Safety and outcomes of real-time ultrasound-guided pericardiocentesis via the left parasternal approach performed by emergency physicians: an 11-year experience

Abstract Aims. Ultrasound-guided pericardiocentesis has largely replaced blind techniques because of its greater safety. No consensus exists regarding the optimal approach. Ultrasound guided pericardiocentesis via in-plane parasternal approach techniques with high-frequency probes offer real-time visualization of needle trajectory. Evidence on this approach remains limited across both emergency medicine and other clinical settings. We evaluated the safety, feasibility, efficacy, and clinical outcomes of an in-plane, left parasternal, medial-to-lateral approach for pericardiocentesis. Methods & Results. A observational cohort study including adult patients diagnosed with cardiac tamponade in the emergency department was conducted over 11 years (2014–2024) across two tertiary care hospitals. The primary outcome was procedural success rate. Secondary outcomes included procedure times, skin-to-pericardium distance, clinical and haemodynamic changes, procedure-related complications, and 72-hour mortality. Among the 201 adult patients enrolled, the procedure achieved 100% success rate with only two complications (1%). Pericarditis was the most common cause of cardiac tamponade (45.8%), followed by sepsis, malignancy, procedure-related complications, myocardial disease, autoimmune disease, and trauma. The 72-hour in-hospital mortality rate was 15.9%, exclusively attributable to the underlying diseases. The mean time from needle puncture to fluid aspiration was 1 minute 51 seconds, while the mean procedural time was 5 minutes 46 seconds. Skin-to-pericardium distance was shorter than with a hypothetical subcostal approach. Hemodynamic parameters improved significantly after the procedure. No procedure-related deaths or major adverse events occurred. Conclusion. The emergency ultrasound guided pericardiocentesis via an in-plane left parasternal approach is a safe, rapid technique for emergency pericardiocentesis, offering a shorter needle trajectory and improved needle control through continuous real-time visualization throughout the entire procedure.