SCMR 22nd Annual Scientific Sessions
Description of Clinical Presentation: A 49-year old female with an unremarkable medical history was referred to cardiology by her primary care physician for increasing fatigue and shortness of breath. Echocardiography revealed a 25 mm thick pericardial effusion, septal shift, a dilated inferior vena cava, an increased respiratory variation of early mitral inflow velocities. A diagnosis of effusive pericarditis was made. The patient underwent pericardiocentesis and started treatment with colchicine and prednisolone. Four months later, the patient had a relapse of the pericardial effusion, this time associated with pleural effusion. Prednisolone was resumed. PET-CT showed an abnormally high 18F-FDG uptake in the pericardium and mediastinal lymph nodes. One month later, the recurrent pericardial and pleural effusions required daily drainage.
Diagnostic Techniques and Their Most Important Findings: The patient was referred for CMR (3T Skyra, Siemens Healthineers, Erlangen, Germany) for evaluation of constrictive pericarditis. CMR identified a mass protruding from the right atrium into the pericardial space, a circumferential pericardial effusion of >20 mm, and bilateral pleural effusions. Native T1 values of the blood pool, pericardial effusion and pleural effusion were 2007 ms, 3596 ms and 3431 ms, respectively. Eighteen minutes after intravenous contrast administration (0.15 mmol/kg gadobutrol, Gadovist®), the T1 values of the blood pool, pericardial effusion and pleural effusion were 330 ms, 266 ms and 1779 ms, respectively. T1 mapping showed a higher excretion of contrast (lower T1) into the pericardial effusion compared to the pleural effusion, which was visualized as a higher apparent extracellular volume fraction (ECV) in the pericardial effusion (84 %) compared to the pleural effusion (7 %). CT-guided biopsy of the pericardium showed atypical cells indicative of angiosarcoma.
Learning Points from this Case:
Cardiac angiosarcoma is the most common histological subtype of the otherwise rare primary cardiac neoplasms. Notable in this case was the apparent difference in excretion of a gadolinium-based contrast agent into the pericardial and pleural spaces, respectively. The difference in native T1 values between the blood pool and pericardial effusion as well as the lower post-contrast T1 of the pericardial effusion make hemopericardium an unlikely explanation for the difference in contrast dynamics. Although not definitive signs, the current findings may be consistent with a higher degree of inflammatory activity in the pericardium compared to the pleural space. The mass, in combination with the abnormally high contrast excretion was noted in the CMR report as suggestive of an active inflammatory process. The use of T1 mapping to quantify contrast dynamics for evaluation of the etiology of pericardial and pleural effusions merits further investigation.