How to assess a pericardial effusion with handheld ECHO

4th Dec 2020

The presence of a pericardial effusion has also been reported in patients infected with the SARS-CoV-2 virus, particularly in patients with a myocardial injury (such as myopericarditis). 

So, how do you identify and assess a pericardial effusion using a handheld echocardiography (HHE) device? 


Identifying a pericardial effusion with handheld echocardiography

A pericardial effusion can be seen in the deep parasternal long-axis (PLAX) or subcostal views. The descending aorta is a useful landmark: fluid anterior to the descending aorta is pericardial and anything posterior to the descending aorta is pleural. 

Deep parasternal long-axis (PLAX) echocardiogram with labels on the pericardial effusion, pleural effusion, and descending aorta.

Figure 1. Deep parasternal long-axis (PLAX) view of a pericardial effusion anterior to the descending aorta and a pleural effusion posterior to the descending aorta. 


It is important to determine the hemodynamic effects of a pericardial effusion to guide clinical decision making. This involves using HHE to assess the volume and distribution of the pericardial effusion. 


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Quantifying a pericardial effusion with handheld echocardiography

To quantify the effusion, measure the space between two pericardial reflections (visceral and parietal) in end-diastole in each view of the standard dataset. It is essential to take multiple measurements from different views, since there may be variability in effusion measurements across views. 

Parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical, and subcostal echocardiograms with pericardial effusion size highlighted.

Figure 2. Pericardial effusions can be quantified with the standard echocardiogram dataset. The apical, subcostal, parasternal long-axis (PLAX), and parasternal short-axis (PSAX) views showing the variation in pericardial effusion measurements between the two pericardial reflections (visceral and parietal) in end-diastole. 


The largest measurement is used to categorize the pericardial effusion as small (less than 1 cm), moderate (2–3 cm), or large (greater than 3 cm). 


Identifying cardiac tamponade with handheld echocardiography

Cardiac tamponade is a medical emergency caused by the accumulation of fluid in the pericardial space, which results in reduced ventricular filling and subsequent hemodynamic compromise. Although this is a clinical diagnosis, HHE can be a supportive tool in the clinical assessment of this condition.


Following careful assessment of a pericardial effusion using a handheld echocardiogram, it is essential to screen for evidence of the life-threatening progression to cardiac tamponade. Medmastery note.

In cardiac tamponade, a pericardial effusion causes collapse of the lower-pressured right-sided chambers. The right atrium is initially affected in diastole with progressive diastolic collapse, which then leads to systolic collapse of the right ventricle. Typically, systolic collapse will also cause hypotension. 

Additionally, a dilated and non-collapsing inferior vena cava (IVC) may suggest the development of cardiac tamponade in an acute setting. 

Subcostal echocardiograms highlighting collapsed right chambers and dilated non-collapsing inferior vena cava (IVC).

Figure 3. Cardiac tamponade is caused by the accumulation of fluid in the pericardial space, which results in reduced ventricular filling and hemodynamic compromise. Assessment with a subcostal ECHO shows a collapsed right ventricle (RV) and dilated non-collapsing inferior vena cava (IVC). 

Identifying these key features with HHE ensures timely diagnosis of cardiac tamponade so that prompt emergency pericardiocentesis can be initiated. 


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Recommended reading

  • Chamsi-Pasha, MA, Sengupta, PP, and Zoghbi, WA. 2017. Handheld echocardiography: Current state and future perspectives. Circulation136: 2178–2188. PMID: 29180495
  • Clerkin, KJ, Fried, JA, Raikhelkar, J, et al. 2020. COVID-19 and cardiovascular disease. Circulation141: 1648–1655. PMID: 32200663
  • Doyen, D, Moceri, P, Ducreux, D, et al. 2020. Myocarditis in a patient with COVID-19: A cause of raised troponin and ECG changes. Lancet395: 1516. PMID: 32334650
  • Drake, DH, De Bonis, M, Covella, M, et al. 2020. Echocardiography in pandemic: Front-line perspective, expanding role of ultrasound and ethics of resource allocation. J Am Soc Echocardiogr33: 683–689. PMID: 32503707
  • Fukuhara, S, Rosati, CM, and El-Dalati, S. 2020. Acute type A aortic dissection during the COVID-19 outbreak. Ann Thorac Surg. 110: e405–e407. PMID: 32333849
  • Haji, K, Wong, C, Neil, C, et al. 2019. Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE). Echo Res Pract6: 91–96. PMID: 31516721
  • Hua, A, O’Gallagher, K, Sado, D, et al. 2020. Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19. Eur Heart J41: 2130. PMID: 32227076
  • Johri, AM, Galen, B, Kirkpatrick, JN, et al. 2020. ASE statement on point-of-care ultrasound during the 2019 novel coronavirus pandemic. J Am Soc Echocardiogr33: 670–673. PMID: 32503704
  • Meyer, P, Degrauwe, S, Van Delden, C, et al. 2020. Typical takotsubo syndrome triggered by SARS-CoV-2 infection. Eur Heart J41: 1860. PMID: 32285915
  • Neskovic, AN, Hagendorff, A, Lancellotti, P, et al. 2013. Emergency echocardiography: The European association of cardiovascular imaging recommendations. Eur Heart J Cardiovasc Imaging14: 1–11. PMID: 23239795
  • Nguyen, VTQ, Ho, JE, Ho, CY, et al. 2008. Handheld echocardiography offers rapid assessment of clinical volume status. Am Heart J156: 537–542. PMID: 18760138
  • Poissy, J, Goutay, J, Caplan, M, et al. 2020. Pulmonary embolism in patients with COVID-19: Awareness of an increased prevalence. Circulation142: 184–186. PMID: 32330083
  • Shi, S, Qin, M, Shen, B, et al. 2020. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol5: 802–810. PMID: 32211816
  • The American Society of Echocardiography. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. 2020.  
  • The American Society of Echocardiography. Cleaning recommendations from ultrasound manufacturers. 2020.
  • The Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0. 2020. 
  • Zeng, JH, Liu, YX, Yuan, J, et al. 2020. First case of COVID-19 complicated with fulminant myocarditis: A case report and insights. Infection48: 773–777. PMID: 32277408