Suspected acute rheumatic fever in a young man in England

A 24-year-old fit and well Caucasian man was referred to acute hospital via his General Practitioner with chest pain, palpitations, shortness of breath and an antecedent sore throat. Investigations revealed pericardial and pleural effusions, pericardial thickening on MRI, mild mitral regurgitation on echocardiogram and a raised Antistreptolysin O (ASO) titre.He was treated as acute rheumatic fever (ARF) with a prolonged course of penicillin, supportive therapy with bisoprolol and colchicine with lansoprazole cover. The patient made a full recovery and subsequent cardiac MRI showed resolution of all changes.

Salvation to Hearts in Distress under Shells of Stress: Subtotal Pericardiectomy in a Series of 9 Patients with Constrictive Pericarditis

Objective: Chronic constrictive pericarditis (CCP) is a rare entity responsible of diastolic heart failure. The true prevalence is yet to be defined. The purpose of this study was to describe the clinical and para-clinical characteristics of patients with CCP, the therapeutic management, the outcomes and impacting factors. Materials and Methods: We conducted a retrospective descriptive study from 2017 to 2020 including 9 patients hospitalized for CCP in our cardiovascular surgery department. Results: The mean age was of 32.6 years. Majority were men (n=7). Dyspnea was the most common sign. Peripheral signs were dominated by signs of right heart failure. Cardiac ultrasonography showed pericardial thickening and calcifications with Doppler adiastolic signs in 90% of cases. Thoracic CT was performed in 7 patients, cardiac MRI in one patient, showing calcifications and measuring the pericardial thickening. Cardiac catheterization performed in 6 patients showed the aspect of Dip plateau. Tuberculosis etiology was retained in 55.6%; post-radiation origin in one patient and 33.4 % of cases were idiopathic. All of patients benefited from subtotal pericardiectomy with good results in the medium and long term. Two deaths occurred, the first patient died following multi-visceral failure, the second died 3 years later from neoplasia. Conclusion: The CCP is a rare condition with poor prognosis. The diagnosis should be raised when there are signs of right heart failure associated with signs of hemodynamic adiastolia. The echocardiography, with computed tomography or cardiac MRI and especially cardiac catheterization confirm the diagnosis and also etiological orientation. Tuberculosis and idiopathic etiologies were the most common at our country. Medical treatment options are limited. Pericardiectomy remains the only radical treatment with good results in immediate, medium and long term.

A case report of tuberculous constrictive pericarditis necessitating total pericardiectomy

Background Constrictive pericarditis (CP) is one of the most serious sequelae of tuberculous pericarditis, which is characterized by heart constriction secondary to intense pericardial inflammation and thickening. Several invasive and non-invasive diagnostic modalities are crucial to address the challenges of confirming the diagnosis of CP and to expedite timely intervention. Case summary This study reports the case of a Bahraini male with tuberculous lymphadenitis diagnosed with CP as a result of various evaluations. The patient underwent urgent total pericardiectomy and showed remarkable recovery with complete resolution of heart failure symptoms. Discussion This case demonstrates the paramount importance of early diagnosis and treatment for patients with CP. In this unique case, the acoustic windows on echocardiography were suboptimal because of pericardial thickening. Further, computed tomography did not show significant calcification of the thickened pericardium. A novel approach of assessing haemodynamics through the right antecubital vein and right radial artery facilitated the accurate diagnosis of CP with confidence. Thereafter, successful pericardiectomy revealed a markedly thickened and stiff pericardium with many abscesses and dense adhesions encasing the heart, and pericardial biopsy showed large caseating granulomas. This case exemplifies the difficulty in diagnosing CP and the favourable outcomes achieved with well-timed surgical intervention.

