P187 Multimodality in tuberculous constrictive pericarditis

CASE PRESENTATION

K.C.P., a 26 y.o. female, presenting dizziness and progressive dyspnea since 9 months ago. Physical examination showed hepatomegaly at 2 centimeters below the right inferior costal border, but without edema, cardiac murmurs or other findings. Electrocardiogram showed atria overload and diffuse ventricular repolarization abnormality. Chest X-ray revealed normal sized cardiac silhouette but with signs of pericardial calcification. Transthoracic echocardiogram revealed: enlargement of both atria, no signs of myocardial left ventricular (LV) hypertrophy; dilated inferior vena cava with minimal respiratory variation; septal bounce; septal e´= 17.20 cm/s, lateral e´= 6.09 cm/s; E/e" septal ratio = 3.9; E deceleration time = 144 ms; thickening and hyper-refringence of the pericardium with calcification adjacent to the lateral and inferior walls of the LV and the free wall of the right ventricle. For evaluation of thickness and extent of pericardial involvement, computed tomography (CT) was performed, showing gross calcifications of the pericardium, mainly in basal and lower portions, without pericardial effusion. Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement revealed areas suggestive of active inflammation adjacent to the basal wall of the LV. With this evidence of active inflammatory activity, the patient was treated empirically against the etiologic agent for tuberculosis. Because of progressively severe edema and dyspnea pericardiectomy was warranted providing relief of symptoms. DISCUSSION: The echocardiogram is the initial image exam for diagnosis and monitoring of pericardial conditions. It is a widely available, low-cost method that does not use ionizing radiation and allows a complete morphological and functional evaluation of the heart. However, in up to 20% of cases, pericardial thickening may not be detectable at echocardiography. CT allows a more accurate assessment of pericardial thickening, while CMR allows detection of active inflammatory process. CONCLUSION: A typical and illustrative clinical case of constrictive pericarditis is presented, where the multimodality of cardiac imaging was decisive for the diagnostic and therapeutic delineation.