Case of Effusive Constrictive Pericarditis Crossover to Surgery

A 42-year-old male with no significant medical history initially presented to the emergency room with progressively worsening pleuritic chest pain radiating to his neck. Aside from associated dyspnea, he denied other heart failure symptoms.

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His initial electrocardiogram (ECG) was remarkable for diffuse ST wave elevations, and he underwent urgent coronary angiography which revealed non-obstructive coronary disease. Echocardiography demonstrated a small pericardial effusion. He was subsequently diagnosed with acute pericarditis complicated by a small pericardial effusion on the basis of his symptoms, ECG findings and echocardiography. His initial C-reactive protein (CRP) was 15.1 mg/L. He was discharged on aspirin 650 mg three times daily (for 2 weeks), colchicine 0.6 mg twice daily, and beta blocker.

3 months later – The patient returned with dyspnea on exertion along with abdominal distension and bloating. Computed tomography angiogram (CTA) chest on admission showed a moderate sized pericardial effusion and pericardial thickening and enhancement. Repeat echocardiography demonstrated a large circumferential pericardial effusion, RV diastolic collapse, plethoric IVC, marked respiratory variation of the mitral inflow velocity, features consistent with tamponade physiology.

He underwent emergent pericardiocentesis with drainage of approximately 400 ml of hemorrhagic fluid. He was discharged home on ibuprofen 400 mg three times daily and colchicine 0.6 mg twice daily.

The patient continued to have recurrent chest pains (more than 4 months after his initial presentation) and presented to the pericardial disease clinic for further evaluation. His vital signs were normal with a blood pressure of 137/82 mmHg, heart rate of 96 beats per minute and oxygen saturation levels of 96 % on room air. His physical exam was remarkable for clear lungs, with an elevated jugular venous pulse (JVP) and evidence of a positive Kussmaul's sign with a distinct pericardial knock.

He underwent cardiac magnetic resonance imaging (MRI) which showed a loculated pericardial effusion overlying the RV free wall and findings consistent with effusive constrictive physiology (Figure 1). There was moderate to severe circumferentially increased pericardial signal intensity on delayed-enhancement imaging consistent with pericardial inflammation. He was commenced on triple-therapy with the addition of prednisone 50 mg along with colchicine 0.6mg twice daily and ibuprofen 200mg three times daily.

Figure 1

Figure 1
Figure 1: Cardiac MRI: fat-suppressed delayed enhancement images demonstrate moderate circumferential enhancement consistent with pericardial inflammation.

After being on triple therapy, his repeat MRI (6 months later), showed mild stable circumferential gadolinium enhancement and constrictive physiology. Patient symptoms of chest pain had improved, and inflammatory markers also trended down. Patient was gradually tapered off prednisone and ibuprofen over next 6 months.

After 1 year of his index presentation, patient reported no episode of chest pain, CRP and erythrocyte sedimentation rate (ESR) had normalized, but he continued to have dyspnea on exertion, leg swelling, abdominal distension despite being managed on diuretic. As patient continued to have symptoms of heart failure despite on medical therapy and repeat echocardiography again showed residual constrictive physiology, patient was referred for pericardiectomy.

In May 2019, the patient underwent radical pericardiectomy for constrictive physiology after eventual failure of medical treatment for over 1.5 years. Pathology confirmed fibrinous constrictive pericarditis. After surgery the patient reported losing 25 pounds, marked resolution of right-heart failure symptoms and significant improvement in exercise tolerance.

Which of the following is consistent with effusive constrictive pericarditis?

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