A 45-year-old man was referred to our cardiology department with pleuritic chest pain without any symptoms of heart failure. Transthoracic echocardiography (TTE) revealed moderate systolic dysfunction of the left ventricle (LV) due to wall motion abnormalities of lateral and posterobasal segments of the LV associated with localized pericardial effusion which was first suspected to be a pseudoaneurysm. Ejection fraction of the LV was approximately 35%. The systolic function of the right ventricle was normal and both the atria were not dilated. Ventriculography revealed dyskinesia of the basal segments of the lateral and posterior walls and no signs of extravasation of the contrast agent. Surprisingly, there was no significant coronary artery disease on coronary angiography explaining the findings above.

We performed cardiac magnetic resonance (CMR) imaging which confirmed moderate systolic dysfunction of the LV and nonischemic pattern of non-homogenous late contrast agent enhancement of the thin lateral and posterior walls without myocardial edema (Fig. 1, Additional file 1: Movie File 1). The lateral wall of the LV was 3 mm thin compared to the interventricular septum which was 12 mm thick. The LV was not dilated with an end-diastolic volume of 159 ml. The aforementioned pericardial effusion was not apparent, instead, CMR raised suspicion of pleural malignant mesothelioma adjacent to the affected myocardium.

This diagnosis was subsequently verified by computed tomography (CT) imaging (Fig. 2) and confirmed with transparietal CT navigated biopsy of the pleura. Positron emission tomography (PET) was performed finding fluorodeoxyglucose (FDG) avid thickening of the pleura in close proximity to the pericardium. No significant invasion into the surrounding structures or the chest wall was apparent. The patient was referred to the oncology department to advise on further management. Detailed history did not reveal any asbestos or radiation exposure.

While medical therapy for heart failure with telmisartan, bisoprolol, and spironolactone was initiated, dysfunction of the LV persisted and the patient remained asymptomatic. After 4 cycles of lower-dose less-toxic neoadjuvant chemotherapy with carboplatin and pemetrexed, the patient underwent extrapleural pneumonectomy with resection of the diaphragm and pericardium and subsequent hyperthermic intrathoracic chemotherapy with cisplatin. There was a need for inotropic support and blood transfusion shortly after the surgery, uncomplicated weaning led to extubation the fourth post-operative day. The chest drain had to be reinserted due to development of tension fluidothorax. The patient developed signs of heart failure which was managed with diuretics shortly thereafter. He was discharged the twentieth post-operative day and was recommended for active surveillance as he did not qualify for adjuvant chemotherapy or radiotherapy due to LV dysfunction. Histopathology revealed tumor free margins of the resected material, therefore, no direct invasion of the tumor into the myocardium was expected, leaving the localized fibrosis of the LV unexplained.

After the surgery, systolic function of the LV deteriorated and the patient tolerated only very low doses of medical therapy for heart failure due to symptomatic hypotension. LV dysfunction thus led to reducing the dose of neoadjuvant chemotherapy; moreover, it made our patient ineligible to receive any adjuvant treatment. Follow-up PET revealed FDG avid tissue in the site of the resected tumor. It could not be determined whether it represents just postoperative fibrosis or is a sign of recurrence of the tumor. One year after the surgical treatment, echocardiography revealed severe LV systolic dysfunction, ejection fraction was approximately 20–25%, and dysfunction of the right ventricle which was not associated with any significant increase in pulmonary arterial pressure. The patient is in functional class NYHA (New York Heart Association) III and was able to return to his job despite significant exertion intolerance. Given the worsening systolic dysfunction of the LV, dysfunction of the right ventricle and symptoms of heart failure, the patient will be referred to assess his eligibility for a biventricular assist device.