Effusive--constrictive epicarditis that developed more than 5 years after ventricular septal defect closure: two cases relieved by epicardiectomy

Constrictive pericarditis following open-heart surgery in a child

A 6-year- old child developed constrictive pericarditis 2 years after undergoing an open-heart surgery for a congenital cardiac disorder. No other cause of pericarditis was identified. The clinical condition improved after pericardiectomy. The case is reported for its rarity.

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.

A girl with right heart failure related to effusive-constrictive pericarditis

Effusive-constrictive pericarditis is characterized by constriction of visceral pericardium with a coexisting tense pericardial effusion. We report a 10-year-old girl with right heart failure due to effusive-constrictive pericarditis. She did not present typical features, such as cardiac tamponade or thickening of pericardium (visceral and parietal), but constrictive physiology was observed by echocardiography and cardiac computed tomography. These noninvasive imaging modalities provided clinical clues to make precise diagnosis. The patient underwent surgical drainage of pericardial fluid and visceral pericardiectomy, which resulted in improved hemodynamics and symptoms.

Isolated subacute effusive and nonconstrictive epicarditis masquerading as a right atrial mass

Epicarditis (visceral pericardial inflammation) is a very unique and rare diagnosis. It is almost always associated with parietal pericardial involvement and may occur in medical conditions such as viral, bacterial (mycobacterial) infections and uremia or postoperatively in the setting of cardiac surgery. Frequently, no etiology is found. Most cases are associated with constrictive physiology, and patients present with symptoms and signs of right-sided heart failure. Effusive epicarditis is often present, and the clinical features may easily be confused with those of pericardial effusion with tamponade. We report a unique case of isolated subacute effusive and nonconstrictive epicarditis mimicking a right atrial mass in a 72-year-old patient who was diagnosed with nonmetastatic gastric adenocarcinoma. Our case is unique for several reasons: inflammation was limited to the epicardium (very few cases have been described to date); the patient was asymptomatic, with no clinical or echocardiographic evidence of constriction (this represents a novel finding, explained in part by the more limited extent of inflammation, with no significant fibrotic component and no parietal pericardial involvement); and this is the first report of epicarditis occurring in association with a malignancy, which we hypothesize may represent an inflammatory paraneoplastic process.