Presentation of Liver Failure From a Pericardial Mass.

June 2019 1 Vinh Q. Nguyen, MD Virginia Workman, MD Kristin Stendahl, MD Lawrence Young, MD Jeffrey Sklar, MD, PhD Lauren A. Baldassarre, MD A 53-year-old man from Central America without any known cardiac history was evaluated for liver transplantation in the setting of cirrhosis. He had placement of an intraperitoneal cavity to superior vena cava (SVC) shunt 6 months prior for refractory ascites without clinical improvement. A pretransplant chest x-ray revealed extensive pericardial calcification (Figure 1), and he was referred to Cardiology. Due to concern for constrictive pericarditis, cardiac magnetic resonance imaging was performed as an outpatient. Steady-state free precession cine imaging revealed mildly impaired biventricular function (left ventricular ejection fraction 52%; right ventricular ejection fraction 41%) with a prominent septal bounce and a large pericardial lesion at the right costophrenic angle (Movie I in the Data Supplement). T2-weighted imaging with fat saturation showed a 13×7.5 cm mass of heterogeneous and intermediate signal intensity, with a central core of increased signal, and significant architectural distortion of the right-sided chambers (Figure 2A). A thrombus was also seen to be associated with the intraperitoneal to SVC shunt in the SVC and the right atrium. T1-weighted imaging with fat saturation showed an intermediate signal intensity of the pericardial structure (Figure 2B). First-pass perfusion showed a nonvascularized structure with absent contrast uptake (Movie II in the Data Supplement). Late gadolinium enhancement imaging using phase-sensitive inversion recovery revealed the lesion as a large fluid-filled cyst with internal septations and overlying wall enhancement (Figure 3). Steadystate free precession cine of the SVC-right atrial sagittal plane was performed to further evaluate the catheter-associated thrombus (Movie III in the Data Supplement), which was confirmed on late gadolinium enhancement using a prolonged inversion time of 600 ms to selectively null avascular tissue (Figure 4). Based on the cardiac magnetic resonance findings, the patient was admitted for anticoagulation and surgical planning for removal of the mass, presumed to likely be a pericardial cyst based on the cardiac magnetic resonance imaging. Pericardial cysts are uncommon findings with an incidence of 1 in 100 000.1 It is typically seen in the fourth and fifth decade of life and comprised of 7% mediastinal masses and 33% of mediastinal cyst.2 The most common location is at the right cardiophrenic angle. The majority of cases are found incidentally and are benign. However, complications may be present in large cysts that cause cardiac compression. The most common location is at the right cardiophrenic angle. The majority of cases are found incidentally and are benign. However, complications may be present in large cysts that cause cardiac compression Laboratory profile was notable for leukocytosis 18 000/μL (89% neutrophils), sodium 124 mmol/dL, blood urea nitrogen 49 mg/dL, and creatinine 1.4 mg/dL. Liver profile showed aspartate aminotransferase 17 U/L, ALT 30 U/L, alkaline phosphatase 234 U/L, international normalized ratio 1.2, total bilirubin 2.1 mg/dL, total protein 8.1 g/dL, and albumin 3.8 g/dL. A diagnostic paracentesis showed a serum© 2019 American Heart Association, Inc. CARDIOVASCULAR IMAGES