A 51-year-old man was admitted to an outside hospital for weight gain, dyspnea on exertion, and orthopnea. He was found to have bilateral pleural effusions, ascites, and marked peripheral edema. An echocardiogram revealed normal right and left ventricular systolic function. As a result of the echocardiographic findings, congestive heart failure (CHF) was given a low priority in the differential. Subsequently, an extensive and comprehensive workup was undertaken, including consultations by specialists in infectious disease, rheumatology, oncology, surgical oncology, and pathology. With the goal of discovering an occult malignancy, multiple tissues and fluids were obtained and sent for pathological evaluation. These included pleural and peritoneal fluid, cervical lymph nodes, pleural biopsy, biopsy of a pelvic mass, and bladder biopsy. All biopsies, cultures, and serologies were negative for neoplasia, infection, or vasculitis. The patient was then referred to our institution for further evaluation.
History and physical examination were consistent with the diagnosis of CHF. A Swan-Ganz catheter was placed for bedside hemodynamic monitoring while aggressive diuretic therapy was administered. Simultaneous right and left heart catheterization demonstrated equalization of elevated ventricular diastolic pressures and normal systolic function. The right ventricular pressure tracing was consistent with a constrictive or restrictive process (Fig 1a⇓). Computerized tomography of the chest demonstrated a thickened pericardium, which confirmed the diagnosis of constrictive pericarditis (Fig 2⇓). The patient was referred to cardiothoracic surgery for pericardiectomy.
On day 7 after surgery, the right ventricular pressure tracing showed resolution of the dip-and-plateau waveform and normalization of the right ventricular diastolic pressure (Fig 1b⇓). The patient was discharged and continued to improve. When he was seen in the clinic at a 2-week postdischarge follow-up visit, all signs and symptoms of CHF were absent.
From the Division of Cardiovascular Medicine, University of California, Davis.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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