Constrictive Physiology Research Articles

Constrictive physiology is not present in all dogs with idiopathic chylothorax.

To determine whether subtotal pericardectomy affects recurrence and long-term outcomes in dogs with idiopathic chylothorax (IC). 12 client-owned dogs diagnosed with IC between July 26, 2016, and March 23, 2023. The diagnosis of constrictive physiology (CP) was established with cardiac catheterization and defined as elevated and equal diastolic pressures in all 4 cardiac chambers. Dogs were then entered into the constrictive physiology (CP) group or non-CP (NCP) group. All dogs received at least a thoracic duct ligation (TDL). The dogs in the CP group had a subtotal pericardectomy performed in addition to TDL. Repeated surgical interventions, recurrence, long-term outcomes, and survival times were recorded. 8 dogs were entered into the CP group and underwent TDL and subtotal pericardectomy. Four dogs were entered in the NCP group and underwent only a TDL. Four dogs in the CP group and 1 in the NCP group required multiple surgeries for recurrent chylothorax. The 1-, 2-, and 3-year disease-free rates were, respectively, 100%, 100%, and 50% for the NCP group and 87.5%, 72.9%, and 72.9% for the CP group (P = .935). The 1-, 2-, and 3-year survival rates were, respectively, 100%, 100%, and 100% for the NCP group and 87.5%, 72.9%, and 72.9% for the CP group (P = .317). Constrictive physiology should be evaluated by cardiac catheterization before surgical treatment of IC in dogs. If CP is not diagnosed, subtotal pericardectomy may not be required.

A Rare Case of Tuberculous Constrictive Pericarditis Due to Disseminated Tuberculosis with Response to Anti-tuberculosis Chemotherapy and Steroids in a Developed City State

A 27-year-old man presented with a 1-week history of atypical chest pain and sinus tachycardia. His physical examination was unremarkable. His resting ECG showed sinus tachycardia with widespread T-wave inversion. His initial blood tests show mildly raised troponin T and inflammatory markers and marked raised D-dimer. A CT pulmonary angiogram was performed to exclude pulmonary embolism but incidentally revealed an anterior mediastinal mass. A transthoracic echocardiogram and cardiac MRI showed features of constrictive pericarditis. A video-assisted thoracoscopic surgical biopsy of the anterior mediastinal mass showed thymic tissue with necrotising granulomatous inflammation and an acid-fast bacilli culture was positive to tuberculosis infection. The patient was started on anti-tuberculosis chemotherapy and a 6-week tapering course of oral steroids. A repeat cardiac MRI performed after 6 weeks of treatment showed a significant response to treatment with resolution of constrictive physiology.

Semiquantitative 18F-FDG PET/CT in monitoring glucocorticoid response of immunoglobulin G4-related effusive constrictive pericarditis: a case report

BackgroundImmunoglobulin G4 (IgG4)-related effusive constrictive pericarditis (ECP) is a rare manifestation of IgG4-related disease (IgG4-RD). It can lead to persistent pericardial fibrosis, resulting in cardiac tamponade, diastolic dysfunction, and heart failure. Glucocorticoids are the primary treatment for effectively reducing inflammation and preventing fibrosis. However, guidelines for monitoring treatment response are lacking and tapering glucocorticoid therapy for specific target organs remains a challenge. Recent studies on IgG4-RD have demonstrated that semiquantitative measurements of fluorine-18 fluorodeoxyglucose (18F-FDG) uptake in the main involved organs in positron emission tomography/computed tomography (PET/CT) scanning are correlated to disease activity. We present a case of IgG4-related ECP to demonstrate the usefulness of 18F-FDG PET/CT for diagnosing and treatment follow-up of IgG4-related ECP.Case presentationHerein, a 66-year-old woman diagnosed with IgG4-related ECP presented with breathlessness, leg swelling, rales, and fever. Laboratory tests revealed markedly elevated levels of C-reactive protein, and transthoracic echocardiography revealed constrictive physiology with effusion. High IgG4 levels suggested an immune-related pathogenesis, while viral and malignant causes were excluded. Subsequent pericardial biopsy revealed lymphocyte and plasma cell infiltration in the pericardium, confirming the diagnosis of IgG4-related ECP. 18F-FDG PET/CT revealed increased uptake of 18F-FDG in the pericardium, indicating isolated cardiac involvement of IgG4-RD. Treatment with prednisolone and colchicine led to a rapid improvement in the patient’s condition within a few weeks. Follow-up imaging with 18F-FDG PET/CT after 3 months revealed reduced inflammation and improved constrictive physiology on echocardiography, leading to successful tapering of the prednisolone dose and discontinuation of colchicine.ConclusionThe rarity of IgG4-related ECP and possibility of multiorgan involvement in IgG4-RD necessitates a comprehensive diagnostic approach and personalized management. This case report highlights the usefulness of 18F-FDG PET/CT in the diagnosis and treatment follow-up of isolated pericardial involvement in IgG4-RD.

