Acute Myeloid Leukemia Presenting as Effusive Constrictive Pericarditis

Figures

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  Figure 1. Twelve-lead electrocardiogram showing sinus tachycardia with low-voltage QRS.

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  Figure 2. Posteroanterior chest radiograph showing cardiomegaly.

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  Figure 3. (A, B) TTE, parasternal views, showing a large pericardial effusion with diastolic right ventricular free wall collapse (arrow). (C) Pulsed-wave Doppler of mitral inflow showing a significant variation of the E-wave velocity (arrows) with inspiration consistent with tamponade. (D) Dilated inferior vena cava with no respiratory variation (plethora) consistent with tamponade.

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  Figure 4. Follow-up TTE after pericardial fluid drainage with findings supportive of constriction. (A) Parasternal long-axis view with minimal residual pericardial fluid. (B) Short-axis view showing interventricular septal shift toward the left. (C) Mitral inflow Doppler showing respiratory variation of the mitral inflow E-wave velocity. (D, E) Medial and lateral tissue Doppler of the mitral annulus demonstrating pulsus reversus of the annular E′-wave velocities with medial E′ greater than lateral E′. (F) Dilated inferior vena cava with no respiratory variation (plethora) consistent with constriction. (G) Pulsed-wave Doppler of a hepatic vein showing diastolic flow reversal.

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  Figure 5. (A) CMR cine frame demonstrates a persistent, circumferential, hemorrhagic pericardial effusion with heterogeneous appearance and fibrinous stranding (arrow) adjacent to mostly right ventricular free wall. The pericardial effusion appears gray on the cine frame. (B) On the CMR phase-sensitive reconstructed late gadolinium enhancement image, the pericardial effusion appears black. The parietal pericardium is thickened and enhanced with late gadolinium imaging (arrows).

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  Figure 6. (A) CMR native T1 map shows a hemorrhagic pericardial effusion (PE) with a native T1 similar to blood in the left ventricle (LV; 1,845 vs 1960 msec). Most transudative pericardial effusions exhibit native T1 similar to water, about 2,900 msec for this pulse sequence. There is also epicardial fat noted with a very low T1 (∼160 msec, dark color). (B, C) Free-breathing real-time cines in the short-axis orientation reveal interventricular septal flattening during inspiration consistent pericardial constraint and/or ventricular interdependence. Short-axis slices of the ventricles show septal shift with the respiratory cycle because of ventricular interdependence. The ventricular septum shifts toward the left ventricle with inspiration (B) and toward the right ventricle with expiration (C) The early diastolic relative septal excursion during deep breathing measured from real-time short-axis cines is 16.6% (abnormal >11.8%), consistent with constriction.

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  Figure 7. (A) Follow-up TTE, parasternal long-axis view, after 4 months of colchicine and decitabine treatment for AML showing a small residual pericardial effusion. (B) M-mode imaging of the parasternal long-axis (C) showing paradoxical septal shift but (D) with no significant mitral E-wave variation.

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  Figure 8. Chest computed tomography showing a small pericardial effusion but no pericardial thickening or calcification that would suggest constriction.