From Pericarditis to Pericardiectomy: Management and Outcomes
A 73-year-old man with a past medical history of idiopathic recurrent pericarditis over the last 25 years, atrial fibrillation with pulmonary vein isolation, and mild to moderate mitral regurgitation presents to clinic with progressively worsening dyspnea on exertion, orthopnea, and NYHA class II symptoms. On physical exam, jugular venous distention is noted to the jaw at 45 degrees, a pericardial knock is auscultated, and 2+ peripheral edema with hepatomegaly is observed.
ECG with normal sinus rhythm and low voltage. Transthoracic echocardiogram shows normal left ventricular systolic function with an ejection fraction of 55% (Figure 1). There is a diastolic bounce of the interventricular septum noted. The IVC is dilated at 3.5 cm and does not collapse with respiration.
Figure 1: ECG demonstrates NSR with low voltage.
Cardiac MRI is obtained and confirms a diastolic septal bounce, respirophasic septal shift, and diastolic restraint (Figures 2 and 3). There is no pericardial delayed gadolinium enhancement to suggest acute or sub-acute pericarditis. Invasive catheterization demonstrated findings consistent with constriction.
Figure 2: Cardiac MRI demonstrated a diastolic septal bounce, respirophasic septal shift and diastolic restraint.
Figure 3: There is no pericardial hyper-enhancement and no evidence of acute pericarditis.
Pericardiectomy was performed at a high volume surgical center and post-operatively the patient's symptoms improved. He completed cardiac rehabilitation and was able to return to golfing without symptoms within 6 months of the surgery.
Which of the following patient characteristics is not associated with improved long term outcomes after pericardiectomy in patients with chronic pericardial constriction?