Mild pericardial effusion on echocardiography from apical four chamber view
Echocardiogram from the apical four chamber view shows mild pericardial effusion as echo free space lateral to the left ventricle and anteromedial to the right ventricle. The quantity of effusion is small and needs only observation. It will be difficult to aspirate such small effusions without injuring the cardiac structures. RV: right ventricle; RA: right atrium; LV: left ventricle; LA: left atrium.
The usual route for aspiration of pericardial effusion is subcostal. Hence it is always better to check the size of pericardial effusion from subcostal view. Aspiration is usually done only if there is a sizable pericardial effusion anterior to the right ventricle in the subcostal view. If the effusion is small, the aspiration needle is likely to injure the right ventricle. Pigtail catheter is often introduced into the pericardial space using Seldinger technique with guidewire and left there till the pericardial effusion stops collecting. This method is especially useful in malignant pericardial effusion in which repeated aspirations are likely to be necessary. In such situations, sclerosing agents like Bleomycin can be instilled into the pericardial space after complete aspiration, to cause adhesion of pericardial layers (visceral and parietal) and prevention of recurrence.