Chylopericardium associated with constrictive pericarditis assessed by multimodality imaging

An 80-year-old male patient developed exertional dyspnea and bilateral peripheral oedema. Investigations including an echocardiogram, cardiac computed tomography and cardiac magnetic resonance suggested calcific pericardial thickening encapsulating the heart with associated constriction. This is an interesting case as constriction was associated with a large chylopericardium of unknown cause

Severe pulmonary regurgitation mimicking constrictive pericarditis: a case report—the sac or the content? That is the question

Background Constrictive pericarditis (CP) is a pathological condition of the pericardium, resulting from fibrosis, scarring, and calcification of the pericardium. Other conditions have been reported to mimic ‘constrictive physiology’ despite the presence of an intact pericardium. However, there has been no report of pulmonary regurgitation (PR) mimicking the haemodynamic characteristics of CP. Case summary A 51-year-old woman was admitted to our institute because of severe right-sided heart failure. Transthoracic echocardiography revealed severe PR concomitant with significant dilatation of the right-sided heart. Septal bounce and the respiratory reciprocation of the transmitral and transtricuspid inflow velocities were also observed, indicating exacerbated ventricular interdependence. Cardiac catheter examination demonstrated elevated right atrial pressure with a prominent y descent, dip, and plateau waveform in the right ventricular pressure, and equalization of the diastolic pressure of all cardiac chambers, which are quite consistent with CP. On surgical inspection, however, there was no pericardial thickening or adhesion, indicating no obvious signs of CP. Discussion Pericardial constriction results from the relative relationship between intrapericardial volume and pericardial reserve. When the intrapericardial volume exceeds the physiological limit, the cardiac chambers compete with each other in a fixed pericardial space. In this case, prominent dilation of the right-sided chambers caused by severe PR resulted in overstretching of the pericardium above the pericardial reserve, which led to a characteristic haemodynamic picture that resembled CP. Thus, it is important to recognize the diagnostic pitfall in the preoperative evaluation of a ‘CP mimic physiology’.

Graft-versus-host disease: a case report of a rare but reversible cause of constrictive pericarditis

Background Constrictive pericarditis (CP), although an uncommon cause of heart failure, requires specialist multidisciplinary input and multi-modality imaging to identify the underlying aetiology and treat potentially reversible causes. Case summary We report the case of a 74-year-old gentleman referred for assessment of progressive exertional dyspnoea and peripheral oedema, 30 months following treatment of acute myeloid leukaemia with high-dose chemotherapy and allogeneic stem cell transplantation. Clinical examination and cardiac imaging revealed a small pericardial effusion and pericardial thickening with constrictive physiology; however, no aetiology was identified despite diagnostic pericardiocentesis. The patient required recurrent hospital admissions for intravenous diuresis, therefore, following multidisciplinary discussions, surgical partial pericardectomy was performed. Histology suggested graft-vs.-host disease (GvHD) and post-operatively, the patient improved clinically. Following immunomodulatory therapy with ruxolitinib for both pericardial and pulmonary GvHD, his functional status improved further with no subsequent hospital admissions. Discussion Although pericardial disease in cancer patients is common, CP is unusual. Determining the underlying aetiology is important for subsequent management, and here, we describe the use of multi-modality imaging to diagnose a rare cause, GvHD, which responded to surgical treatment and immunomodulatory therapy.

