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Number 07-21 An unexpected cause of ascites

Case from: Jonathan R Dalzell, Nicola Johnston, Adrian J Brady, Giles Roditi. Departments of Cardiology/Radiology, Glasgow Royal Infirmary, Glasgow, UK

Clinical history: A 31 year old male with a 2 year History of recurrent ascites, peripheral oedema and deranged LFTs. Budd-Chiari syndrome suspected. Proteinuria noted so Renal MRA requested to exclude renal vein thrombosis

Renal MRA findings: Dilated veins (IVC, hepatic, renal) on late phase images (red arrow). Initial MRI pilot images showed the right heart was grossly enlarged (blue arrow). Action: CMR was performed to investigate this further.

Cine CMR: Dilated RA. Severe TR. “Atrialisation” of RV (Ebstein's anomaly - cine image bottom right). Paradoxical diastolic bowing of inter-ventricular septum toward the LV indicating high right sided pressures (cine image bottom left). Small pericardial effusion and mild mitral regurgitation.

Diagnosis: The cause of the ascities was Ebstein's anomaly. She underwent tricuspid valve replacement and bidirectional cavopulmonary connection.

Perspective: An incidental finding on abdominal MRI above the diaphragmn was clarified rapidly with CMR.

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