Chronic pericarditis mimicking a pericardial neoplastic mass

A 57-year-old man with a previous history of myocardial infarction was admitted to the emergency department complaining of chest pain, mild dyspnoea, and lower limb oedema. Serum troponin levels were normal. Computed tomography (Panel A) excluded any acute aortic or pulmonary pathology, but detected mitral annular calcification (black arrow), coronary artery calcifications (black arrowhead), and a large, non-enhancing intrapericardial mass (asterisk) with peripheral calcifications. The lesion appeared to be hypoechoic on trans-thoracic echocardiography and determined left ventricular compression with mild inflow and outflow obstructions. Doppler recordings showed partial respiratory interdependence of transmitral/transtricuspid flows. On magnetic resonance (Panels B and C, see Supplementary data, Figure S1), the pericardial mass presented signal characteristics (patchy hyperintensity in T1-weighted, T2-weighted, and post-contrast images) typical of chronic inflammation. Besides mild left ventricular inflow and outflow obstructions (see Supplementary data, Movies S1 and S2), the right ventricular pericardial thickening (white arrow) and early-diastolic interventricular septal flattening suggested global pericardial constriction. Cardiac catheterization revealed right coronary artery chronic occlusion, left anterior descending artery stenosis, as well as ‘dip-and-plateau’-shaped diastolic pressures with end-diastolic equalization, confirming the constrictive physiology. The patient underwent successful surgical coronary revascularization and partial pericardiectomy. Histological analysis of the excised pericardial tissue indicated an inflammatory process, with leucocytic infiltration, fibrin clots, and fibrosis. The patient remained asymptomatic after a 6-month follow-up, without further recurrences. Among pericardial masses, chronic pericardial inflammation represents a common condition, with variable progression to pericardial stiffening and constriction. Multimodality cardiac imaging provides important diagnostic and prognostic information, helping to differentiate benign from malignant masses and to tailor an appropriate therapy. Conflict of interest: none declared. Supplementary data are available at European Heart Journal – Cardiovascular Imaging online.