Management of Chronic Idiopathic Pericardial Effusions - Part II | Patient Case Quiz

Editor's Note: This is the second half of a two-part Patient Case Quiz. Go to Part I.

Case B Presentation: A 32 year old female with no past medical history presents to your clinic for a second opinion regarding her chronic pericardial effusion. The effusion was discovered on an echocardiogram performed six years ago for palpitations which are no longer problematic. Over the past year, she has developed central chest pain that typically lasts for 1 minute and occurs five to ten times daily. At baseline, she is very active and recently underwent an exercise stress test (peaked at 13 METS). Her local physician follows the effusion with yearly echocardiograms (all demonstrating stability in size). She was prescribed a two week course of a non-steroidal anti-inflammatory agent but this has failed to improve her symptoms or reduce the size of the effusion.

Physical exam: Pleasant young female, appears anxious. Blood pressure 134/76, pulse 90, respirations 12. Body mass index 20 kg/meter-squared. Her JVP is 6 cm, lungs are clear with no gallop or murmur. Her PMI is non-displaced, skin is warm, and there is no lower extremity edema. Abdominal exam reveals no organomegaly.

Laboratory testing: Thyroid stimulating hormone normal; Sedimentation rate 5 mm/hr; C-reactive protein 0.3 mg/L; CK-MB negative, Troponin negative. ANA and Rheumatoid Factor were negative. Sodium 138, Potassium 3.8, Chloride 110, Bicarbonate 24, Blood urea nitrogen 7, Creatinine 0.62. She had normal liver enzymes and a normal complete blood count.

EKG: Normal sinus with premature atrial complexes. PR interval is 120 milliseconds, QRS duration is 72 milliseconds. Her corrected QT is 430 milliseconds.

Echocardiogram: The left and right ventricles are normal in size and systolic function. Diastolic function is normal. The estimated right ventricular pressure is normal. The left and right atrial cavities are normal in size. There are no major valvular abnormalities. There is a moderately sized circumferential pericardial effusion measuring 16 mm posteriorly with no right atrial or ventricular diastolic inversion.

Cardiac MRI: No pericardial delayed enhancement.

Case B
Two-dimensional echocardiogram shows a moderate-sized circumferential pericardial effusion (red asterisk). The effusion measures 16 mm.

Video 1: Short Axis

Video 2: Long Axis

How would you manage the chronic idiopathic pericardial effusion?

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