Right ventricular dysfunction after pericardiectomy for tuberculous constrictive pericarditis: A case report

Abstract

This case report provides a peculiar case of tuberculous constrictive pericarditis (TCP) who presented with right ventricular dysfunction after pericardiectomy. Right ventricular dysfunction is one of the main postoperative complications after pericardiectomy. Rapid and accurate identification of right ventricular dysfunction confirmed by transthoracic echocardiography (TTE), associated with the rapid initiation of diuretics and inotropic therapy is necessary for the patient's complete recovery.

Abstract: TCP is a condition characterized by chronic inflammation and fibrosis of the pericardium. Pericardiectomy is the standard treatment for patients with constrictive pericarditis and persistent symptoms. One possible surgical complication is right ventricle (RV) failure. We report a case of a 44‐year‐old man who developed RV failure after pericardiectomy for TCP. A 41‐year‐old man with no medical history was referred to our hospital due to progressive dyspnea associated with edema of the lower limbs and significant weight loss (30 kg) over the past 5 months. TTE revealed significant pericardial thickening and mild pericardial effusion with normal RV function. Chest X‐ray showed moderate bilateral pleural effusion. The patient underwent pericardiectomy and bilateral pleural drainage. Histopathological examination showed tuberculosis granulomas with caseous necrosis, and antituberculosis medication was initiated. Postoperative TTEs showed normal RV function and mild pericardial thickening. The patient was discharged home after successful postoperative recovery. Three weeks later, the patient was admitted to the emergency department with dyspnea and hypoxemia. TTE revealed RV systolic dysfunction. Chest CT showed a recurrence of moderate pleural effusion, this time loculated, with restrictive atelectasis of the adjacent lung parenchyma. Diuretics and inotropic therapy were initiated, and the patient underwent lung decortication after confirmation of tuberculous empyema. The patient experienced significant clinical improvement. TTE before discharge showed a decreased RV chamber size with improved RV systolic function. The patient was discharged in a stable condition 30 days after admission with a low dose of oral furosemide. Four months after discharge, he remained asymptomatic with good functional status. Pericardiectomy for TCP may carry the risk of developing RV dysfunction. Furthermore, TCP itself may be associated with other complications, such as empyema. We emphasize the importance of conducting a thorough clinical evaluation for patients with TCP, particularly those undergoing pericardiectomy, to mitigate potential adverse outcomes.

FIGURE 1

Preoperative TTE showed normal RV systolic function and small sized RV. (A) Parasternal short axis view; (B) Apical four‐chamber view. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. yellow arrow: significant pericardial thickening.

FIGURE 2

(A) Preoperative chest X‐ray posteroanterior view showing moderate bilateral pleural effusion; (B) Postoperative chest X‐ray posteroanterior view showing absence of pleural effusion.

FIGURE 3

Postoperative TTE 2 showed marked dilatation and low ejection fraction of the RV. (A) Parasternal short axis view; (B) Apical four‐chamber view. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

FIGURE 4

ECG on admission (2 weeks after pericardiectomy) showing sinus rhythm with nonspecific ST‐T repolarization abnormalities (black arrows).

FIGURE 5

TTE of admission of second hospitalization (21 days postoperative) revealed a reduction in RV size with improved RV systolic function. (A) Parasternal short axis view; (B) Apical four‐chamber view. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

FIGURE 6

Chest CT showing moderate bilateral pleural effusion, and significant pericardial thickening. Yellow arrow: significant pericardial thickening; red arrow: bilateral pleural effusion.

FIGURE 7

TTE of the second hospitalization (44 days postoperative) showing RV less dilated than seen previously. (A) Parasternal short axis view; (B) Apical four‐chamber view. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.