Quick Fire Cases
Christina Arraut-Hernandez, MD
Advanced Cardiac Imaging Fellow
University of Florida
Christina Arraut-Hernandez, MD
Advanced Cardiac Imaging Fellow
University of Florida
Hussain Khalid, MD
Clinical Assistant Professor of Cardiology
University of Florida
Arleen Ramirez Jimenez, MD
Cardiac Advanced Imaging Fellow
University of Florida
We present a 36-year-old male with a history of opioid use disorder, essential hypertension, rheumatoid arthritis, and pulmonary embolism/deep vein thrombosis on oral anticoagulation with Apixaban who presented to the ER after a syncopal episode. The use of multimodality imaging led to diagnosis of located pericardial effusion with constrictive physiology. The patient underwent an initial TEE-guided drainage of the pericardial effusion through a subxiphoidal window. Given persistent RV constriction with elevated mean diastolic gradients across the tricuspid valve, the surgery was converted to a full sternotomy for partial cystectomy with relief of RV constriction by gross inspection and TEE guided assessment decrease in mean diastolic gradient across the tricuspid valve. Drainage yielded “a dark serous fluid and pale-yellow cottage cheese-like material’, confirmed by pathology to be an “organizing fibrin with cholesterol cleft granuloma”.
Diagnostic Techniques and Their Most Important Findings: CTA revealed a focal pericardial fluid collection compressing the basal-to-mid right ventricle with IVC dilation. TTE allowed partial visualization of this fluid collection, demonstrating a constrictive physiology with RV compression and LV inflow obstruction. Cardiac MRI demonstrated the presence of a complex loculated pericardial collection causing significant mass effect(Figure 1). The fluid collection appeared hyperintense to the myocardium on T1-weighted images and hyperintense to the myocardium on T2-weighted sequences, suggesting this was not a simple pericardial effusion and also less likely a pericardial cyst (Figure 2). There was no evidence of pericardial inflammation on T2-weighted sequences or on late gadolinium enhancement (LGE) sequences (Figure 3).
Learning Points from this Case:
Cholesterol pericardial disease is rarely reported in literature. Typically, its characterized by a slowly developing large pericardial effusions that’s not usually associated with constrictive physiology. However, in the presence of small amounts of blood, and dense adhesions pericardial constriction can less commonly develop. Although transthoracic echocardiogram (TTE) offers accessible high temporal resolution that allows hemodynamic assessment, its sometimes limited in its field of view. Cardiac MRI provides superior visualization and delineation of the pericardium allowing for better tissue characterization without the need for ionization radiation.
This case highlights the importance of a multimodality imaging approach to evaluation of pericardial disease, more so a rare case of cholesterol pericardial disease and the benefits of visualization of pericardial pathology and tissue characterization by MRI—particularly for focal and loculated pericardial disease.
