Primary pericardial malignant mesothelioma (PPMM) is a rare malignancy arising from the serous mesothelial lining of the pericardium. These neoplasms are aggressive, pose diagnostic difficulties, and have a poor prognosis. The median survival is less than six months. Presenting symptoms are non-specific and include fatigue, dyspnea, and low-grade fever. Given the nature of presenting symptoms, it is imperative that appropriate imaging, tissue sampling, and histological analysis are undertaken to establish a clinical diagnosis. In cases of localised disease, surgical resection remains the primary treatment. In advanced disease, chemotherapy or palliative procedures may be beneficial. We describe two cases of PPMM and provide an update and guidance on the contemporaneous management of this challenging condition.