An unusual case of dyspnea? How echocardiography and right- heart catheterization guided us to the right diagnosis: a clinical case

Background 

Constrictive pericarditis is frequently overlooked in patients presenting with symptoms of heart failure, especially when predisposing conditions are missing (e.g. a history of pericardial effusion, chest radiation due to malignoma or heart surgery). A thorough diagnostic pathway comprising echocardiography and right- heart catheterization can guide to the right diagnosis- and treatment. This clinical case underlines the importance of considering constrictive pericarditis in patients presenting with symptoms of heart failure without an obvious underlining pathology. 

Clinical Case

A 43-year-old male patient was referred from another clinic due to symptoms of heart failure (NYHA III) and ankle edema. The symptoms had been increasing over three weeks before admission. The patient had a history of pleural- and pericardial effusion without a clear pathology. All symptoms began after the patient had started doing renovations in an old and abandoned house he had bought. An extensive work up, including HIV, rheumatological disorders and infections had already been conducted. Also, pericardial and pleural drainage with microbial and pathologic examinations had been done with no explaining results. At the time of admission to our clinic, the patient had pleural effusions and ankle edema, but no pericardial effusion. NTproBNP was markedly elevated (2507 ng/l). Echocardiography demonstrated good left ventricular function (LVEF 60%). However, respirophasic abnormal septal motion was visible in conjunction with e’ septal (10,6 cm/sek) > e’ lateral (9,7 cm/sek), suggesting a diagnosis of constrictive pericarditis being the cause of the symptoms. To confirm the diagnosis, right heart catheterization was performed. Indeed, pressure curves of both ventricles demonstrated dip- plateau phenomena and elevated early diastolic pressure further underlining the diagnosis of constrictive pericarditis. Finally, the findings were discussed in the heart team together with the colleagues from cardiothoracic surgery and anesthesiology and the patient underwent pericardiectomy.

Conclusion

Constrictive pericarditis is a frequently overlooked reason for decompensated heart failure especially when predisposing conditions are missing, left- ventricular function is good and no obvious pathology can be found. A thorough diagnostic pathway comprising echocardiography and right heart catheterization is important for correct diagnosis and appropriate treatment.