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Epicardial Lipomatous Hypertrophy Mimicking
Pericardial Effusion
Characterization With Cardiovascular Magnetic Resonance
Christopher A. Miller, MRCP; Matthias Schmitt, MD, PhD
A
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62-year-old man with no history of cardiac disease was
referred because of exertional dyspnea. His body mass
index was elevated at 29 kg/m2, and a large cutaneous lipoma
was present on his abdominal wall. Transthoracic echocardiography was performed and initially reported to demonstrate
a moderate-sized global pericardial effusion (Figure 1 and
Movies 1 and 2). Consideration was given to pericardiocentesis; however, subsequent review suggested that the appearances may have been due to pericardial thickening (Movie 3).
Cardiovascular magnetic resonance (CMR) imaging was
performed for clarification.
A thick layer of epicardial tissue, measuring up to 29 mm
deep, was seen to surround the myocardium on balanced
steady-state free precession (SSFP) cine images (Figure 2 and
Movie 4). On both SSFP and half-Fourier single-shot fast
spin-echo images, signal intensity was high, indeed identical
to that from subcutaneous fat. Using a spatial modulation of
magnetization sequence (“tagging”), the epicardial tissue
appeared to be adherent to the myocardium (Movie 5). The
interatrial septum was also markedly thickened (23 mm), with
sparing of the fossa ovalis, and had the same high signal
intensity (Figure 2C). Fast spin-echo images with a fatsaturation inversion recovery prepulse (which significantly
reduces, or “nulls,” the signal from fat) confirmed the
epicardial and interatrial septal tissue to be fat (Figure 3). A
diagnosis of epicardial lipomatous hypertrophy with concomitant lipomatous hypertrophy of the interatrial septum was made.
The pericardium itself was thin and of normal appearance, with
no evidence of pericardial effusion; indeed, the contrast provided
by the fat allowed for unusually good delineation of the
pericardium, highlighting its cranial extension.
Cardiac lipomatosis is characterized by the accumulation
of nonencapsulated mature adipose tissue caused by hyperplasia of lipocytes. The etiology is unknown, but it may be
associated with obesity and advancing age.1 The most frequent manifestation is lipomatous hypertrophy of the interatrial septum. Massive epicardial lipomatous hypertrophy is
less well documented. Although histologically benign, it has
been reported to cause cardiac tamponade, requiring decompressive pericardiectomy.2 In the presented case, cine imaging
demonstrated normal right heart and caval appearances, phase
contrast imaging with velocity encoding demonstrated normal
systemic venous inflow, and on real-time, free-breathing imaging, ventricular septal motion was seen to be normal, all of
which suggested reassuring cardiac filling physiology.
The case highlights the possibility of mistaking epicardial
lipomatous hypertrophy for pericardial effusion on transthoracic
echocardiography. The tissue characterization provided by CMR
allowed the diagnosis to be made, avoiding the need for invasive
investigation or unnecessary intervention. The functional data
Figure 1. Echocardiographic images. Parasternal
long-axis (A) and short-axis (B) views showing the
echolucent zone surrounding the heart that was
mistaken for a pericardial effusion (asterisk,
dashed line). LV indicates left ventricle; RV, right
ventricle; LA, left atrium; and Ao, aorta.
Received April 21, 2010; accepted September 21, 2010.
From the Cardiovascular Magnetic Resonance Unit, North West Regional Cardiac Centre, University Hospital of South Manchester, Manchester,
United Kingdom.
The online-only Data Supplement is available at http://circimaging.ahajournals.org/cgi/content/full/CIRCIMAGING.110.957498/DC1.
Correspondence to Dr Christopher Miller, Cardiovascular Magnetic Resonance Unit, North West Regional Cardiac Centre, University Hospital of
South Manchester, Southmoor Road, Wythenshawe, Manchester, UK. E-mail [email protected]
(Circ Cardiovasc Imaging. 2011;4:77-78.)
© 2011 American Heart Association, Inc.
Circ Cardiovasc Imaging is available at http://circimaging.ahajournals.org
77
DOI: 10.1161/CIRCIMAGING.110.957498
78
Circ Cardiovasc Imaging
January 2011
Figure 2. Cardiovascular magnetic resonance
SSFP images. Left ventricular outflow tract (A),
short-axis (B), 4-chamber (C), and coronal (D)
images showing extensive epicardial lipomatous
hypertrophy (asterisk) and lipomatous hypertrophy
of the interatrial septum (double dagger). The pericardium (arrows) has a normal appearance, and its
cranial extension is particularly evident (D) due to
the contrast provided by the fat. RA indicates right
atrium; PA, pulmonary artery.
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Figure 3. Cardiovascular magnetic resonance fat
saturation images. In the corresponding fatsaturation fast spin-echo 4-chamber (A, corresponding to Figure 2C) and coronal (B, corresponding to Figure 2D) views, the signal from the
epicardial (asterisk) and atrial septal (double dagger) lipomatous hypertrophy is “nulled,” confirming
its fatty composition.
provided by CMR suggested that the epicardial lipomatous
hypertrophy was not affecting cardiac function.
Disclosures
None.
References
1. Isner JM, Swan CS, Mikus JP, Carter BL. Lipomatous hypertrophy of the
interatrial septum: in vivo diagnosis. Circulation. 1982;66:470 – 473.
2. Myerson SG, Roberts R, Moat N, Pennell DJ. Tamponade caused by
cardiac lipomatous hypertrophy. J Cardiovasc Magn Res. 2004;6:
565–568.
Epicardial Lipomatous Hypertrophy Mimicking Pericardial Effusion: Characterization
With Cardiovascular Magnetic Resonance
Christopher A. Miller and Matthias Schmitt
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Circ Cardiovasc Imaging. 2011;4:77-78
doi: 10.1161/CIRCIMAGING.110.957498
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Copyright © 2011 American Heart Association, Inc. All rights reserved.
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