Reversible Constrictive Pericarditis: Implications for Management in India

Abstract Tuberculosis is the most common etiology for constrictive pericarditis in developing part of world, but a certain diagnosis may remain obscure. Reversal of constrictive physiology is possible if antitubercular therapy (ATT) and steroids are administered in early stage of disease and only few case reports are available indicating the role of ATT alone in reversing constriction.

Milk of Calcium Causing a Case of Calcific Pericardial Effusion

A 60-year-old man presented with heart failure symptoms and was found to have a calcified pericardial effusion consistent with “milk of calcium” and constrictive physiology. The patient received a pericardiectomy and has had favorable outcomes at his 1-year follow-up. There are minimal reports of calcific pericardial effusion with constrictive pathology.

Biologically derived epicardial patch induces macrophage mediated pathophysiologic repair in chronically infarcted swine hearts

There are nearly 65 million people with chronic heart failure (CHF) globally, with no treatment directed at the pathologic cause of the disease, the loss of functioning cardiomyocytes. We have an allogeneic cardiac patch comprised of cardiomyocytes and human fibroblasts on a bioresorbable matrix. This patch increases blood flow to the damaged heart and improves left ventricular (LV) function in an immune competent rat model of ischemic CHF. After 6 months of treatment in an immune competent Yucatan mini swine ischemic CHF model, this patch restores LV contractility without constrictive physiology, partially reversing maladaptive LV and right ventricular remodeling, increases exercise tolerance, without inducing any cardiac arrhythmias or a change in myocardial oxygen consumption. Digital spatial profiling in mice with patch placement 3 weeks after a myocardial infarction shows that the patch induces a CD45pos immune cell response that results in an infiltration of dendritic cells and macrophages with high expression of macrophages polarization to the anti-inflammatory reparative M2 phenotype. Leveraging the host native immune system allows for the potential use of immunomodulatory therapies for treatment of chronic inflammatory diseases not limited to ischemic CHF.

Abstract 18486: Recurrent Pericarditis Following Atrial Fibrillation Ablation: Unmasking Latent Tuberculosis Infection

Background: Tuberculous pericarditis is rare in the United States but can lead to serious sequelae in the absence of diagnosis and treatment. We report a case of recurrent pericarditis following catheter ablation of atrial fibrillation (AF) due to reactivation of latent TB infection. Case Summary: A 52-year-old male with no past medical history underwent a difficult trans-septal puncture & cryo-balloon PV isolation, complicated by acute pericarditis and pericardial effusion with cardiac tamponade. He underwent pericardiocentesis with removal of 260cc bloody fluid. He had resolution of chest pain with ibuprofen, but experienced recurrence after 3 months and was given a longer NSAID course. Two months later, he presented with chest pain along with night sweats & low-grade fever. He had an elevated C-reactive protein, and echocardiography revealed thickened pericardium & constrictive physiology. He received high-dose aspirin, prednisone, and colchicine for recurrent pericarditis. Extensive Infectious Disease & Rheumatology work-up ruled out autoimmune & viral etiologies but his T-Spot TB test was positive. He denied personal or contact history of TB except travel to Asia 20 years ago. CT scan ruled out pulmonary TB infection. A 6-month course of Rifampin was prescribed. He experienced a 4th episode of pericarditis while tapering off prednisone, and restarted prednisone, Ibuprofen, and colchicine. Additionally, Rilonacept was prescribed. After completing 6-months of Rifampin and Rilonacept, he had significant improvement and no further recurrences on 1 year follow up. Discussion: Pericarditis is a common complication of catheter ablation, often resulting from direct injury. We report a case of recurrent pericarditis, initially believed to be a traumatic complication of AF ablation. However, investigation revealed underlying latent pericardial TB infection. Appropriate treatment led to complete resolution without sequelae.

