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Br Heart J: first published as 10.1136/hrt.39.5.529 on 1 May 1977. Downloaded from British Heart J7ournal, 1977, 39, 529-535 Potential pitfalls in quantification of pericardial effusions by echocardiography' IVAN D'CRUZ, RAVINDRA PRABHU, HOWARD C. COHEN, AND GERALD GLICK From the Cardiovascular Institute, Department of Medicine, Michael Reese Hospital and Medical Center, Chicago, Illinois, and the University of Chicago Pritzker School of Medicine, Chicago, Illinois, U.S.A. In the echocardiographic assessment ofpatients with pericardial effusions, the apparent width of the echo-free space between the left ventricular posterior wall and the parietal pericardium is commonly used to estimate the amount of pericardial fluid present. In 4 patients with pericardial effusions, we showed a distinct disparity between the widths of the posterior pericardial space at different levels of the left ventricular posterior wall. In 2 of them, a 'swinging heart' appearance was recorded when the ultrasound beam was directed caudally, but not when its direction was cephalad or less caudad. It is suggested that the left ventricle should be scanned at allpossible sites to minimise potential errors in estimating the amount of a pericardial effusion. Since the pioneering studies of Feigenbaum et al. pericardial fluid by echocardiography. We do wish (1965), echocardiography has played an increasingly to emphasise that in some patients with pericardial important role in the diagnosis and follow-up of effusions, the nonuniform distribution of fluid patients with pericardial effusions. The next im- within the pericardial sac may result in inaccurate portant advance occurred when Horowitz et al. data unless the echocardiographer is careful to (1974) correlated the amount of fluid within the visualise the ventricles at all levels, with all possible http://heart.bmj.com/ pericardial cavity with the width of the echo-free transducer directions. space between the epicardium of the left ventricular In this report, we describe the echocardiograms of posterior wall and the parietal pericardium. 4 representative patients with pericardial effusions According to this method, which is now widely in which we produced distinct variations in the accepted and applied in routine clinical practice, width of the echo-free posterior pericardial space the width of the sonolucent space between the left by scanning in different directions with the trans- ventricular posterior wall and parietal pericardium, ducer. Thus, a cursory study might well have in systole and in diastole, is used to estimate the yielded an inaccurate estimation of the amount of on September 25, 2021 by guest. Protected copyright. size of pericardial effusions. Moreover, the dif- pericardial fluid present. ference between the cubed diameters of the peri- cardium and epicardium at end-diastole is presumed Case reports to indicate the volume of pericardial fluid present (Horowitz et al., 1974). CASE 1 We have found, however, that the echocardio- The echocardiogram (Fig. 1) of a 22-year-old man graphic appearances in patients with pericardial with chronic renal failure, hypertension, and sickle- effusions sometimes can be deceptive, and that on cell disease was recorded with the transducer beam occasion the method of Horowitz et al. may yield directed first to the aortic root and left atrium, then ambiguous or inexact data unless certain precautions to the basal left ventricle at the level of both mitral are taken in scanning technique. We do not claim to cusps, and finally to the mid left ventricle at the level invalidate the technique ofHorowitz et al. (which we of the posterior mitral cusp only. The apparent have found reliable and useful in most patients with diminution of the pericardial space posterior to the pericardial effusion), nor to introduce a new or basal left ventricle is attributable to a solid layer different procedure for estimating the volume of (site marked X), which perhaps represents fibrinous material or granulation tissue, that is adjacent to, 'This study was supported in part by funds contributed by the Alfred and seems to move with the 0. Hergott Heart Fund and the Michael Reese Medical Research parietal pericardium. Institute Council. However, as the transducer beam shifts laterally Received for publication 30 November 1976 away from the anterior mitral cusp, the echo-free 529 Br Heart J: first published as 10.1136/hrt.39.5.529 on 1 May 1977. Downloaded from 530 D'Cruz, Prabhu, Cohen, and Glick Fig. 1 Echocardiogram of a 22-year-old man with pericardial effusion secondary to chronic renalfailure. A scan was performedfrom aortic root (left), to basal left ventricle at the level of both mitral cusps (centre), and then to the mid left ventricle at the level of the posterior mitral cusp only (right). A sonolucent space, caused by posterior pericardial fluid is seen between the left ventricular posterior wall (LVPW) and parietal pericardium (PP). This pericardial space is