Dyspnea in a 62-Year-Old Esophageal Cancer Survivor
A 62-year-old female presents with NYHA class III dyspnea. She reports no chest discomfort, orthopnea or paroxysmal nocturnal dyspnea. Cardiovascular risk factors include 40 pack-years of tobacco use. Five months prior, she was diagnosed with a stage IIIA T3N1M0G3 esophageal carcinoma and had undergone neoadjuvant chemoradiation therapy with a CROSS-style regimen for a total dose of 41.4Gy in 23 fractions. Concurrent chemotherapy included carboplatin and paclitaxel. On physical examination, she had a blood pressure of 100/60 mmHg and a regular heart rate of 80 beats/min. Jugular venous pressure was 12 cm H2O; however, no Kussmaul sign was detected. Auscultation revealed a normal S1, normal splitting of S2 and an intermittent pericardial rub without a pericardial knock. Laboratory data included a hemoglobin level of 12.4mg/dL, normal WBC count with differential and platelet count. Electrolytes, blood urea nitrogen and creatinine, lipids and liver enzymes were normal. Both erythrocyte sedimentation rate and high-sensitivity C-reactive protein levels were elevated (42 mm/hr and 87 mg/L, respectively). Electrocardiogram showed normal sinus rhythm and inverted T-waves in the inferior and anterolateral leads. Transthoracic echocardiography revealed new pericardial thickening along with a small circumferential pericardial effusion, LVEF of 52%, right ventricular systolic pressure of 42 mmHg and a mildly dilated inferior vena cava (2.3cm, normal range ≤2.1cm) with no inspiratory collapse. Global averaged left ventricular longitudinal peak systolic strain was -15% (normal more negative than -18%). Doppler assessment with respirometer showed ventricular inter-dependence and diastolic flow reversals in the hepatic veins. Annulus reversus was not present. (Figures 1 and 2)
Which of the following is the most likely diagnosis?