Recurrent Pericarditis Evolving to Constrictive Pericarditis and Pericardiectomy Over 18 Years.

Figures

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  Visual Summary. Timeline Depicting Disease Progression, Treatments, Imaging Findings, Laboratory Results, and Complications CCF = Cleveland Clinic Foundation; CP = constrictive pericarditis; CRP = C-reactive protein; CT = computed tomography; ECG = electrocardiogram; EF = ejection fraction; ESR = erythrocyte sedimentation rate; HF = heart failure; LGE = late gadolinium enhancement; MRI = magnetic resonance imaging; NSAID = nonsteroidal anti-inflammatory drug; RA = right atrium; TTE = transthoracic echocardiography; US = ultrasensitive.

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  Figure 1. Features of Constrictive Pericarditis (A) Apical 4-chamber view with increased pericardial thickening and tethering of the mitral and tricuspid annuli (red arrows); and left ventricle cylindrical (blue arrow) and right ventricle conical (yellow arrow) deformities. (B) Tissue Doppler of mitral annulus lateral e′ is lower than medial e′ velocity, indicating annulus reversus. (C) M-mode through the interventricular septum showing respirophasic shift with increase of RV cavity with inspiration (Insp) and decreased in RV cavity with expiration (Exp) and reciprocal changes in LV cavity. Note septal bounce and shudder in interventricular septum (white arrows). (D) Short-axis view of the LV showing respirophasic shift of the interventricular septum and flattening of the septum on inspiration (Insp) (white arrow) compared to expiration (Exp) (red arrow). (E) Pulsed-wave Doppler of mitral inflow showing significant respirophasic variation from expiration to inspiration (>38%). (F) Pulsed-wave Doppler of hepatic vein showing increased expiratory end-diastolic reversal velocity (white arrow). (G) IVC dilated at 2.8 cm. (H) Global longitudinal LV strain showing “hot septum” sign and strain…

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  Figure 2. Magnetic Resonance Imaging With Late Gadolinium Enhancement (A) Short-axis and (B) 4-chamber views demonstrating severe pericardial circumferential late gadolinium enhancement (red arrows). The white asterisk represents a small pericardial effusion adjacent to the right and left ventricles.

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  Figure 3. Magnetic Resonance Imaging Short-Axis View Demonstrating Pericardial Thickening and Mild Late Gadolinium Enhancement (Arrow)

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  Figure 4. Pathology of the Pericardiectomy Specimen Movat pentachrome stain shows multiple layers of organizing and organized fibrous thickening on top of the parietal fibrosa layer (dotted lines). The organized layer is fibrotic without vessels or inflammation, the organizing layer has fibroblasts and inflammatory cells, while the topmost layer shows organizing fibrin (asterisk) representing the most recent episode of pericarditis.