much wider behind the mid left ventricle (right) than it is behind the basal left ventricle (centre) because of the solid layer of material (site marked X) contiguous to the pericardium behind the basal left ventricle. ECG, electrocardiogram; RVAW, right ventricular anterior wall; AAR, anterior aortic root; AV, aortic valve; PAR, posterior aortic root; LA, left atrium; VS, ventricular septum; AML, anterior mitral leaflet; PML, posterior mitral leaflet. pericardial space widens to about 2 cm, with dis- space is detected posterior to the left ventricular http://heart.bmj.com/ appearance of the solid layer. posterior wall. On this scan (Fig. 2C) alone, the pericardial effusion appears to be small. However, CASE 2 if the mid left ventricle had not been scanned, the During the examination of a 28-year-old woman in pericardial effusion would have been classified as chronic renal failure, a scan was performed going moderate in size, since a wide separation is seen from the mid left ventricle (at chordae level), to the between the left ventricular posterior wall and the basal left ventricle (at mitral valve level), and then parietal pericardium at the basal left ventricular to the aortic root and left atrium (Fig. 2A). Only a level (central segment of Fig. 2A, right segment of narrow echo-free space, wider in systole than in Fig. 2B). on September 25, 2021 by guest. Protected copyright. diastole, is visualised between the ventricular posterior wall and parietal pericardium at mid left CASE 3 ventricular level. This echo-free space widens This 35-year-old man developed a large pericardial considerably (to about 1-5 cm) behind the basal left effusion after irradiation of the mediastinum ventricle, and then disappears abruptly as the for Hodgkin's disease. The recording shown in transducer beam shifts from mitral valve to aortic Fig. 3A was obtained with the transducer placed root. A similar increase in the width of the peri- on the chest wall adjacent to the sternal margin in cardial space is seen (Fig. 2B) when another scan of the fourth left intercostal space and directed the left ventricle was done from the level of the caudally and slightly medially; the recording shown chordae tendineae to the level of the mitral valve. in Fig. 3B was obtained with the transducer During the same study (Fig. 2C), a scan in the directed cephalad and slightly laterally. In panel A reverse direction was obtained by shifting abruptly a 'swinging heart' appearance was obtained with an the direction of the transducer from the region of apparently small anteroposterior cardiac diameter the aortic root-left atrium to the mid left ventricle and excessive cardiac mobility. Individual cardiac (level of the posterior mitral cusp and chordae structures cannot be differentiated at first (left of tendineae), thereby missing or skipping the inter- panel A) but a slight shift in the direction of the mediate region of the basal left ventricle where both transducer (right of panel A) makes it possible to mitral cusps are visualised. Only a narrow echo-free distinguish the left ventricular posterior wall, Br Heart J: first published as 10.1136/hrt.39.5.529 on 1 May 1977. Downloaded from Echocardiography in pericardial effusion 531 M%O. .v -RIO I i '. y e k -.AMLA:,'N. % %?/~$~-,. Fig. 2 Echocardiogram of a -^+~A > > - 28-year-old woman in chronic - LA renalfailure. (A) A scan was ~~~~~~~~. ~~~~~~~~~~~~~~ performedfrom the mid left tv. ventricle at chordae level (left), to the basal left ventricle at the level of both mitral cusps (centre), and then to the aortic root (right). The sonolucent (A) space caused by posterior pericardial fluid is narrow _ ~ ".-;:*g;;behindthe mid left ventricle but widens behind the basal -RV left ,~;vo -gV ventricle and ends abruptly as the aortic root and left atriun are visualised. (B) Another scan f- from mid (left) to basal left AMLf ventricle (right) again shows widening of the fluid-filled .%PML posterior pericardial space C. k posterior to the basal left ventricle. (C) This scan was done from the aortic root (left) a,i!,3@p@: abruptly to the mid left ventricle http://heart.bmj.com/ (right), skipping the basal left __E' ventricular region. The sonolucent space between the left ventricular (B) posterior wall and parietal pericardium is narrow, suggesting a small pericardial effusion. (PPF,posteriorpericardialfluid; tj£t+"E other abbreviations as for Fig.) 1 on September 25, 2021 by guest. Protected copyright. AMLn *. P*,.L ,l LVPW (C) ventricular septum, and right ventricular anterior than in panel A, and the anterior mitral leaflet can wall. In panel B the width of the anterior pericardial be recognised in addition to the right ventricular space remains approximately the same as in panel A, anterior wall, ventricular septum, and left ven- but the echo-free space between the left ventricular tricular posterior wall. The appearance is no posterior wall and the parietal pericardium is less longer that of a 'swinging heart'.

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