P187 Multimodality in tuberculous constrictive pericarditis

CASE PRESENTATION K.C.P., a 26 y.o. female, presenting dizziness and progressive dyspnea since 9 months ago. Physical examination showed hepatomegaly at 2 centimeters below the right inferior costal border, but without edema, cardiac murmurs or other findings. Electrocardiogram showed atria overload and diffuse ventricular repolarization abnormality. Chest X-ray revealed normal sized cardiac silhouette but with signs of pericardial calcification. Transthoracic echocardiogram revealed: enlargement of both atria, no signs of myocardial left ventricular (LV) hypertrophy; dilated inferior vena cava with minimal respiratory variation; septal bounce; septal e´= 17.20 cm/s, lateral e´= 6.09 cm/s; E/e" septal ratio = 3.9; E deceleration time = 144 ms; thickening and hyper-refringence of the pericardium with calcification adjacent to the lateral and inferior walls of the LV and the free wall of the right ventricle. For evaluation of thickness and extent of pericardial involvement, computed tomography (CT) was performed, showing gross calcifications of the pericardium, mainly in basal and lower portions, without pericardial effusion. Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement revealed areas suggestive of active inflammation adjacent to the basal wall of the LV. With this evidence of active inflammatory activity, the patient was treated empirically against the etiologic agent for tuberculosis. Because of progressively severe edema and dyspnea pericardiectomy was warranted providing relief of symptoms. DISCUSSION: The echocardiogram is the initial image exam for diagnosis and monitoring of pericardial conditions. It is a widely available, low-cost method that does not use ionizing radiation and allows a complete morphological and functional evaluation of the heart. However, in up to 20% of cases, pericardial thickening may not be detectable at echocardiography. CT allows a more accurate assessment of pericardial thickening, while CMR allows detection of active inflammatory process. CONCLUSION: A typical and illustrative clinical case of constrictive pericarditis is presented, where the multimodality of cardiac imaging was decisive for the diagnostic and therapeutic delineation.

P5279Pericardial inflammation basced on cardiac magnetic resonance imaging in patients with tuberculous pericarditis

Background While constrictive pericarditis has been traditionally considered a disabling disease, reversible constrictive pericarditis has been described in previous studies. But there are limited studies on cardiac imaging of tuberculous pericarditis. In particular, no studies on cardiac magnetic resonance imaging (CMR) have been reported. We aimed to investigate CMR findings including pericardial late gadolinium enhancement (LGE) and T2 fat suppression and black blood sequences in patients with tuberculous pericarditis. Methods We retrospectively analyzed medical records of patients with tuberculous pericarditis between January 2010 and January 2017 in Samsung Medical Center. Definite diagnosis of tuberculous pericarditis is based on the identification of Mycobacterium tuberculosis in pericardial fluid or tissue; probable diagnosis was made when there was other evidence of tuberculosis elsewhere in patients with unexplained pericarditis. We performed CMR at initial diagnosis. Treatment consists of the standard 4-drug antituberculosis regimen for 6 months with or without steroids. Echocardiography was also conducted at initial diagnosis and 6 months later. Results Total 39 cases with tuberculous pericarditis in immunocompetent patients were enrolled. Ten patients were diagnosed as definite tuberculous pericarditis. CMR finding at initial diagnosis divided into five groups: 1) pericardial effusion only (n=20, 51.3%), 2) effusive constrictive pericarditis (n=5, 12.8%), 3) constrictive pericarditis (n=11, 28.2%), 4) pericardial abscess formation (n=4, 10.3%) and 5) absence of pericardial effusion and constrictive physiology (n=1, 2.6%). One of the 4 patients with pericardial abscess formation was together with pericardial effusion and the other was accompanied by effusive constrictive pericarditis. Pericardial thickness increased to more than 4mm in 25 patients (64.1%) and the mean pericardial thickness was 10.0±6.9mm. Delayed enhancement of pericardium was noticed in 29 patients (74.4%). In T2 fat suppression and black blood sequences, 30 patients showed increased T2 signal intensity indicating inflammation with extensive edema. Pericardial thickening (>4mm) with constriction (n=15) was not statistically significant in the delayed enhancement and increased T2 signal intensity compared with pericardial thickening without constrictive pericarditis (n=10) (delayed enhancement 93.8% vs. 77.8% p=0.287; increased T2 signal intensity 88.9% vs. 87.5%, p=0.713). After 6 months, only 3 patients still had constrictive pericarditis in echocardiography. Effusive constrictive pericarditis Conclusions Pericardial thickening is associated with delayed enhancement and increased T2 signal intensity in patients with tuberculous pericarditis regardless of constrictive pericarditis. Even though there were hemodynamic feature of constrictive pericarditis and pericardial inflammation with extensive edema in CMR at initial diagnosis, 80% of the patients were improved from constrictive pericarditis. Acknowledgement/Funding None