Transient Constriction, Cardiac MRI, Gadolinium Enhancement, Biologic Therapy
A 79-year-old former senior triathlete with a history of recently diagnosed diabetes (hemoglobin A1C of 14.4% (normal < 5.7%) and congestive heart failure of two years duration presented for evaluation of pericardial disease.
He had been in excellent health until late 2016, when he was diagnosed with insulin-dependent diabetes and subsequently hospitalized with New York Heart Association (NYHA) stage III congestive heart failure. After subsequent hospitalizations for congestive heart failure, he was referred to a tertiary care center for further evaluation in January 2017.
On examination, his blood pressure was 127/80 mmHg, heart rate was 67 bpm and regular, and he saturated 95% oxygen on room air. His jugular venous pressure was measured at 17cm H20 with a positive Kussmaul's sign. Breath sounds were decreased 1/3 of the way bilaterally. A pericardial knock was present. Examination of the abdomen revealed ascites, and examination of the extremities showed tense edema. Serologic testing was significant for an elevated erythrocyte sedimentation rate (ESR) at 33mm/hr (normal <15mm/hr) and elevated C-reactive protein (CRP) at 14.7mg/dL (normal <0.9mg/dL). NT-ProBNP was elevated at 1104 pg/mL (normal <450 pg/mL). Electrocardiogram (ECG) (Figure 1) and chest x-ray (Figure 2) are shown below.
His echocardiogram showed a septal bounce, shift of the septum leftward during inspiration, tethering of the right ventricle and right atrium during the cardiac cycle, and the Doppler findings in Figures 3 and 4.
Right heart catheterization showed equalization of left and right heart pressures: RA 22 mmHg, RV 37/22 mmHg, PA 34/21 (mean 27) with mean PCWP of 21 mmHg. Cardiac magnetic resonance imaging (MRI) was performed, showing findings consistent with acute pericarditis with constrictive physiology, and a diagnosis of transient constrictive pericarditis (transient CP) was made. The patient was started on ibuprofen, and colchicine. Due to his difficult-to-control diabetes, the patient could not tolerate corticosteroids, and the decision was made to start anakinra 100mg twice daily. On follow-up visits, the patient's symptomatology improved, his ESR and CRP normalized to 2mm/hr and 0.1mg/dL respectively, and he was able to be weaned off of anakinra over a 9-month period. His serial echocardiograms showed resolution of constrictive physiology.
Which of the following MRI findings would you expect in a patient with transient constrictive pericarditis?