Landmark-Guided vs Ultrasound-Guided Pericardiocentesis

landmark-guided vs ultrasound-guided pericardiocentesis Cardiac tamponade is uncommon, occurring in 5 per 10,000 admissions in the United States. Since it can reduce cardiac output and precipitate obstructive shock and subsequent cardiovascular collapse, promptly recognizing this condition is necessary so that proper pericardiocentesis can be administered.

But how do you go about it?

Between landmark-guided vs ultrasound-guided pericardiocentesis, which should you choose? Learn the details from Hospital Procedures Consultants. We’ll also provide expert insights into the benefits and techniques of an ultrasound-guided approach.

Which is the Superior Choice?

Landmark pericardiocentesis, performed using specific anatomic landmarks, can be a life-saving procedure for pericardial drainage.

Studies show that the subxiphoid approach, which takes the extrapleural route, offers the highest success rate (87% vs. 66-85%) and the lowest complication rate (5% vs. 9-31%) for landmark-guided pericardiocentesis compared with other insertion sites. However, it is important to clarify that ultrasound-guided pericardiocentesis is much safer than landmark-guided pericardiocentesis if this is an option.

The key is to start in Larrey’s triangle, which are small zones between the muscular fibers of the costal and sternal attachments of the thoracic diaphragm. Clinicians must then direct it toward the left midclavicular point with a needle. The needle should be directed to the left midclavicular point with a 30-degree inclination.

However, it should only be used when ultrasound guidance is unavailable.

An ultrasound-guided approach can confirm the presence of an effusion and enable the assessment of its hemodynamic impacts. It has a high success rate of 97% and low total complication rates (major, 1.2%; minor, 3.5%).

The alternative is to use surgical techniques, however, these have 30-day mortality rates ranging from 20% to 50%.

Choosing the Right Approach

There are 3 approaches to choose from when it comes to pericardiocentesis:

  • Parasternal: It has shallow intercoastal tissue and offers a constant view of the needle tip as it advances. However, it has a high risk of LIMA injury if performed to close to the sternum as the artery runs parallel to and 1 cm lateral to the sternum. Therefore, the parasternal approach should use an insertion point at least 2 cm lateral to the sternum to avoid LIMA injury.
  • Apical: It provides a direct route to the pericardial cavity, but increases the risk of pneumothorax and ventricular apex piercing.
  • Subxiphoid: It calls for taking the extrapleural route. It is associated with the most complications at 79.7% which isn’t surprising since it can traverse the lung, liver, internal thoracic artery, left anterior descending artery, colon, and stomach.

Among the 3, the parasternal medial-to-lateral approach is best because of its perfect success rate and complication-free results. In addition, it allows the clinician to view the trajectory of the needle in real time as well as key structures like the lung, myocardium, and pleura or internal thoracic vessels. There is also no risk of injuring the liver.

Performing Ultrasound-Guided Pericardiocentesis

Now that we’ve established ultrasound-guided pericardiocentesis as the superior choice, let’s review how to perform it. 

Step 1: Prepare the Patient 

Place the patient in a supine position, with the ultrasound machine to the right and the operator to the left. If the patient has a malignant pericardial effusion (MPE), ask the patient to sit down with the left arm above the head to prevent damage to the myocardium.

Step 2: Use Ultrasound to Visualize Reference Points 

Adjust the depth of the rectangle on the ultrasound screen so that only the pericardial effusion and the left ventricle are visible. 

Use a high-frequency probe to identify the sternum bone, ribs, lungs, internal thoracic vessel, and lung sliding. It will help you find the optimal path for drainage, lower the risk of laceration, and shorten procedural time. 

Step 3: Apply Anesthesia 

Apply a local anesthetic (2% lidocaine) at the site where you’ll be creating a puncture wound, usually about 2 cm lateral to the sternum in the 4th ICS.

Step 4: Needle Insertion

A linear array probe enables improved spatial resolution and allows clinicians to identify pericardial effusions with 100% sensitivity, 97% specificity, and 98% diagnostic accuracy

Use an in-plane needle guidance keeping the probe parallel to the ribs with a wide angle (45°) to visualize the needle trajectory in the short space and increase the accuracy and efficiency of the procedure.

Step 5: Confirm Hemodynamic Stabilization

Inject a small volume (5ml) of agitated saline in the pericardium to confirm that the needle tip is in the pericardial cavity. It should have a bubble appearance, which can be visualized through echocardiography. 

Step 6: Wire and Catheter Position 

Use a standard Seldinger wire technique and insert a single-lumen catheter to allow the complete drainage of the pericardium

Step 7: Monitoring 

Patients with large, malignant chronic effusions or those susceptible to chronic idiopathic pericardial effusions may require repeat pericardial fluid aspiration every 4 to 6 hours. This ensures hemodynamic stability.

Once the net drainage is less than 50 ml for 24 hours, remove the drainage catheter and sheath to reduce the risk of recurrent tamponade.

Understanding What’s at Stake

The most severe complications include, but aren’t limited to:

  • Injury of the cardiac chambers
  • Intercostal or internal thoracic vessel injury
  • Laceration of the coronary arteries
  • Pericardial decompression syndrome
  • Pneumopericardium
  • Pneumothorax
  • Puncture of the abdominal viscera or peritoneal cavity
  • Ventricular arrhythmias

Minor complications include bradycardia, pleuropericardial fistulas, supraventricular arrhythmias, and transient vasovagal hypotension. 

Landmark pericardiocentesis, also known as blind pericardiocentesis, has a morbidity rate of around 20% and mortality rates as high as 6%. Whenever possible, choose ultrasound-guided techniques for better outcomes.

Importance of Developing Operator Experience 

Ultrasound-guided pericardiocentesis requires advanced skills and knowledge. Clinicians with inadequate training could jeopardize the success of the procedure and compromise the patient. 

Instead of relying on landmarks, professionals must be trained in ultrasound-guided pericardiocentesis—the current gold standard in medicine.

Simulation models allow hospital personnel to train and focus on learning without risks. They offer realistic experiences while allowing students to repeat techniques until they become familiar with them. They also improve procedural confidence.

HPC: Gain Familiarity With Ultrasound-Guided Pericardiocentesis 

Between landmark-guided vs ultrasound-guided pericardiocentesis, the latter is the clear winner. 

Sharpen your skills with our pericardiocentesis course. You’ll learn the proper techniques for a successful procedure, with insights on determining the optimal insertion site and what to do when complications occur.

You can also watch an ultrasound-guided pericardiocentesis video on our website.


Stashko, E. Meer, J. M. Cardiac Tamponade. StatPearls
Blanco, P. Figueroa, L. Menéndez, M. F. Berrueta, B. Pericardiocentesis: ultrasound guidance is essential. Ultrasound J. 2022 Dec; 14: 9.

Published online 2022 Feb 14. doi: 10.1186

Tsang, T. S. Oh, J. K. Seward, J. B. Tajik, A. J. Diagnostic value of echocardiography in cardiac tamponade. Review Herz

. 2000 Dec;25(8):734-40. doi: 10.1007
Osman, A. Wan Chuan, T. Ab Rahman, J. Via, G. Tavazzi, G. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J Emerg Med. 2018 Oct; 25(5): 322–327. Published online 2017 May 15. doi: 10.1097

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