, are gathered and set up.

Patient preparation
* The patient is placed on the bed in a half-sitting or lying-down position, with the bed’s head raised about 30 to 45 degrees.
* Pain management and/or sedation are given as needed.
* The area where the doctor will make the incision — usually below the breastbone or near the breast or heart’s tip — is cleaned using a sterile technique, and an intravenous (IV) line is confirmed.

Team readiness
* The team, including a heart specialist to do the procedure, a specialist in anesthesia to handle sedation, and a heart surgeon on standby in case surgery is needed, prepares to work together.

Plan for after the procedure
* If needed, arrangements are made to analyze the fluid from around the heart.

The patient is closely monitored in a special care setting to quickly identify and manage any possible complications.

How is Pericardiocentesis performed

Pericardiocentesis is a medical procedure used to remove fluid that has built up around the heart. This fluid is located in a space called the pericardial sac. The procedure is often used when too much fluid has accumulated and is affecting the heart’s function. This could be a problem known as tamponade, where the heart is being squeezed by the excess fluid. Doctors use imaging techniques like ultrasound (echocardiography) or X-ray (fluoroscopy) to guide the procedure and avoid complications.

Right now, echocardiography-guided pericardiocentesis is the standard method used by doctors. Its advantages include being relatively inexpensive, not exposing the patient to radiation, and being able to be done at the patient’s bedside. The doctor identifies the best place to insert the needle that won’t hit vital structures like blood vessels, lungs, and the diaphragm. There are a few different places they might choose, like below the xiphoid process, which is a small bone at the bottom of your sternum, near the heart’s apex, or next to the sternum. After the needle reaches the pericardial space, a small tube, or catheter, is used to drain the fluid.

Fluoroscopy-guided pericardiocentesis is another option used if echocardiography isn’t possible or if the patient needs a more in-depth type of monitoring. This requires the patient to lie flat on their back, and fluoroscopy is used to watch the needle in real-time as it is placed. Usually, the needle is inserted in the same place as in the echocardiography-guided procedure. The doctor then injects a special dye to confirm that the needle is in the correct place. After that, they insert a special wire and catheter to drain the fluid.

In both methods, the needle is covered with a sheath and guided to the pericardial sac. Once the needle gets to the right place and fluid is aspirated, or pulled out, the needle is taken out, leaving the catheter in place to keep draining the fluid.

Sometimes it can be difficult to tell the difference between blood from the heart and fluid from the pericardial sac. The doctors will use their clinical judgment alongside different methods to differentiate the two, like looking at how the blood clots, comparing the count of red blood cells, and using certain tests using dyes or solutions. If the needle accidentally goes into the heart, it is quickly taken out, and careful monitoring is required.

Often, it’s necessary to keep a drain in place, especially if the fluid keeps accumulating. The amount of fluid being drained is measured regularly.

After the procedure, the patient needs to be carefully monitored for possible complications like heart rhythm problems, bleeding, or more fluid accumulation. The drained fluid can be analyzed to help the doctor figure out what caused the issue in the first place. Further treatment, like surgery, may be needed if there are complications, or if the fluid keeps building up. Part of managing the problem involves finding and treating the underlying reason for the fluid build-up, such as an infection, cancer, or other diseases, and providing care for other health conditions the patient might have.

Possible Complications of Pericardiocentesis

When carried out by skilled healthcare professionals, a procedure called pericardiocentesis generally leads to good results. However, there is a small risk of complications which occurs in 5% or more cases. These complications usually show up quickly and need prompt treatment. To decrease the risk of complications, it is highly recommended that doctors use ultrasound or other types of imaging while performing the procedure. Also, it’s helpful if doctors have quick access to heart surgery specialists, preferably within the same facility.

Pericardiocentesis involves removing fluid from the sac around the heart. Potential complications include damage to the heart muscle with possible bleeding into the space around the heart, leading to a dangerous condition called cardiac tamponade. If the needle is inserted incorrectly, it could damage major blood vessels and other organs. The procedure could also cause an irregular heartbeat, infection, or a collapsed lung, which is known as pneumothorax.

An immediate lowering of heart pressure through pericardiocentesis can cause up to 25% of patients to have a drop in heart rate, also known as vasovagal bradycardia, so doctors should be ready to handle this. Beyond that, if a lot of fluid is drained quickly from around the heart, it could lead to a condition called acute cardiac decompression syndrome, highlighted by a sudden drop in blood pressure and fluid build-up in the lungs.