Abstract 16644: Unusual Manifestation of Acute Pericarditis in the Setting of Primary Biliary Cirrhosis

Introduction: Primary biliary cirrhosis (PBC) is an immune-mediated liver disease leading to destruction of intrahepatic bile ducts and cirrhosis. However, its association with pericarditis has not been investigated. Here, we describe a case of a female with PBC who presented with severe pericardial disease. Clinical Case: A 57-year-old female with past medical history of primary biliary cirrhosis, thrombocytosis and type 2 diabetes who presented with sudden onset sharp chest pain, worse with movement or breathing. Workup was notable for elevated D-dimer, CT chest with no evidence of pulmonary embolism but did reveal a moderate pericardial effusion, further confirmed on echocardiogram. Nuclear stress test was unremarkable. CRP 13 mg/dL and ESR 82 mm/hr. Given concern for pericarditis, she was started on colchicine and ibuprofen. On further evaluation in clinic, cardiac MRI showed severe LGE and edema consistent with active pericarditis (figure 1) with mild constrictive physiology and worsening inflammatory markers (ESR 95 mm/hr, us-CRP 118mg/L). Therefore, decision was made to start triple therapy with the addition of prednisone. Repeat cardiac MRI 6 months later showed resolution of LGE and pericardial edema (figure 2). Given clinical improvement, patient was tapered off steroids, started anakinra and weaned off ibuprofen and colchicine. She remained on anakinra for two years after which she was transitioned to single therapy with colchicine with no episodes of recurrence. Discussion: PBC commonly exists with liver autoimmune disorders, but its association with pericardial disease has not been investigated. NSAIDs are often used as first-line therapy for pericarditis, but can be detrimental in advanced liver failure, often seen in patients with PBC. Steroid use is not only advantageous in pericardial disease but also in PBC. As a result, it is critical to identify the link between pericardial disease and PBC to determine appropriate therapeutic management.

Abstract 18975: First Reported Case of SLE Associated Recurrent Pericarditis Treated With Rilonacept

Description of case: A 42 year old female presented with a 1 month history of exertional dyspnea and intermittent pleuritic chest pain. She had a 12-year history of systemic lupus erythematosus (SLE) and non-specific interstitial pneumonitis being managed with mycophenolate mofetil. Labs showed an ESR of 76 mm/hr and CRP of 5.5 mg/dL. CT chest ruled out pulmonary embolism but showed a moderate pericardial effusion, also seen on an echocardiogram. A cardiac MRI (cMRI) showed moderate diffuse circumferential pericardial enhancement. She was diagnosed with lupus pericarditis and initially treated with ibuprofen, colchicine, prednisone, and hydroxychloroquine; however, continued to have persistent symptoms over the next few months. Repeat cMRI showed a transition to effusive constrictive physiology. She was offered pericardiectomy but following shared decision making and multi-disciplinary discussion, she was started on Rilonacept. She experienced significant and sustained relief in symptoms, improvement in inflammatory markers and reduction of pericardial enhancement on cMRI. Discussion To the best of our knowledge, this is the first case of Rilonacept used to successfully treat recurrent pericarditis from SLE. Recurrence in chronic idiopathic pericarditis is thought to be driven by the innate immune system and Interleukin-1 (IL-1), while in autoimmune diseases, it is mediated by the adaptive immune system and Type 1 Interferon, which is associated with a poorer prognosis. The RHAPSODY and AIRTRIP trials demonstrating efficacy of IL-1 blockers in recurrent pericarditis excluded patients with autoimmune diseases. Use of IL-1 blockers to treat Lupus pericarditis has only been reported in 2 cases using Anakinra. Our patient’s positive response to Rilonacept suggests the presence of additional target pathways in autoimmune diseases that may mediate pericarditis recurrence. Future prospective studies are needed to elucidate this further.

Pericardial infiltration and constriction due to cardiac actinomycosis—case report

