An odd case of giant intrapericardial mass

Abstract A 70–year–old man was admitted to our emergency department (ED) for chest pain during the previous 3 days variable with breathing and chest movements. Clinical history included chronic coronary syndrome (2018: transient ST–segment elevation treated with PTCA + DES on proximal LAD), chronic kidney disease (CKD), chronic myeloid leukemia, chronic hepatitis B and C. At the ED an ECG showed atrial fibrillation (AF) with medium ventricular response (100 bpm). Transthoracic echocardiogram (TTE, Fig.1a, 1b, 1d) and transesophageal echocardiogram (TEE, Fig.1c) revealed a voluminous roundish iso–ipoechoic mass (“red star”) with regular and hyperechoic margin, apparently intrapericardial and close to the lateral wall of the left atrium, measuring 8 x 5.5 x 2 cm, without infiltrating the wall and without obstructing pulmonary veins return. Minimal pericardial effusion was present. On contrast TTE (Sonovue) there was no uptake of contrast agent (Fig.2a). The MRI (Fig.2b) showed a heterogeneous formation with slight late contrast enhancement consistent with intrapericardial hematoma. We submitted the case to cardiac surgeons who recommended close echocardiographic follow–up, given the absent hemodynamic impact of the mass. Management of pericardial hematoma in this clinical setting is controversial, it has limited available evidence, and thus there is significant variability in clinical practice. Due to AF, anticoagulant therapy with warfarin (imbricating with heparin) was initiated; anti–inflammatory treatment with ibuprofen and colchicine was prescribed. The patient was discharged in good general conditions. One month later we scheduled a follow–up visit with echo: a clear volumetric reduction of the intrapericardial hematoma was documented (Fig.3) and the patient reported a complete disappearance of the symptoms. We chose this case to highlight the importance of using all cardiac imaging techniques in the differential diagnosis of cardiac/pericardial masses; among others, MRI certainly represents the gold standard in this field but also Sonovue contrast echocardiography is definitely useful. Furthermore, a multidisciplinary approach involving clinical cardiologists, radiologists and cardiac surgeons is essential.