A 73 year old male patient with ischaemic cardiomyopathy and congestive heart failure (New York Heart Association functional class IV) presented with cachexia and chronic pleural effusion. He was sent for abdominal and thoracic computed tomography (CT) scans to rule out malignancy. Aside from cardiomegaly and pleural effusion the CT showed few developmental cysts of the liver but no suspicion of a malignant tumour.

The images were unusual for a distinctive trilaminar contrast density in the inferior vena cava (panel A) that was found 70 seconds after dye injection into the right cubital vein. The opaque bottom layer was explained by a substantial retrograde flow of almost undiluted contrast medium below the level of the right atrium. The middle layer consisted of contrasted blood returning from both renal veins into the inferior vena cava after first passing through the kidneys. The top layer represented poorly contrasted blood mainly returning from the lower extremities.

This study is remarkable because there was almost no admixture between these three distinctly contrasted layers. We attribute this “tricolore phenomenon” of heart failure to the physicochemical properties of the contrast medium in coherence with slow laminar flow secondary to low cardiac output.