Pericardiocentesis of moderate, small or loculated pericardial effusions is a controversial issue. It should not be routinely performed if the patient is not symptomatic and effusion is spontaneously resolving and unless further diagnostic and/or therapeutic options are available (e.g. pericardioscopy, epicardial or pericardial biopsy, application of intrapericardial treatment). In addition, access to the small or moderated effusions requires a learning curve. Several experimental and few clinical concepts have been developed for access of a small pericardial effusion or normal pericardium. These procedures will be reviewed in the following sections.