Diagnosis and treatment of effusive-constrictive pericarditis: a case report

Abstract

Background: Effusive-constrictive pericarditis (ECP) is a rare syndrome involving pericardial effusion and concomitant constrictive pericarditis. The hallmark is a persistently elevated right atrial pressure of >10 mmHg or reduction of less than 50% from baseline despite pericardiocentesis. Aetiologies include radiation, infection, malignancy, and autoimmune disease.

Case summary: A 71-year-old man with a history of atrial fibrillation, obesity, hypertension, obstructive sleep apnoea, managed with continuous positive airway pressure presented with acute pericarditis complicated by pericardial effusion leading to cardiac tamponade. He was diagnosed with ECP after pericardiocentesis and was managed surgically with a pericardial window.

Discussion: Early detected cases of ECP can be managed by medical therapy. Therapeutic interventions include pericardiocentesis, balloon pericardiostomy, and pericardiectomy. This report describes a case of new-onset congestive heart failure secondary to ECP.

Keywords: Cardiac tamponade; Case report; Constrictive; Pericarditis.

Figure 1

Electrocardiogram on presentation: sinus rhythm, heart rate 98 beats per minute, with low voltage.

Figure 2

Transthoracic echocardiogram in parasternal long-axis view on presentation showing a large circumferential pericardial effusion with mild right ventricular diastolic collapse suggestive of early cardiac tamponade. LA, left atrium; LV, left ventricle; P, pericardium; PE, pleural effusion; RV, right ventricle.

Figure 3

(A) Right atrial pressure on first admission before pericardiocentesis with markedly elevated mean right atrial pressure of 34 mmHg (nl 0–8 mmHg). (B) Right atrial pressure after drainage of pericardial effusion and with pericardial. Persistent elevated mean right atrial pressure of 13 mmHg with a rapid y-descent (red arrow) reflecting constrictive disease. The rapid y descent indicates absence of tamponade physiology.

Figure 4

Cardiac magnetic resonance imaging (A) delayed enhancement imaging in short-axis shows circumferential pericardial oedema. (B) Real-time cine imaging in long-axis demonstrates slightly enlarged atria and ventricles have a tubular configuration suggestive of pericardial constriction. (C) Real-time cine imaging in short-axis with (D) diastolic interventricular septal flattening on deep inspiration indicating increased ventricular coupling which diagnosis of pericardial constriction. IVS, interventricular septum; LA, left atrium; LV, left ventricle; P, pericardium; PE, pleural effusion; RA, right atrium; RV, right ventricle.

Figure 5

(A) Transthoracic echocardiogram showing mitral valve doppler with an E/A ratio of 1.5 which indicates restrictive mitral inflow velocity. (B) Pulsed wave Doppler of the hepatic vein shows end-diastolic reversal of the blood flow with end-expiratory increment. (C) The inferior vena cava is dilated (red arrow, diameter >21 mm) and does not collapse during inspiration, suggesting an elevated right atrial pressure of 20 mmHg. (D) Tissue Doppler showing the increased medial and reduced lateral mitral annular velocity which is typical for constrictive pericarditis. The constricting pericardium limits movement of the lateral aspect of the heart, while movement is still preserved at the septum. Medial E′ velocity: 14.4 cm/s (red arrow) and lateral E′ velocity: 8.5 cm/s (blue arrow).