A 65 year old man with an 18 year history of ischaemic heart disease was admitted with a six week history of severe weakness and orthostatic hypotension. Eight weeks before admission he underwent echocardiography at his local hospital to evaluate exertional dyspnoea; pericardial effusion was suspected. Because of poor ultrasound conduction, ventricular or valvar function could not be evaluated. The patient was treated with diuretics; however, symptoms did not improve and the diuretics were increased to a maximum of 750 mg frusemide daily.

On admission there were no clinical findings of heart failure. The patient had severe orthostatic hypotension and felt vertiginous. Transthoracic echocardiography (A) revealed normal systolic left ventricular function and thickened left ventricular wall. The subepicar-dial space was enlarged to about 2 cm, which appeared not to be completely free from echos suggesting chronic pericardial effusion. Magnetic resonance imaging (B) and computed tomography revealed density of the subepicardial space from fat tissue.

Massive subepicardial lipomatosis should be considered in the differential diagnosis of pericardial effusion suspected by echocardiography, especially in case of poor ultrasound conduction. If there is still doubt, further examination with computed tomography or magnetic resonance imaging should be considered. (ES, epicardial space; LV, left ventricle; LA, left atrium; AO, aortic root; RV, right ventricle.)

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