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Graphical abstract, Highlights • Tuberculous pericarditis is the most common cause of pericarditis worldwide. • Consider the possibility of TB-IRIS in patients with tuberculous pericarditis. • Corticosteroids might be necessary, but there are several caveats to consider.

A 72-year-old man on rivaroxaban developed effusive constrictive pericarditis secondary to hemopericardium. His condition improved with anti-inflammatory therapy supporting a diagnosis of transient constrictive pericarditis. On follow-up, residual constriction developed requiring surgical pericardiectomy. Although many cases with transient constrictive pericarditis resolve with medical management, some may progress and require pericardiectomy. (Level of Difficulty: Advanced.), Graphical abstract

A 52-year-old female developed acute idiopathic pericarditis, which was complicated with tamponade. Constrictive physiology persisted after pericardiocentesis, and effusive-constrictive pericarditis (ECP) was diagnosed. Constrictive physiology improved in 10 days with anti-inflammatory therapy. This case was remarkable because it showed that ECP may present in an acute and reversible form. (Level of Difficulty: Beginner.), Graphical abstract, A 52-year-old female developed acute idiopathic pericarditis, which was complicated with tamponade. Constrictive physiology persisted after…

Graphical abstract, Highlights • AML infrequently causes tamponade and effusive constrictive pericarditis. • Pericardial cytology has limited sensitivity for malignancy. • Imaging identifies pericardial effusion and confirms tamponade and constriction.

Primary malignant pericardial mesothelioma is a rare cardiac neoplasm. The authors evaluated risk factors, clinical presentation, and outcomes…, Primary malignant pericardial mesothelioma is a rare cardiac neoplasm. The authors evaluated risk factors, clinical presentation, and outcomes by reviewing all biopsy-confirmed cases at one institution. The use of multimodality imaging, detailed hemodynamic assessment for the presence of an effusive-constrictive profile, and cytology evaluation can support the diagnosis. (Level of Difficulty: Advanced.), Graphical abstract

This report describes a case of pericardial effusion and tamponade that appeared several weeks after WATCHMAN device…, This report describes a case of pericardial effusion and tamponade that appeared several weeks after WATCHMAN device (Boston Scientific, Natick, Massachusetts) placement for left atrial appendage occlusion. The report also discusses the likely etiology and clinical management of this uncommon condition. (Level of Difficulty: Intermediate.), Graphical abstract

An 80-year-old man presented to our hospital complaining of loss of appetite. During the medical examination, he developed variant angina accompanied with heart failure. Oral calcium channel blocker therapy controlled his variant angina, but medical management of heart failure became increasingly difficult due to gradually increasing pericardial effusion, and pericardiocentesis leading to the diagnosis of effusive-constrictive pericarditis (ECP). Here, we report a rare case of idiopathic pericarditis caused variant angina with already having endothelial dysfunction and eventually developed ECP.

Case presentation A 33 year-old black female, born in Angola, staying in Portugal 1 week before admission presented to the emergency department of our hospital with a history of worsening but recurring pleuritic chest accompanied by dyspnea, fatigue, peripheral oedema and sweating in the past 4 years. Initial workup in Angola and more recently in Namibia was unrevealing. The patient had taken 3 months of antituberculous agents and a systemic corticosteroid and was medicated with furosemide and spironolactone. Since then the symptoms persisted and multiple admissions for decompensated heart failure followed. At presentation median blood pressure was 60mmHg, heart rate 90 beats per minute, temperature 37,6ºC. Auscultation had signs of pulmonary congestion and muffled heart sounds, the neck veins were distended. An electrocardiogram showed sinus rhythm and low-voltage complexes in limb and precordial leads. Initial transthoracic echocardiogram revealed a thickened pericardium with circunferencial effusion and marked respiratory variation (>25%) of the mitral and tricuspid inflow doppler velocities. Pericardiocentesis was performed with improved dyspnea and blood pressure after drainage of 650 mL of serohematic fluid. Echocardiographic follow-up showed a mild circunferencial pericardial effusion and extensive areas of thickened crypted pericardium with fibrin strands containing heterogeneous fluid (figure 1). There were signs of constriction. A cardiac CT revealed no calcium deposition. Fluid cytology was predominant for lymphocytes and biochemistry, cultures, polymerase chain reaction and immunochemistry were inconclusive and no pathologic agent was isolated. The image findings in the transthoracic echocardiogram coupled with the demographics and past clinical history of the patient prompt the initiation of antituberculous therapy in association with systemic corticosteroids in an attempt to ameliorate the pericardial constriction. Despite initial therapeutic response, constriction was deemed irreversible and pericardiectomy was performed. The workup for definitive diagnosis is still undergoing. Discussion Effusive-constrictive pericarditis is defined by a pericardial effusion with signs of concurrent pericardial constriction. In these cases the scarred pericardium not only constricts cardiac volume but can also accommodate pericardial fluid under increased pressure leading to signs of cardiac tamponade. The initial approach should be the treatment of the underlying condition but if such remains ineffective, pericardiectomy is the remaining option and is reserved for patients in which constriction becomes severe and/or persistent. This condition is more prevalent with tuberculous pericarditis and when suspected presumptive treatment should be initiated in immunocompetent patients from endemic regions. Antituberculous treatment regimens in conjunction with systemic corticosteroids have shown to prevent complications from pericardial constriction. Abstract P875 Figure.

