Blind percutaneous pericardiocentesis (PC) is a more challenging procedure and has a higher incidence of complications in children than in adults. Complication rates of up to 33% have been reported in children. PC guided by 2-dimensional echocardiography (2DPC) has been shown to be very safe and effective in adults. To assess whether 2DPC also reduces risk in children, we reviewed the results of 70 2DPCs performed in 57 children (≤ 18 yrs), from 1982 and 1995. Mean age = 7.4 ± 4.8 yrs (25 pts ≤ 5 yrs, 44%). 2DPC was performed for postoperative pericardial effusion in 54 cases (77%). Twenty-seven cases had hemodynamic instability with effusion and 37 had compromised cardiac function without clinical instability. Six 2DPCs were for diagnostic purposes. Echo was used to define the most direct path to the effusion. The majority of 2DPCs (80%, 56/70) were then performed from non-standard, echo-defined entry sites on the chest wall. A classical subxiphoid entry site was chosen in only 20% (14/70). Sixty-nine of 70 attempted 2DPCs were successful. Only 7 required more than a single needle insertion. Pericardial drainage lasted > 24 hrs in 21 pts (37.5%, mean duration - 4 days, range - 1 to 18 days). There were no deaths and only 1 complication (a pneumothorax in a pt on high pressure ventilation). Thirteen pts (32%), initially treated and stabilized with 2DPC, had eventual, elective pericardiectomy or pericardiotomy for prolonged pericardial drainage. The remaining 68% resolved without surgery. Conclusion: 2DPC is safe and effective in children. Most effusions can be treated without surgery. When surgery is necessary, it can be performed electively, after initial stabilzation with 2DPC. 2DPC is the initial procedure of choice for pericardial fluid drainage in children.