Anatomy of Common Procedures
The clinical anatomy of pericardiocentesis
T
he heart and the roots of the great
vessels are contained within the coni-
cal fibrous pericardium, the apex of
which is fused with the adventitia of the
great vessels and the base with the central
tendon of the diaphragm. Anteriorly it is
closely related to the body of the sternum,
inferior to the angle of Louis, and is teth-
ered to the back of the sternum by the ster-
nopericardial ligament. On either side of
the sternal body, it relates to the third–sixth
costal cartilages and it is overlapped by the
anterior borders of the lungs. Posteriorly
lie the oesophagus, the descending aorta
and vertebrae T5–T8, while on either side
lie the roots of the lungs, the mediastinal
pleura and the phrenic nerves.
The inner aspect of the fibrous pericar-
dium is lined by the adherent parietal layer
of pericardium, which, in turn, is reflected
around the roots of the great vessels to
become continuous with the visceral layer
of pericardium, or epicardium. Between
these layers lies the pericardial cavity,
containing a thin film of serous pericardial
fluid.
Figure 1. The surface markings of the heart.
Surface anatomy
The outline of the pericardium can be Figure 2. The anterior aspect of the heart.
represented on the chest surface by an
irregular quadrangle bounded by four
points (Figure 1):
1. The second left costal cartilage Aortic arch
2. The third right costal cartilage
3. The sixth right costal cartilage Pulmonary trunk
4. The fifth left intercostal space 3.5 " Superior vena cava
(9 cm) from the midline, i.e. the apex
beat of the heart.
In clinical practice the size and position of
the heart and pericardium can be marked
out by placing the subject’s closed right fist
palmar surface down immediately below
the manubrio-sternal junction (the angle Left atrium
of Louis). Note how this bulges over to the Right atrium
left side to correspond with the apex beat.
Note also that the anterior surface of the Left ventricle
heart consists principally of the low pres-
sure chambers of the right atrium and right
Professor Harold Ellis is Clinical
Anatomist, Guy’s, King’s and St Thomas’
School of Biomedical Science, London SE1 Right ventricle
1UL
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Anatomy of Common Procedures
ventricle, with the high pressure left ven-
tricle forming its left margin (Figure 2). A
stab wound of the heart is statistically more
likely to involve a low pressure chamber. Hub of needle angled
approximately 15°
Haemopericardium to skin
The clinical consequences of a fluid accu-
mulation within the pericardial cavity
depend on the amount of fluid and the
speed of its accumulation. If slow, this
can be tolerated, but if blood rapidly col-
lects – in penetrating cardiac injury, car-
diac rupture after an infarct or following
cardiac surgery, it is life-threatening. The
clinical features are shock, tachycardia,
hypotension, distended neck veins and
muffled heart sounds. If a chest X-ray is
available, it shows that the heart shadow is
enlarged and globular. The electrocardio-
gram shows low voltage complexes.
Pericardiocentesis
Treatment is immediate drainage. This is
Apical area
best achieved through a left fifth space
thoracotomy, which also allows the under-
lying injury to be repaired. As a life-saving
temporary measure, needle aspiration may
be performed. Its disadvantages are danger Paraxiphoid area
of laceration of the underlying heart and a
50% false negative rate. Figure 3. Pericardiocentesis.
A large needle, such as a central venous
cannula, should be used. This is inserted Refinements such as the use of ultra- the myocardium are probably almost never
through a scalpel nick at the angle between sound guidance or the use of an electrocar- possible given the urgency of this proce-
the xiphoid cartilage and the left costal diogram electrode attached to the needle dure in clinical practice. BJHM
margin (Figure 3) and is directed from the as a warning device if the needle touches Conflict of interest: none.
midline upwards, at an angle of 15–20°
from the abdominal wall, aimed at the
direction of the left shoulder tip, aspirat- KEY POINTS
ing continuously. If blood is reached, a n The pericardial sac and heart can be outlined by the subject’s clasped right fist placed immediately
central venous catheter is passed along the below the angle of Louis.
cannula to provide pericardial drainage. n Haemopericardium may result from penetrating cardiac injury, cardiac rupture after infarction or
Aspiration of even a small amount following cardiac surgery.
of blood should improve the patient’s
haemodynamic condition and allow trans- n Pericardiocentesis is carried out in the angle between the xiphoid and left costal margin.
fer to the operating theatre for definitive n The large bore needle is directed at an angle of 15° and aimed at the left shoulder tip.
treatment.
Forthcoming articles in this series
n The applied anatomy of appendicectomy
n Examination of the thyroid gland
n The applied anatomy of rectal examination
Previous articles in the series can be accessed via our website www.bjhm.co.uk
British Journal of Hospital Medicine, July 2010, Vol 71, No 7 M101
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