Abstract Background Constrictive pericarditis associated with actinomycosis infection is a rare and challenging diagnosis due to its insidious manifestation. We describe the successful treatment of pericardial infiltration and constriction due to actinomycosis. Case summary A 50-year-old Aboriginal man presented with insidious onset of fatigue, dyspnoea, pleuritic chest pain, fever, drenching sweats, severe exercise intolerance to 50 m, and recurrent itchy skin lesions over 8 months. Prior investigations, including serial fluorodeoxyglucose (FDG)-Positron emission tomography scans, found a progressively enlarging, metabolically active anterior mediastinal mass with two biopsies on separate occasions showing no malignancy, granulomas, tuberculosis, or other pathology. Screening for infective, autoimmune, and connective tissue disease was negative. A transthoracic echocardiogram (TTE) showed fibrinous pericarditis with extensive myocardial tethering and constrictive physiology confirmed on heart catheterization. A pericardial biopsy showed inflammatory tissue only. Biopsy of a skin lesion on the buttock showed abscess formation with Splendore Hoeppli phenomenon with Gram-positive and Grocott-positive filamentous bacteria suggestive of actinomyces, confirmed by 16S rRNA gene sequencing. He was diagnosed with cardiac actinomycosis, likely due to mediastinal infiltration from a lung infection, with haematogenous spread and treated with Penicillin G with adjunctive high-dose steroid therapy with resolution of symptoms and marked improvement in TTE features of constriction after 6 weeks. Discussion Actinomycosis is an extremely rare cause of pericardial infiltration and constriction yet highly sensitive to penicillin, highlighting the importance of accurate diagnosis. Corticosteroids are a useful adjunct to prevent chronic constrictive pericarditis and to avoid the high morbidity and mortality associated with pericardiectomy.

An Unusual Case of Pericardial Calcification

Abstract The pericardium is normally, a rigid, avascular, fibrous sac. Its primary functions are to anchor, lubricate, and prevent overdistention of the cardiac chambers. Normally, the pericardium does not contain any calcium deposits; calcification may be a sign of underlying inflammation. Pericardial calcification alone is generally asymptomatic; however, signs and symptoms usually result secondary to the constrictive physiology caused by the rigid pericardium. But again, it should be noted that only 25% of patients with constriction have pericardial calcification. Our patient was a 58-year-old male with slowly progressive symptoms of abdominal distension and pedal edema, who was evaluated and was found to have calcification of the pericardium, in quite unusual locations, resulting in even more unusual complications.

Post-Radiation Constrictive Pericarditis: Case Report

Constrictive pericarditis secondary to radiation is a rare complication, due to its pathogenesis, the patient may present asymptomatic for a long period of time with a slight decrease in functional class that may go unnoticed, however, once constrictive physiology is established, presents greater functional deterioration, and favors the development of predominant arrhythmias, atrial fibrillation and preserved LVEF heart failure, the clinical course of the disease is progressive with high morbidity and mortality. The patient presented in the case report refers to the timely diagnosis through the different methods explained that leads to a favorable outcome.

Cardiac magnetic resonance imaging of pericardial diseases: a comprehensive guide.

Cardiac magnetic resonance (CMR) imaging has been established as a valuable diagnostic tool in the assessment of pericardial diseases by providing information on cardiac anatomy and function, surrounding extra-cardiac structures, pericardial thickening and effusion, characterization of pericardial effusion, and the presence of active pericardial inflammation from the same scan. In addition, CMR imaging has excellent diagnostic accuracy for the non-invasive detection of constrictive physiology evading the need for invasive catheterization in most instances. Growing evidence in the field suggests that pericardial enhancement on CMR is not only diagnostic of pericarditis but also has prognostic value for pericarditis recurrence, although such evidence is derived from small patient cohorts. CMR findings could also be used to guide treatment de-escalation or up-titration in recurrent pericarditis and selecting patients most likely to benefit from novel treatments such as anakinra and rilonacept. This article is an overview of the CMR applications in pericardial syndromes as a primer for reporting physicians. We sought to provide a summary of the clinical protocols used and an interpretation of the major CMR findings in the setting of pericardial diseases. We also discuss points that are less well clear and delineate the strengths and weak points of CMR in pericardial diseases.

