Thread by @OKiamanesh, EFFUSIVE-CONSTRICTIVE PERICARDITIS ** MONTHLY ILLUSTRATIVE CASE **A 55-year-old female marathon runner presents [...]

EFFUSIVE-CONSTRICTIVE PERICARDITIS

** MONTHLY ILLUSTRATIVE CASE **

A 55-year-old female marathon runner presents to clinic w/ 6-months of worsening breathlessness (half-marathon time increased by 30 m).

https://doi.org/10.1002/ehf2.12926

w/ @BadiwalaMD @MakLab_
Consent given.

She had gained 15 kg and swollen legs. Exam showed BP 100/82, HR 74, JVP 15 cm ASA, Kussmaul's sign, marked pedal edema, and clear lungs.

We did a transthoracic echocardiogram to workup right-heart failure. This showed a small‐to‐moderate circumferential pericardial effusion. Look at the thickness and brightness the epicardium. There were classic features of constrictive pericarditis (see next slide).

(A) a dilated inferior vena cava with <50% respiratory variation, (B) a septal mitral annular e’ velocity of 9.5 cm/sec, (C) mild diastolic reversal of the hepatic vein with expiration not meeting diagnostic criteria ...

(D) a leftward ventricular septal shift with inspiration and a diastolic septal shudder by M‐mode imaging of the ventricular septum. These findings suggest constrictive pericarditis.

We performed a right-heart catheterization to diagnose constrictive pericarditis. A dip and plateau sign, ventricular interdependence, and diastolic equalization of all chambers (21 mmHg) were shown by a simultaneous left and right heart catheterization.

We diagnosed EFFUSIVE-CONSTRICTIVE PERICARDITIS. We performed a conventional parietal pericardiectomy that yielded little intraoperative haemodynamic improvement.

Therefore, we performed a pericardial waffle procedure to relieve a thick and constricted epicardium. This resulted in immediate haemodynamic improvement (cardiac index 1.9 to 3.1 mL/min/m2 and right atrial pressure 25 to 8 mmHg).

Teaching point: In rare cases of pericardial constriction, the epicardium (i.e. visceral pericardium) is thickened and calcified. A conventional pericardiectomy removes the parietal pericardium and may not alleviate constriction by the epicardium.