Although pericardiocentesis is a relatively safe procedure, there are some hazards, particularly when hemorrhagic fluid is aspirated. Having the opportunity to outline the space from which the fluid is withdrawn is of particular interest in this situation. A current technique of echocardiography with contrast enhancement involves injection of a few milliliters of agitated saline solution or reinjection of blood-stained fluid. Performing this procedure, we repeatedly observed a weak and inhomogeneous echo contrast; therefore, we evaluated the applicability of the ultrasound contrast medium SH U 454 (Echovist Schering, Berlin, Germany) for contrast enhancement in hemorrhagic pericardiocentesis. In all patients, pericardiocentesis was performed in a supine position by a subxiphoid approach. A Teflon catheter/needle unit attached to a syringe containing a few milliliters of contrast medium was introduced in the usual way. On the return of hemorrhagic fluid, 1-2 ml of Echovist was injected to provide contrast from the space from which it had been aspirated. We observed excellent contrast clearly outlining the pericardial space through the injection of 1-2 ml of contrast medium. No adverse or side effects were seen resulting from Echovist injection to the pericardial sac. In conclusion, contrast echocardiography appears to be a useful tool to secure the correct position of the needle during pericardiocentesis of hemorrhagic or loculated effusions. It is suggested that injection of Echovist should be considered whenever the contrast obtained by the conventional technique is poor and inconclusive.