Saudi Journal of Anaesthesia

: 2015  |  Volume : 9  |  Issue : 2  |  Page : 230--232

Pericardial effusion: Real and false

Monish S Raut, Arun Maheshwari 
 Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Dr. Monish S Raut
Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi

How to cite this article:
Raut MS, Maheshwari A. Pericardial effusion: Real and false.Saudi J Anaesth 2015;9:230-232

How to cite this URL:
Raut MS, Maheshwari A. Pericardial effusion: Real and false. Saudi J Anaesth [serial online] 2015 [cited 2022 May 16 ];9:230-232
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Case 1: A 18-year-old male patient with severe mitral stenosis, severe pulmonary hypertension, tricuspid regurgitation and right heart failure was scheduled for mitral valve replacement surgery. Intraoperative transesophageal echocardiographic (TEE) transgastric view revealed large collection of fluid around the posterior aspect of heart giving picture of tamponade compressing heart [Figure 1] and [Video Clip 1].{Figure 1}


Case 2: A 48-year-old male patient operated case of mitral valve replacement 1 month back presented with severe breathlessness. Patient was intubated in view of respiratory distress and TEE was done. TEE revealed normal prosthetic valve function, but a large pericardial collection on the anterolateral aspect of heart giving tamponade effect [Figure 2].{Figure 2}

In images of above presented two cases, collection compressing heart is evident in the same transgastric short axis view. However, other TEE views in case 1 did not show pericardial effusion [Figure 3]. In transgastric view, falciform ligament is seen which indicates that the collection is of ascitic fluid [Figure 1]. Hence, this case depicts false appearance of pericardial effusion in presence of ascites. In case 2, other views also demonstrated pericardial effusion giving compression effect [Figure 4]. This was a case of true pericardial effusion with tamponade. Effusion was drained by creating pleuropericardial window.{Figure 3}{Figure 4}

The echo-free spaces near the heart which can be confused with pericardial effusion are-mediastinal cysts, lymphomas, thymomas, diaphragmatic hernia, left the atrial aneurysm, left ventricular pseudoaneurysm and coronary artery aneurysm. [1]

Echocardiographically, such ascitic echo-free spaces can be mistaken for pericardial effusions and pericardial cysts, which can also present as echolucent spaces anterior to the right ventricle. [1] Understanding the anatomical relationship of the space to the diaphragm, the liver, and the midline linear echo of the falciform ligament can help to distinguish ascites from pericardial fluid accumulation as in this case. The pericardium, diaphragm and parietal peritoneum separates the heart from ascitic fluid. [1]

On transthoracic echocardiography, falsiform ligament can be seen in the subdiaphragmatic view. Identification of falsiform ligament helps in the differential diagnosis of echofree space around the right heart border and the liver. Ascites is always recognized by visualizing falsiform ligament in this echolucent space. [2]

Transesophageal echocardiographic is definitely diagnostic in pericardial effusion, but comprehensive TEE examination will give proper diagnosis after ruling out other things.


1D'Cruz IA. Echocardiographic simulation of pericardial effusion by ascites. Chest 1984;85:93-5.
2Cardello FP, Yoon DH, Halligan RE Jr, Richter H. The falciform ligament in the echocardiographic diagnosis of ascites. J Am Soc Echocardiogr 2006;19:1074.e3-4.