Chronic pericardial effusions are a major cause of morbidity in some clinical settings. Although the treatment of choice for acute symptomatic pericardial effusions (tamponade) is pericardiocentesis, the long-term management of symptomatic chronic pericardial effusions provides a greater challenge. The aim of this review is to provide insight into the presentation, diagnosis, and different treatment options available to patients with chronic symptomatic pericardial effusions, with emphasis on malignant pericardial effusions. Pericardiocentesis with sclerosing agents, radiation therapy, percutaneous, and surgical pericardiotomy and other surgical techniques are particularly efficacious, depending on the underlying cause and the patient’s prognosis.