The shortest path to the heart - apical versus subxiphoid pericardiocentesis for treating pericardial effusion

Pericardiocentesis is the standard procedure for diagnosing and treating pericardial effusion. Although the subxiphoid approach is the traditional access site, the widespread use of ultrasound guidance for invasive procedures allows alternative windows tailored to effusion location and patient anatomy. Despite its increasing use, there is a scarcity of published data detailing the apical approach.

We present our institutional experience with pericardiocentesis, comparing the effectiveness, safety and outcomes of the apical and the subxiphoid aproaches.

Retrospective analysis of patients undergoing pericardiocentesis for pericardial effusion between 2022 and 2025, at a tertiary cardiac care center. Patients were categorized according to access site: apical or subxiphoid. Data was collected from electronic health records. Statistical comparisons were performed using two-sided Fisher’s exact test.

Procedural details: Bedside echocardiographic imaging of the effusion was performed to select the safest approach, favoring the largest effusion window with the lowest risk of perforating adjacent structures. For the apical approach, the entry site was typically located 1–2 cm lateral to the apex beat, between the 5th and 7th intercostal spaces. The chosen site was either marked on the skin or continuously monitored with ultrasound. A needle was advanced above the corresponding rib’s upper border, to avoid injury to the intercostal neurovascular bundle. Aspiration of pericardial fluid confirmed entry into the pericardial space and ultrasound assessed correct needle placement. Drainage was maintained as clinically indicated.

A total of 45 patients underwent pericardiocentesis, 14 (31%) performed via the apical and 31 (69%) via the subxiphoid approach. There was a higher proportion of women in the apical group but body mass index was comparable. Post-procedural iatrogenic pericardial effusion (32% vs 14%) and hemodynamic instability (68% vs 36%) were more common in the subxiphoid group. The overall success rate was 91% and severe complications occurred in four patients (8%), with no statistically significant difference between the two techniques. No pneumothorax occurred. In the apical group, one case (7%) was complicated with left ventricular puncture. In the subxiphoid group, three patients (10%) had immediate complications: one right and two left ventricular punctures, with one patient going into cardiac arrest and requiring emergent sternotomy with subsequent death at 16 days, attributed to the procedure. Patient outcomes, including overall (p-value 0.519) and in-hospital survival (p-value 1), showed no statistically significant differences (median follow-up: 260 [75-121] days).

Our institutional experience supports the apical approach as a safe and effective alternative for the traditional subxiphoid technique, enabling tailored treatment to each patient’s effusion and anatomy.

Apical aproach