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History
A 48-year-old male presented with one week history of chest pain, increased weight, leg edema and progressive dyspnea. Past history of hypertrophic obstructive cardiomyopathy Treated with septal myectomy and bilateral pulmonary vein isolation one month before presentation.
Physical examination
Vitals: 98.6 F, 146/88, 82, 20, 95% on RA Mild respiratory distress CVS: elevated JVP , regular, no murmurs Lungs: bibasilar diminished breath sounds Abdomen: soft, non-tender Extremity: 2+ bilateral LE pitting edema Skin: midline sternotomy wound, no erythema
ECG
Laboratory data
WBC 7.37 HB 9.4 HCT 30.7 PLT 382 Troponin normal BNP 680
What is next?
CMR
CMR report
Early diastole intraventricular septal bounce Localized pericardial effusion adjacent to the right ventricle (left panel). Thickened pericardium at 7 mm Circumferential late gadolinium enhancement of pericardium
RHC
Right and left ventricular pressure tracings showing diastolic equalization of pressures in both ventricles (left panel) Findings consistent with large pericardial effusion with constrictive features
Clinical Management?
Histopathology
Histopathology showed
Marked fibrosis and granulation tissue with organizing hemorrhage. Fibrotic with thickened pericardium
Presentation
Shortness of breath Difficulty doing stairs Abdominal swelling Chest pain, sharp in nature, increased with exertion
Physical examination
Vitals were stable Neck: JVD elevated to angle of jaw Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, pericardial knock Abdomen: Ascites with shifting dullness. Extremities: 2+ pitting bilateral leg edema
Work up
EKG: NSR with LBBB WSR 45 (0 - 15 mm/H) CRP 8.1 (0.0 - 1.0 mg/dL) Prednisone was increased to 60 mg daily
TDI
CMR
CMR report
Diffuse mild thickening of the left pericardium Pericardial thickening 4 mm. Changes in the pericardial space over the RV Diastolic septal bounce Exaggerated inspiratory flattening and conical deformity of the ventricles Mild circumferential enhancement of the pericardium Right pleural effusion
Next step
Findings are suggesting ongoing constriction of the left paricardium LAD trauma from right pericardiectomy was entertained. LHC was done and normal Referred for complete pericardiectomy
Complete pericardiectomy
Through a left anterior thoracotomy Histopathology showed:
Pericardium is markedly thickened Organized hemorrhage Mild chronic inflammation.
Discharged on:
Prednisone 50 mg PO daily Ibuprofen 400 TID Colchicine 0.6 mg BID Referred to heart failure clinic and started on diuretics
5 months later
5 months later
Patient remained chest pain-free Remains on diuretics and mild heart failure symptoms Inflammatory markers normalized Prednisone was tapered off Remained on colchicine and NSAID and stopped a year later.
Pre
Post
30
WSR
20
10
0
myectomy Total pericardiectomy Right pericardiectomy
Thank you