P398 ACUTE PERICARDITIS COMPLICATED BY RAPID DEVELOPMENT OF CONSTRICTION: A CASE REPORT

Abstract A 57–years–old man with no previous cardiovascular history presented with fever, hypotension, dyspnoea at rest and chest pain. The electrocardiogram showed sinus tachycardia, PR–segment depression and diffuse concave–upwards ST–segment elevation. Elevated C–reactive protein and low pro–BNP level were found at lab tests, procalcitonin and troponin were negative. Chest X–ray showed bilateral pleural effusion. Transthoracic echocardiogram (TTE) revealed mild–to–moderate serofibrinous pericardial effusion with initial diastolic collapse of right chambers, suggesting cardiac pre–tamponade. Because of the exiguity of liquid component, pericardiocentesis was not performed, patient was stabilized by fluid–challenge with hypertonic solution. Ibuprofen and colchicine were started. Left thoracentesis was performed removing one liter of fluid overall compatible with transudate. Cytological and microbiological examinations were negative. Despite of initial clinical improvement, the patient showed kidney failure and worsening of lung failure; perianal abscess was detected causing sepsis and requiring surgical drainage and antibiotic therapy with vancomycin and piperacillin/tazobactam. Culture exams were negative. After ibuprofen replacement with indomethacin a repeated TTE showed reduced pericardial effusion, but also respiratory variation in ventricular filling with signs of interventricular dependence. Cardiac magnetic resonance showed thickening and high signal intensity of pericardial layers on T2 weighted imaging and ventricular septal shift on free–breathing cine sequences, suggesting effusive–constrictive pericarditis. Left and right cardiac catheterization demonstrated ventricular “dip and plateau” pattern and ventricular discordance. Considering the lack of clinical improvement on medical therapy, off–bypass pericardiectomy was performed. Incomplete adhesion between the two pericardial layers and thick gelatinous material were found. After surgery patient experienced rapid clinical improvement; cardiac index increased from 1.5 to 3.5 L/min/m2. Effusive–constrictive pericarditis is a rare and dreaded complication of acute pericarditis. Surgery, when appropriated, is crucial for prognosis. In our case initial response to anti–inflammatory therapy with reduced pericardial effusion unmasked constrictive physiology in an effusive–constrictive pericarditis. Clinical management was complicated by sepsis which could have played a role in constriction developing.

Resolution, recurrence, and chyle redistribution after thoracic duct ligation with or without pericardiectomy in dogs with naturally occurring idiopathic chylothorax

To document outcomes of thoracoscopic treatment of idiopathic chylothorax (IC) in dogs with and without constrictive pericardial physiology (CPP) and evaluate patterns of chyle flow redistribution after thoracic duct ligation (TDL). 26 client-owned dogs. In this prospective cohort study, echocardiography and cardiac catheterization were performed to document CPP in dogs with IC. Thoracoscopic TDL with pericardiectomy was performed if CPP was present (TDL/P group). Dogs without evidence of CPP underwent thoracoscopic TDL alone (TDL group). Dogs underwent preoperative, immediate postoperative, and 3-month postoperative CT lymphangiography studies when possible. Perioperative morbidity, resolution and late recurrence rates, and long-term outcome were recorded. 17 dogs underwent TDL, and 9 underwent TDL/P. Twenty-five of 26 (96%) survived the perioperative period. One dog died from ventricular fibrillation during pericardiectomy. Resolution rates for TDL and TDL/P were 94% and 88%, respectively (P = .55), with 1 late recurrence occurring in the TDL group in a median follow-up of 25 months (range, 4 to 60 months). On 3-month postoperative CT lymphangiography studies, ongoing chyle flow past the ligation site was demonstrated in 5 of 17 dogs, of which 1 dog developed recurrence at 13 months postoperatively. In 15 of 17 dogs, chylous redistribution after TDL was principally by retrograde flow to the lumbar lymphatic plexus. In dogs without evidence of CPP, TDL alone was associated with a very good prognosis for treatment of IC. In the absence of CPP, the additional benefit of pericardiectomy in the treatment of IC is questionable.

Pericardial Mesotheliomas.

Primary pericardial mesothelioma (PM) is a rare tumor arising from the mesothelial cells of the pericardium. It has an incidence of <0.05% and comprises <2% of all mesotheliomas; however, it is the most common primary malignancy of the pericardium. PM should be distinguished from secondary involvement by the spread of pleural mesothelioma or metastases, which are more common. Although data are controversial, the association between asbestos exposure and PM is less documented than that with other mesotheliomas. Late clinical presentation is common. Symptoms may be nonspecific but are usually related to pericardial constriction or cardiac tamponade, and diagnosis can be challenging usually requiring multiple imaging modalities. Echocardiography, computed tomography, and cardiac magnetic resonance demonstrate heterogeneously enhancing thickened pericardium, usually encasing the heart, with findings of constrictive physiology. Tissue sampling is essential for diagnosis. Histologically, similar to mesotheliomas elsewhere in the body, PM is classified as epithelioid, sarcomatoid, or biphasic, with the biphasic type being the most common. Combined with morphologic assessment, the use of immunohistochemistry and other ancillary studies is helpful for distinguishing mesotheliomas from benign proliferative processes and other neoplastic processes. The prognosis of PM is poor with about 22% 1-year survival. Unfortunately, the rarity of PM poses limitations for comprehensive and prospective studies to gain further insight into the pathobiology, diagnosis, and treatment of PM.

