Calcific Constrictive Pericarditis: What to Do?
A 77-year-old male presents to outpatient clinic with chronic dyspnea on exertion (NYHA Class II symptoms), lower extremity swelling, and intermittent chest pain on exertion. He describes his chest discomfort as occasionally pleuritic and non-positional. Past medical history includes coronary artery disease (CAD) status-post multiple stents, chronic diastolic heart failure, permanent atrial fibrillation with two failed cardioversions, hypertension, hyperlipidemia, and type II diabetes mellitus. He has worked in a paper mill for many years.
The chest pain began in 2017 with associated nasal congestion. He presented to a local hospital and was diagnosed with new onset right sided pleural effusion. He underwent thoracentesis with recurrence of effusion in 3-4 months. He was subsequently discovered to have interstitial lung disease and calcified pleural plaque related to asbestos exposure.
On exam, he was in no acute distress. He had a positive jugular venous distention and positive Kussmaul's sign. He had decreased breath sounds at right lung base without any wheezing or crackles. Pulse was irregularly irregular with a diastolic murmur and a pericardial knock. He also had 2+ bilateral pitting edema.
Labs showed: normal complete blood count and normal comprehensive metabolic panel. Erythrocyte sedimentation rate (ESR) was 28 which was slightly elevated.
What is the best recommended next step in management?