Objective. Classically pericardiocentesis has been described and performed through the subxiphiod approach, which is feasible if the pericardial fluid is circumferential or collected inferior or anterior to the heart. However, not uncommonly, the collection of fluid is at the base of the heart or in the posterior or apical portion of the pericardium, necessitating a different approach. The purpose of this study is to describe echo and fluoroscopic guided pericardiocentesis to evacuate noncircumferential effusions, which are not accessible from the standard subcostal approach. Methods. Retrospective review of all patients with localized/noncircumferential effusions at Rady Children's Hospital San Diego between May 2007 and February 2010 was performed. During these procedures, effusions were identified at the point closest to the skin. The pericardial drains were introduced, directed, and advanced under echocardiographic and fluoroscopic guidance while avoiding major organs. Results. Ten patients were identified (age ranged from 20days to 22years, weight ranged from 1.6kg to 94kg). All procedures were successful in draining the pericardial effusions with minimal residual fluid and no complications. Conclusion. Echocardiographic and fluoroscopic guided pericardiocentesis is a feasible, relatively safe, and reliable technique to drain loculated pericardial effusions using nonstandard entry sites.