Calcified Constrictive Pericarditis (Concretio Cordis) in a Renal Transplant Recipient: A Multimodal, Hemodynamic, and Surgical Challenge

Calcified constrictive pericarditis is an uncommon but severe clinical entity that causes restrictive right-sided heart failure. Its occurrence in renal transplant recipients presents a highly complex scenario due to interactions with immunosuppression, the risk of graft dysfunction caused by hemodynamic instability, and the surgical challenges of decortication. We report a 45-year-old male, renal transplant recipient (2018) on maintenance therapy with tacrolimus, everolimus, and prednisone, who was evaluated for progressive refractory ascites that masked the underlying cardiovascular disease. Computed tomography and transthoracic echocardiography revealed massive 6 mm pericardial thickening with complete circumferential calcification (concretio cordis) and pathognomonic hemodynamic signs: early diastolic septal bounce, a 30% respiratory variation in transmitral flow, and annulus reversus (septal E' greater than lateral E'), associated with secondary congestive hepatopathy and moderate thrombocytopenia. He underwent subtotal off-pump pericardiectomy via median sternotomy. During decortication of the 0.5 cm thick calcified pericardium, incidental injuries occurred in the right atrium and the right ventricular outflow tract, which were successfully repaired using bovine pericardial patches and autotransfusion with a Cell Saver system. The postoperative course showed hemodynamic stability, preservation of graft function, and a drastic weight reduction (from 51.2 kg to 49 kg) due to ascites volume depletion. During mid-term outpatient follow-up, the patient achieved complete remission to New York Heart Association (NYHA) functional class I, with definitive resolution of the ascitic syndrome and normalization of electrocardiographic and functional echocardiographic parameters, highlighting the disappearance of septal bounce and restoration of inferior vena cava collapse greater than 50%. In conclusion, pericardial constriction is a clinically elusive condition that mimics primary liver disease, meaning it must be included in the differential diagnosis of refractory ascites in transplant patients. Therapeutic success relies on diagnostic suspicion, transdisciplinary integration, and safe surgical decortication to preserve the allograft.