What's With the Sniff? Echocardiographic Findings in Constrictive Pericarditis

A 31-year-old male with cystic fibrosis (CF) presented with 5 days of worsening respiratory status as well as increasing abdominal girth, bilateral lower extremity swelling, and 20-pound weight gain. Physical examination revealed fever, scattered pulmonary rales, and a new pericardial friction rub. He was admitted for CF exacerbation secondary to bacterial pneumonia with respiratory sputum cultures eventually growing methicillin-resistant staphylococcus aureus and multidrug resistant pseudomonas. However, despite usual therapies for CF exacerbation, he developed squeezing chest pain and worsening dyspnea. Re-examination revealed jugular venous distention, pulsus paradoxus of 16 mmHg, and more pronounced pericardial friction rub.

Electrocardiogram revealed sinus tachycardia without ST changes. Chest computed tomography showed ground glass and tree-in-bud opacities in the bilateral peri-cardiac regions of the lungs. Urgent transthoracic echocardiogram revealed multiple features concerning for pericardial constriction including thickened pericardium, respiratory variation of the mitral and tricuspid Doppler inflow velocities, ventricular septal shift, and increased diastolic flow reversal on hepatic vein Doppler during expiration (Figure 1A-B). A trivial, circumferential pericardial effusion without evidence of tamponade was also present. Constrictive findings were further confirmed with cardiac magnetic resonance imaging (CMR) revealing thickened pericardium at 7 mm and ventricular interdependence without fibrosis (Figure 1C-D).

Several days of oral colchicine led to resolution of the friction rub and loop diuretics facilitated return to euvolemia. At 3-month follow-up, the patient's echocardiogram and CMR showed continued constriction without effusion.

Figure 1

Figure 1
Figure 1: Paradoxical Septal Motion with Respiratory Variation. [A-B] Apical Four Chamber Transthoracic Echocardiography and [C-D] Short Axis CMR revealing accentuated septal movement towards the left ventricle (yellow arrows) during inspiration [A, C] with significant septal rebound back into the right ventricle (white arrows) during expiration [B,D] indicative of ventricular interdependence and consistent with constrictive pericarditis.

Which of the following echocardiographic findings during inspiration would be expected in constrictive pericarditis?

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