A 64-year-old male presented with dyspnea and new-onset atrial fibrillation. His past medical history was remarkable for a fifty packyear history of smoking, asbestos exposure in his youth, and a family history of two uncles diagnosed with mesothelioma. The patient required oxygen of 6L nasal cannula to sustain a saturation of 92% and maintained a heart rate of 100 beats/min on a diltiazem drip. A chest CT showed tumor contiguous with the pericardium (Fig. 1A). Pleural biopsy was performed and pathology showed epitheliod type malignant mesothelioma (Fig. 1B). Transthoracic two-dimensional echocardiography demonstrated a large pericardial effusion (asterisks) with significant pericardial wall thickening (arrows), indicative of tumor extension from the pleura into the pericardium (Fig. 1C, D). Due to worsening dyspnea and the large pericardial effusion, the patient underwent pericardiocentesis with removal of 1000 cc of serosanguinous fluid. The patient's clinical status, however, continued to deteriorate, and the goals of care were altered to comfort care.Although unique cardiac findings have been reported in conjunction with malignant pleural mesothelioma, pericardial involvement occurs frequently. 1,2 It has been noted that approximately 50% of patients with malignant pleural mesothelioma have pericardial involvement based on the echocardiographic findings of pericardial effusion, thickening, calcification, or constriction physiology. 3 Autopsy studies have shown an even greater percentage of cardiac involvement in patients with malignant pleural mesothelioma. 2 Although symptoms of chest pain, dyspnea, and fatigue are generally attributed to pleural disease, echocardiography has been shown to assist in differentiating cardiac manifestations from progressive pulmonary involvement. 2 This case illustrates the echocardiographic findings of pericardial involvement by malignant pleural mesothelioma. Figure 1. (A) Infused chest CT scan depicting abutment of the right-sided pleural mesothelioma with the pericardium. (B) Pleural biopsy demonstrating infiltrative epitheliod type malignant mesothelioma cells. (C) and (D) Short-axis and apical four chamber views demonstrating a large pericardial effusion (asterisk marks) and significant pericardial wall thickening (arrow).