Subacute effusive-constrictive pericarditis: Echocardiography-guided diagnosis and management

A 49-year-old man presented with flu-like symptoms of two weeks. Electrocardiogram showed diffuse ST elevation. Blood samples revealed severe renal failure and moderate inflammatory results. Echocardiogram showed large pericardial effusion, dilated inferior vena cava, but no right ventricular collapse. The patient underwent hemodialysis, after which he developed clinical signs of cardiac tamponade with echocardiographic features of collapse of the right ventricle. Pericardial drainage was then performed revealing purulent fluid of 800 ml. Streptococcus agalactiae was found in the cultures of urine, blood, and pericardial fluid. Despite removal of the pericardial fluid, echocardiogram failed to show any improvement in dilated inferior vena cava and estimated right atrial pressure remained elevated. Thus, a diagnosis of subacute effusive-constrictive pericarditis was made. Following antibiotic treatment for purulent pericarditis, early pericardiectomy was performed under transesophageal echocardiographic monitoring which successfully guided surgeons to careful removal of thick and adhesive visceral pericardium as well as an additional Waffle procedure resulting in significant clinical and hemodynamic improvement. Echo-guided approach is most practical in establishing the diagnosis of effusive-constrictive pericarditis and also most helpful in obtaining successful surgical results. <Learning objective: Diagnosis of effusive-constrictive pericarditis is difficult and is not often made because of mixtures of clinical findings associated with effusion/tamponade and constriction. Echo-guided approach is most practical in establishing the diagnosis by detecting absence of normalization in dilatation of the inferior vena cava after pericardial drainage. Also, since careful removal of visceral pericardium is mandatory, transesophageal echocardiographic monitoring during pericardiectomy plays an essential role in obtaining successful surgical results.>.