A 34-year-old male with unrecognized constrictive pericarditis and an LVEF of 60% developed overt shock following VATS and expired prior to pericardiectomy due to delayed diagnosis.
Case Report (n=1)
This case highlights the diagnostic challenges of constrictive pericarditis, particularly when body habitus limits echocardiography, emphasizing the need for early recognition and multidisciplinary management.
Abstract Introduction Constrictive pericarditis is a form of diastolic heart failure that arises due to an inelastic pericardium impairing diastolic filling of the cardiac chambers. The diagnosis should be considered in any patient who presents with unexplained symptoms of heart failure, particularly when the left ventricular (LV) ejection fraction is preserved. However, affirming a diagnosis of constrictive pericarditis can be challenging as the symptoms are also consistent with other cardiac disorders such as restrictive myocardial disease or severe tricuspid regurgitation. Case Description We present a case of a 34-year-old male with medical history of hypertension, hyperlipidemia, and end-stage renal disease on hemodialysis for 7 years, who initially presented to outside hospital for worsening dyspnea. There, large bilateral loculated pleural effusions were identified and thoracentesis performed. He was subsequently transferred to our hospital for video-assisted thoracoscopic surgery (VATS) evaluation for management of the effusions and presumed trapped lung. He underwent right VATS with decortication and pleurectomy, during which abundant purulent fluid and chronic-appearing pleural peel were noted. He became hypercapnic and hypotensive in recovery and was reintubated, necessitating transfer to our critical care unit, where he subsequently developed worsening shock prompting reevaluation of the case. Computerized tomography of the thorax revealed diffuse pericardial calcification. Transthoracic echocardiogram demonstrated LV ejection fraction of 60% but poorly visualized right atrium and ventricle. Given the concerning pericardial finding, invasive hemodynamic evaluation with cardiac catheterization was performed which demonstrated severely elevated pressures of all chambers with equalization of diastolic pressures. The patient was re-evaluated by cardiothoracic surgery for possible pericardiectomy but unfortunately expired prior to intervention. Discussion The first-line diagnostic modality for constrictive pericarditis is echocardiography. Key diagnostic criteria include the dissociation of intrathoracic and intracardiac pressures, respiration-related ventricular septal shift, preserved or increased medial mitral annular e’ velocity, and prominent expiratory diastolic flow reversals in the hepatic veins. However, in our patient, body habitus limitations made confirmation of these findings challenging, necessitating invasive hemodynamic assessment via cardiac catheterization. Definitive treatment for constrictive pericarditis is pericardiectomy, a technically demanding and high-risk procedure with a perioperative mortality rate of 40-60% in patients with advanced disease. Given this significant risk, a multidisciplinary approach is essential to optimize outcomes. This patient’s constrictive physiology was unfortunately recognized only after development of overt shock - earlier recognition may have facilitated more timely evaluation for pericardiectomy. This case underscores the challenges in diagnosing and optimally timing the treatment of constrictive pericarditis. This abstract is funded by: None
Caballero et al. (Fri,) conducted a case report in Constrictive pericarditis (n=1). Video-assisted thoracoscopic surgery (VATS) and cardiac catheterization was evaluated. A 34-year-old male with unrecognized constrictive pericarditis and an LVEF of 60% developed overt shock following VATS and expired prior to pericardiectomy due to delayed diagnosis.