Multimodality Imaging of Right Atrial Rupture Secondary to Pericardial Metastasis of Breast Cancer

A 53-year-old woman with a 3-month history of breast cancer was diagnosed with metastatic pericardial effusion. The patient underwent pericardial drainage and intrapericardial injection of cisplatin (20 mg/day on days 1, 3, 7, and 9), and the effusion disappeared 2 weeks later. Routine transthoracic echocardiography showed an anechoic cavity with low-velocity flow on the right side of the pericardium (Figure A) 6 months later. Transesophageal echocardiography revealed a large rupture of the lateral right atrial (RA) wall (biplane imaging: 4.5×2.1 cm, full-volume imaging: 13.6 cm²), low-velocity bidirectional flow through the rupture, a pseudoaneurysm confined by the parietal pericardium, and a hypoechoic mass attached to the parietal pericardium (Figure B–D; Supplementary Movie). Delayed enhanced cardiovascular magnetic resonance imaging with long T1 (600 ms) confirmed the RA rupture and the pseudoaneurysm, and also presented uneven late gadolinium enhancement at the outer edge of upper end of the mass and no enhancement at the lower end, suggesting that the mass was a mixture of a metastatic pericardial tumor and thrombus (Figure E). We speculated that the metastatic pericardial tumor caused the RA rupture, and that adhesive pericarditis after metastatic pericardial effusion led to loculated hemopericardium and thus formation of the pseudoaneurysm. The patient refused surgery because of poor overall health and died 7 months later.

Figure.

(A) Transthoracic echocardiography images show a cavity (*) on the side of the pericardium. (B) Biplane, (C) full-volume, and (D) PW Doppler images of transesophageal echocardiography show the RA rupture, the pseudoaneurysm (*), the mass (triangle) and bidirectional flow through the RA rupture. (E) Delayed enhanced cardiovascular magnetic resonance image with long T1 (600 ms) shows the RA rupture, the pseudoaneurysm (*), and gadolinium enhancement in the mass (arrow). PW, pulsed wave; RA, right atrium.

Cardiac rupture is a rare but dangerous complication of invasive cardiac neoplasm. This is the first reported case of RA rupture secondary to cardiac metastasis of breast cancer that was accurately diagnosed by multimodality imaging.

Declaration of Conflicts of Interest

None to declare.

IRB Information

The First Hospital of China Medical University Ethics Committee, AF-SOP-07-1.1-01.

Supplementary Files

Supplementary Movie. Biplane imaging of the RA rupture on transesophageal echocardiography.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-21-0251