Efficacy and safety of apical access in percutaneous pericardiocentesis: a comparison with subxiphoid approach

Percutaneous pericardiocentesis represents the sole curative intervention for significant pericardial effusion, especially in cardiac tamponade. While the subxiphoid route is traditionally the most utilized, alternative approaches - such as the apical access - have also been adopted. To date, no studies have directly compared the performance, risk profile, and clinical implications of these techniques. This study aims to evaluate and compare the effectiveness, complication rates, and short- to medium-term outcomes of apical versus subxiphoid pericardiocentesis.

We performed a retrospective analysis of pericardiocentesis procedures carried out at the Cardiac Intensive Care Unit of the IRCCS San Gerardo dei Tintori Foundation in Monza, Italy, between January 2011 and December 2024. Patients were categorized based on the access site: apical or subxiphoid.

Among 199 procedures, 85 (42.7%) were performed via the subxiphoid route and 114 (57.3%) through apical access. Most interventions addressed acute tamponade or pretamponade states. Imaging guidance was employed in 89.6% of cases. Baseline demographics, comorbidities, and echocardiographic features were comparable between the two groups. The overall success rate was 98.5%, with no significant differences between approaches. Major complications were rare (0.5%), and minor complications occurred in 11.1% of cases, without notable variance between techniques. Patient outcomes - including overall survival, in-hospital survival, and pericardiocentesis-free survival - showed no statistically significant differences (median follow-up: 17.2 months; interquartile range: 3.8-69.2 months).

Apical access for percutaneous pericardiocentesis demonstrates similar efficacy and safety to the subxiphoid approach, representing a valid alternative in appropriate clinical contexts.