A 59-year-old female was admitted for heart failure. She had previous history of breast cancer 20 years before, treated by mastectomy and radiotherapy without recurrence.
The transthoracic echocardiogram showed signs of constrictive physiology and a cardiac magnetic resonance (CMR) was performed for an in-depth assessment of the pericardium. A diffuse thickening of pericardial layers (yellow arrowheads) with adhesions (asterisks) to the right ventricle was observed (Panels A and B). Furthermore, pericardium showed a diffuse and intense late gadolinium enhancement (LGE) (blue arrows, Panel C).
The patient underwent pericardiectomy. During the intervention, the right ventricle suffered a laceration that was repaired with a patch.
The presence of LGE, suggesting neovascularization that is usually associated with active inflammation, was discordant with other findings as normal C-reaction protein and history of chest radiotherapy, which are related with low-inflammation processes. These discordant findings were solved by the histological assessment because breast cancer metastatic cells all over the pericardial tissue were found (Panel D).
LGE is uncommon in chronic constrictive pericarditis secondary to chest radiotherapy, being described in cases of acute post-radiotherapy constrictive pericarditis. Therefore, the tissue invasion by metastatic cells likely explained the pericardial neovascularization found in the CMR.
In conclusion, chronic constrictive pericarditis with an intense and diffuse LGE in a long-term survivor of breast cancer should raise the suspicion of pericardial metastatic recurrence. Moreover, an accurate description of pericardial adherences could help to predict the risk of lacerations during pericardiectomy.
