Constrictive Pericarditis: There Is Nothing More Deceptive than an Obvious Fact

Figures

• 

  Figure 1. A 72-year-old man with a diagnosis of constrictive pericarditis was referred to our cardiology unit in April 2024 to assess his eligibility for a pericardiectomy. The previous diagnosis of constrictive pericarditis was based on symptoms of volume overload (peripheral oedema and weight gain) with typical features on a transthoracic echocardiogram (TTE). Upon admission, the TTE showed paradoxical motion of the interventricular septum during early diastole (septal bounce, panel (A)) and moderate pericardial effusion (panel (B)). Septal bounce is an echocardiographic sign of ventricular interdependence, serving as one of the diagnostic criteria for constrictive pericarditis identified by the Mayo Clinic [1]. Additionally, both bidimensional and M-mode assessments showed a dilated inferior vena cava that exhibited no motion during spontaneous breathing or forced inspiration (sniff), as illustrated in panels (C,D). These observations indicate inferior vena cava plethora, which may also occur in volume overload conditions or cardiac tamponade; therefore, if present, it is not included in the Mayo Clinic’s diagnostic criteria due to its low specificity and sensitivity. Lastly, a pulsed…

• 

  Figure 2. Cardiac magnetic resonance imaging (CMRI) was performed to assess the patient’s pericardial disease prior to referral to cardiac surgery. Breath-hold steady-state free precession (SSFP) cine of bright blood horizontal long axis (A) and midventricular short axis (B) views with evidence of a large pericardial effusion without compression of the ventricles in late diastole. The visceral (red arrow) and parietal (white arrow) pericardial layers are slightly thickened (3 mm). (C) Free-breathing SSFP cine in real time showing ventricular interdependence as a sign of constrictive pathophysiology; the left panel was taken during expiration, and the right panel during inspiration, showing septal bounce (black arrow) and crushing of the left ventricular chamber during inspiration. (D) The native T1 mapping sequence (modified look-locker inversion recovery) shows increased T1 times in the pericardium. (E) A short tau inversion recovery (STIR) T2 sequence showing pericardial hyperintensity (red arrow) compatible with oedema. (F) A late gadolinium enhancement (LGE) phase-sensitive inversion recovery (PSIR) sequence showing increased signal intensity in the pericardial layers (red arrow). The…