Abstract 15557: Missed Diagnosis of Constrictive Pericarditis: Importance of Multimodality Imaging

Abstract

Introduction: Constrictive pericarditis is a potentially reversible cause of hypotension that is diagnostically challenging. Multimodality imaging is important in the evaluation of patients for constrictive pericarditis to ensure timely management. Case Presentation: A 68-year-old female with a history of chronic hypotension controlled with midodrine and fludrocortisone, end-stage renal disease, and rheumatoid arthritis was admitted to our hospital following a ground-level fall leading to left femur fracture. At admission, her blood pressure was 100/72 mmHg and heart rate was 84 per minute. No pericardial rub, murmurs, or jugular venous distension were present. Laboratory evaluation revealed normal serum electrolytes, thyroid-stimulating hormone, and morning cortisol levels. A routine transthoracic echocardiogram was performed as part of her perioperative cardiac evaluation that demonstrated a beat-to-beat septal diastolic shudder and annulus reversus suggestive of constrictive pericarditis. These findings were confirmed with cardiac magnetic resonance imaging (CMR) that showed pericardial thickening, tubular-shaped right ventricle with impaired filling, septal bounce as well as respirophasic early diastolic septal flattening. Cardiothoracic surgery was consulted however definitive management with pericardiectomy is pending at the time of this report. Conclusion: With recent advances in tissue Doppler imaging, echocardiography can be used in clinical practice to diagnose constrictive pericarditis. Reversal of the relationship between lateral and medial e` velocities (annulus reversus) and respiration-related ventricular septal shift (septal shudder) are suggestive of constrictive pericarditis.