Constrictive Pericarditis Due to Metastatic Squamous Cell Carcinoma: A Rare and Ominous Condition.

Figures

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  Figure 1. Key Transthoracic Echocardiography Features Consistent With Constrictive Physiology (A) Pulsed-wave Doppler of mitral inflow demonstrating inspiratory decrease in peak E-wave velocity >25%, consistent with dissociation of intrathoracic and intracardiac pressures. (B) Pulsed-wave Doppler of tricuspid inflow showing inspiratory increase in peak E-wave velocity >40%. (C) Tissue Doppler imaging at the medial mitral annulus demonstrating preserved medial e′ velocity (13.9 cm/s). (D) Tissue Doppler imaging at the lateral mitral annulus showing lateral e′ velocity (8.8 cm/s). Annulus reversus (medial e′ > lateral e′) and annulus paradoxus (normal E/e′ ratio despite elevated left ventricular end-diastolic pressure of 20 mm Hg on left heart catheterization) are present.

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  Figure 2. Invasive Hemodynamic Assessment Demonstrates Classic Findings of Constrictive Pericarditis Mean right atrial pressure was noted to be 19 mm Hg with prominent x- and y-descents. Second panel showing the “square root sign” (dip-and-plateau pattern) is present in both LV and RV diastolic pressure tracings, consistent with rapid early diastolic filling followed by abrupt cessation owing to pericardial constraint. The third panel shows near-equalization of RV and LV end-diastolic pressures of 20 mm Hg and respirophasic discordance of ventricular pressures, signifying ventricular interdependence. LV = left ventricle; RV = right ventricle.

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  Figure 3. Chest CT and CMR Findings of Malignant Constrictive Pericarditis (A) Chest CT axial view showing nodular pericardial thickening. (B) CMR axial T1-weighted turbo spin-echo image demonstrates circumferential pericardial nodular thickening measuring >8 mm. (C) Phase-sensitive inversion recovery sequence with late gadolinium enhancement demonstrates avid pericardial enhancement, consistent with active pericarditis. (D) Dilated inferior vena cava and hepatic vein. (E) T2-weighted dark blood imaging with bright pericardial signal showing active inflammation. (F) Axial T1-weighted turbo spin-echo images acquired immediately after gadolinium administration show circumferential pericardial enhancement, suggestive of active pericardial inflammation. CMR = cardiac magnetic resonance imaging; CT = computed tomography.

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  Figure 4. FDG PET/CT Lesions PET/CT shows FDG-avid left hilar lymphadenopathy (1.6 cm, SUVmax: 4.8) and nodular circumferential pericardial thickening with intense uptake (SUVmax: 9.7), highly suspicious for malignant pericardial metastasis. FDG = fluorodeoxyglucose; PET/CT = positron emission tomography/computed tomography; SUVmax = maximum standardized uptake value.