Despite these risks, performing the procedure with guided imaging can lower the chances of accidentally harming nearby critical areas like the main arteries supplying blood to the heart, lungs, and diaphragm. Here’s a summary of potential complications:

  • Damage to the heart chambers
  • Injury to the internal mammary artery (an artery supplying blood to the chest and breast area)
  • Injury to the intercostal vessels (blood vessels located between the ribs)
  • Damaging the coronary arteries (blood vessels supplying blood to the heart)
  • Pneumothorax or collapsed lung
  • Irregular heart rhythms or arrhythmias
  • Low blood pressure and sudden drop in heart rate
  • Accidental puncture of the liver or belly
  • Infection
  • Death

What Else Should I Know About Pericardiocentesis?

Pericardiocentesis is a medical procedure that can save your life, especially in urgent situations where there’s an abnormal buildup of fluid around your heart, known as acute cardiac tamponade. If this condition isn’t detected and managed quickly, it can be deadly.

The procedure is not just used in emergencies; it can also help identify the cause of health problems or manage uncomfortable fluid buildup around the heart. Sometimes, medical procedures like inserting a catheter or a pacemaker lead can accidentally cause fluid to gather around the heart, and pericardiocentesis can help relieve this.

Heart specialists often deal with conditions affecting the pericardium – the sac-like covering around the heart. These can include inflammation of the pericardium (pericarditis), fluid buildup associated with cancer, or autoimmune diseases that cause your body’s immune system to attack your own cells. That’s why it’s so important for heart doctors to be skilled in performing pericardiocentesis. It’s essential for diagnosing and treating these conditions.

With advancements in heart procedures, the ability to perform image-guided pericardiocentesis using special imaging techniques like echocardiography or fluoroscopy has become increasingly significant. In this process, doctors use sound waves or X-rays to visualize the heart and guide the procedure, which help make pericardiocentesis safer and more effective.

Frequently asked questions

1. What is the purpose of the pericardiocentesis procedure in my case? 2. What are the potential risks and complications associated with pericardiocentesis? 3. Will the procedure be guided by imaging, such as echocardiography or fluoroscopy? 4. How will the procedure be performed? What equipment will be used? 5. What should I expect after the procedure in terms of recovery and follow-up care?

Pericardiocentesis is a procedure that relieves the pressure caused by excessive fluid in the pericardium, a condition known as tamponade. This procedure involves draining the fluid from the pericardium, which helps restore normal heart function. By relieving the pressure, pericardiocentesis can alleviate symptoms such as a drop in blood pressure and improve the overall functioning of the heart.

You may need Pericardiocentesis if you have a condition called tamponade, where fluid accumulates around the heart and puts pressure on it. This procedure can quickly improve your circulation and hemodynamics. However, there are certain situations where Pericardiocentesis may not be the best choice, such as if you have uncorrected coagulopathy, a low platelet count, unclear chest anatomy or diagnosis, difficulty cooperating during the procedure, or an ongoing infection at the insertion site.

A person should not get pericardiocentesis if they have uncorrected coagulopathy or a low platelet count, if the specifics of their chest anatomy are unclear or the diagnosis is uncertain, if they are unlikely to cooperate during the procedure, or if there is an ongoing infection at the insertion site.

To prepare for Pericardiocentesis, the patient should follow the instructions provided by their healthcare team. This may include fasting for a certain period of time before the procedure, stopping certain medications, and informing the healthcare team about any allergies or medical conditions. The patient should also be prepared for the possibility of receiving anesthesia or sedation during the procedure.

The complications of Pericardiocentesis include damage to the heart chambers, injury to the internal mammary artery, injury to the intercostal vessels, damaging the coronary arteries, pneumothorax or collapsed lung, irregular heart rhythms or arrhythmias, low blood pressure and sudden drop in heart rate, accidental puncture of the liver or belly, infection, and death.

Symptoms that require Pericardiocentesis include cardiac tamponade, which can cause the heart to not function correctly, as well as chest pain or shortness of breath caused by the amount of extra fluid around the heart. Additionally, traumatic injuries to the heart structures resulting in cardiac tamponade may also require this procedure.

Join our newsletter

Stay up to date with the latest news and promotions!

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

We care about your data in our privacy policy.