Constrictive Pericarditis: Pericardiectomy Didn't Fix the Problem!
A 54-year-old Caucasian man presented with worsening dyspnea on exertion, anasarca and a previous computed tomography (CT) chest scan showing calcification around the heart as shown in figure 1. History was significant for acute pericarditis 15 years ago, hypertension and sleep apnea. Echocardiogram and cardiac magnetic resonance imaging confirmed constrictive pericarditis (CP) with normal left ventricular and valvular function. Catheterization showed diastolic equalization of pressures, dip and plateau pattern of right and left ventricular pressures, and a systolic area index of 1.38. He underwent phrenic to phrenic resection of the pericardium. Intraoperatively he had extensive pericardial adhesions and severe calcifications.
Patient was discharged home after successful post-operative recovery but continued to require diuretics. He returned to clinic with recurrent symptoms of right heart failure (HF) with ascites, pedal edema, and new atrial flutter. Figure 2 is a comparison of echocardiograms pre- and post- operatively, 4 weeks apart.
Which of the following is the possible etiology of his recurrent right HF symptoms?