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Journal of the American College of Cardiology Vol. 56, No. 15, 2010© 2010 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00P

IMAGES IN CARDIOLOGY

Neoplastic Pericardial Effusion InducesFunctional Nonvalvular Mitral Valve StenosisPeter Bernhardt, MD,* Armin Imhof, MD,* Johannes Schwaab, MD,† Jochen Balbach, MD,‡Daniel Walcher, MD,* Jochen Spie�, MD,* Mathias Schmid, MD§

Ulm, Germany

rom the *Department ofnternal Medicine II,niversity of Ulm, Ulm,ermany; †Department ofathology, University oflm, Ulm, Germany;Department of Cardiacurgery, University of Ulm,lm, Germany; and theDepartment of Internaledicine III, University oflm, Ulm, Germany.anuscript receivedovember 16, 2009;

evised manuscript receivedovember 30, 2009,

ccepted December 8, 2009.

We describe a 53-year-old man with primary diagnosis of non–small-cell lung canceradmitted to the hospital with progressive dyspnea. Transthoracic echocardiographyrevealed a nonechodense pericardial mass (PM) (Online Video 1) and secondary

obstruction of the mitral orifice. Cardiac magnetic resonance imaging showed an inhomoge-neous mass lateral of the left atrium (LA) and left ventricle (LV) (Online Video 2) causing amitral valve (MV) stenosis (A and B). No contrast uptake of the mass could be seen on first-pass cardiac magnetic resonance perfusion (C), but diffuse and sparse contrast uptake by lategadolinium enhancement (D). A mean pressure gradient of 7 mm Hg and a maximal pressuregradient (PG) of 16 mm Hg (E) were found by echocardiography. The valvular opening wasrestricted to 1.2 cm2 as assessed planimetrically by cardiac magnetic resonance imaging (F).Histology of the effusion showed large atypical cells with prominent nuclei and an increasednucleus-cytoplasm-ratio adequate to a pleural manifestation of the carcinoma (G). MPG � meanpressure gradient; RA � right atrium; RV � right ventricle; VTI � velocity time integral.

ublished by Elsevier Inc. doi:10.1016/j.jacc.2009.12.077