Abstract 13711: Cardiomyopathy Complicated by Constriction Resulting in Transplant Listing

Introduction We describe a case of severe cardiomyopathy complicated by pericardial constriction resulting from epicardial VT ablation requiring heart transplant listing. Case Presentation A 43-year-old with a history of silent MI, LV aneurysm and thrombus, cardiomyopathy (EF 15%), Stage C heart failure, and VT on amiodarone initially presented with symptomatic VT requiring AICD therapy. He underwent epicardial ablation with no immediate complications. Post-ablation, he developed polymorphic VT prompting LHC revealing new LAD artery stenosis treated with stents. He was discharged on DAPT and warfarin. He subsequently re-presented with worsening dyspnea, lethargy, and edema. Invasive hemodynamics revealed elevated filling pressures and cardiogenic shock with constrictive physiology. Milrinone and aggressive diuresis were initiated with mild improvement in symptoms. Echocardiogram and cardiac MRI confirmed diagnosis of constrictive pericarditis and presence of hemopericardium. Discussion Multidisciplinary discussions were held to determine treatment. Management of constrictive pericarditis with pericardial stripping was considered. The high-risk nature of the procedure with unknown benefit, his age, and now Stage D heart failure made sternotomy a potential increased risk for future cardiac transplant. Ultimately, decision was made for pericardiocentesis, treatment with colchicine, a switch from triple therapy to warfarin and aspirin, and listing for transplant. Surveillance RHC 6 weeks post hospitalization showed resolution of constrictive physiology and normal cardiac output on milrinone.

Abstract 10436: Spontaneous Hemopericardium After Rivaroxaban

Direct oral anticoagulants (DOACs) such as rivaroxaban have become the drugs of choice when treating a variety of conditions requiring anticoagulation. We describe a case of a patient found to have hemopericardium with tamponade physiology on a routine echo ordered for evaluation of tachycardia. A 49-year-old man with systemic hypertension was found to have a right lower lobe pulmonary embolus (PE) during a hospitalization for diabetic ketoacidosis complicated by pneumoperitoneum s/p small bowel resection. Rivaroxaban 15 mg twice daily was initiated for treatment of PE. On day 2 rivaroxaban, patient became tachycardic. Chest CT showed a small to moderate pericardial effusion with pericardial enhancement. On day 7, a echo showed trivial pericardial effusion without hemodynamic compromise. Tachycardia persisted after hospital discharge, but patient was otherwise asymptomatic. Patient transitioned to rivaroxaban 20 daily after 3 weeks. Outpatient echo done 2 months after discharge showed a large pericardial effusion with tamponade physiology. Patient was instructed to go to hospital for admission. Labs were significant for Hgb 7.8, and elevated PT 52.50, INR 4.5 and PTT 33.80. Rivaroxaban was held, and patient was given 2 units FFP, Vitamin K 10 mg oral, Kcentra 4208 units and 2 units pRBCs. Patient underwent a pericardiocentesis with removal of 600 cc of sanguineous fluid. Fluid analysis was consistent with hemorrhagic effusion. Repeat echo showed a small residual, anterior pericardial effusion with constrictive physiology. Patient was discharged on reduced dose of rivaroxaban 10 daily and Vitamin K 5 mg daily until outpatient follow up. Our case of hemopericardium occurring in a middle-aged man without confounding issues is unusual. Although hemopericardium with DOACs have been reported, the majority of cases have occurred in patients with pre-disposing risk factors. A systemic review of 26 cases by Asad, et al. described risks associated with cardiac tamponade with DOACs. The incidence of hemopericardium and tamponade appeared highest in elderly men with renal and coagulation abnormalities. Our case highlights the importance of vigilance in patients on DOACs who present with subtle symptoms suggestive of hemodynamic compromise or instability.

A RARE CAUSE OF MULTIFOCAL PNEUMONIA AND CONSTRICTIVE PERICARDITIS: COXSACKIEVIRUS A

A RARE CAUSE OF MULTIFOCAL PNEUMONIA AND CONSTRICTIVE PERICARDITIS: COXSACKIEVIRUS A

AN UNUSUAL CULPRIT FOR EXERTIONAL DYSPNEA

AN UNUSUAL CULPRIT FOR EXERTIONAL DYSPNEA