A 59 year old man was admited to hospitalization for persistent chest pain related to acute pericarditis. Within the admision tests, a transthoracic echography was performed, showing a moderate pericardial effusion with ventricular septal bounce and significant respiratory variations in mitral and tricuspid inflows, all of it consistent with effusive-constrictive pericarditis (Panel A). Anti-inflammatory treatment with ibuprofen and colchicine was started. During the first 48 hours of admission there was a clinical and hemodinamic worsening in the patient’s condition that forced the performance of a pericardial window, obtaining a very little quantity of dense pericardial fluid. Looking for a more accurate study of the pericardium, a cardiovascular magnetic resonance (CMR) was performed, revealing a thick heterogeneous pericardial effusion (Panel B) and a significant late gadolinium enhancement of both pericardial layers (Panel C). All these findings where consistent with an effusive constrictive pericarditis with persistent inflammatory activity despite high doses of conventional inflammatory treatment. Furthermore, the growth of Propionibacterium acnes in the pericardial fluid disclosed the etiology of this condition. Medical treatment was enhanced with high doses of intravenous corticosteroid, ceftriaxone and doxycycline. During the following days, the patient showed an excellent response achieving the complete clinical and echocardiographic relief of constrictive signs (Panel D). Effusive constrictive pericarditis is characterized by the presence of pericardial effusion and constriction secondary to an inflammatory process of the pericardium. Pericardiectomy might be necessary in case of failure of medical treatment, a very common scenario in this kind of .pericarditis. Our case is remarkable because it demonstrates the value of CMR to detect persistent inflammation of pericardium despite high doses of conventional medical treatment for pericaricarditis guiding the successful escalation to intravenous corticosteroid and avoiding the risk of an unnecessary cardiac surgery. Abstract 1095 Figure.

Chronic effusive-constrictive pericarditis was successfully treated by removal of the visceral pericardium in a 15-year-old Thai female. The constrictive visceral pericardium was barely detected by noninvasive studies. This case highlights the importance of removal of the visceral pericardium in this condition. If only the parietal pericardium is removed, the patient will not improve clinically.

Transient effusive constrictive pericarditis is a rare complication of purulent pericarditis in children. It is due to persistent elevation of right atrial pressure even after the effusion is drained. Immediate pericardiocentesis, antibiotics, nonsteroidal anti inflammatory drugs and early diagnosis of transient CP will improve the outcome. We present a 2 year old child with this condition and its conservative management.

We present the case of a 55‐year‐old female marathon runner who presented with progressive exercise intolerance and was diagnosed with effusive‐constrictive pericarditis. Stereotypical findings of this challenging diagnosis are shown by transthoracic echocardiographic and right heart catheterization. We treated the patient with a parietal pericardiectomy and pericardial waffle procedure to relieve a thick and constrictive epicardium.

Peak left ventricular strain measured by speckle tracking echocardiography has previously been shown to normalize following pericardectomy in constrictive pericarditis, as indicated by an increase of the strain ratio between the lateral wall and septum. Here we present a case of effusive constrictive pericarditis treated with corticosteroids. Pre-treatment we observed reduced contractility of the lateral walls of both ventricles as measured by peak strain, with sparing of overall septal function, but with hypercontractility of the basal septal segment. Septal and lateral wall function normalized with corticosteroid treatment. Our observations from this case prompts investigation into the value of lateral/septal wall strain ratios in both ventricles for quantitatively monitoring the response of constrictive pericarditis to medical therapy. .

Effusive-constrictive pericarditis (ECP) is an uncommon syndrome with concomitant tamponade and constriction of visceral pericardium. A previously healthy 36-year-old male presented with worsening dyspnea, abdominal distention for 7 months, just 11 months after a falling trauma with knee, rib

Background and objectives In East Asia, tuberculous pericarditis still occurs in immunocompetent patients. We aimed to investigate clinical course of tuberculous pericarditis and the trends of echocardiographic parameters for constrictive pericarditis. Methods We retrospectively analyzed medical records of patients with tuberculous pericarditis between January 2010 and January 2017 in Samsung Medical Center. Treatment consists of the standard 4-drug anti-tuberculosis regimen for 6 months with or without corticosteroids. We performed echocardiography at initial diagnosis, 1, 3 and 6 months later. Results Total 50 cases with tuberculous pericarditis in immunocompetent patients were enrolled. Echocardiographic finding at initial diagnosis divided into 3 groups: 1) pericardial effusion only (n=28, 56.0%), 2) effusive constrictive pericarditis (n=10, 20.0%) and 3) constrictive pericarditis (n=12, 24.0%). The proportion of patients with constrictive pericarditis decreased gradually over time. After 6 months, only 5 patients still had constrictive pericarditis. Out of the 28 patients who initially presented with effusion alone, only one patient developed constrictive pericarditis. Echocardiographic parameters representing constrictive pericarditis gradually disappeared over the follow up period. Ventricular interdependency improved significantly from 1 month follow-up, whereas septal bounce and pericardial thickening were still observed after 6 months without significant constrictive physiology. Conclusions Tuberculous pericarditis with pericardial effusion without constrictive physiology is unlikely to develop into constrictive pericarditis in immunocompetent hosts, if treated with optimal anti-tuberculous medication and steroid therapy. Even though there were hemodynamic feature of constrictive pericarditis, more than 80% of the patients were improved from constrictive pericarditis.

Pericarditis is the most common pericardial disease worldwide, and can be recurrent in one third of the patients with viral and idiopathic pericarditis [1]. The diagnosis of pericarditis should be based on clinical criteria, history, clinical findings, electrocardiographic (ECG) changes and evidence of a pericardial effusion [2]. Elevation of the inflammatory markers and evidence of pericardial inflammation by an imaging technique such as contrast enhancement on the pericardium-CT scan or pericardial edema and pericardial late gadolinium enhancement on cardiac magnetic resonance imaging (MRI) are additional supportive criteria in the diagnosis [1].

Background: Patients admitted with chest pain and electrocardiographic (ECG) changes have more than one possibility. Wrong diagnosis and management can lead to complications up to death. Case presentation: A 55 year male presented with severe chest pain. ECG revealed raised ST segment in inferior leads. The PR segment depression of pericarditis was overlooked. The patient was admitted, received loading doses of dual antiplatelet (DAP) (ASA 300 mg & Clopidogrel 300 mg) plus heparin. Clinical findings: Exam: B.P.: 110/70, T. 37 ˚C. Normal jugular venous pulse (JVP). Heart: Normal. Echo revealed no regional wall motion abnormalities and no pericardial effusion. CKMB = -ve, Troponin Zero. Diagnostic assessments: Coronary angio revealed 95% lesion in proximal RCA segment (Figure). Therapeutic interventions: Primary stenting was done. He was still complaining of the chest pain; 3 days later pericardial Rub was heard. ECHO revealed Large Pericardial effusion with no signs of tamponade. Ibuprofen (400 mg t.i.d.) + DAP with stomach protection. Follow-up and outcomes: Three weeks later the patient was complaining of dyspnea grade III, no cyanosis. Cardio-thoracic surgery was consulted for open pericardiocentesis; 12 hours later, the patient\'s dyspnea became Grade IV, his blood pressure was 80/50 mmHg with pulsus paradoxus, RR= 40 cycles/min. The patient became anuric. Lab: INR = 2.5, K = 6.9 mmol/L, BUN = 87 mg/dl, then 110, Cr = 3.5 mg/dl, then 5. SGOT= 1023, SGPT= 501. One session of hemodialysis was done. Patient arrested before open pericardiocentesis was done. Conclusions: Acute pericarditis if subjected to dual antiplatelet therapy can lead to hemorrhagic pericardial effusion, then constrictive pericarditis and congestive heart failure.

Myopericarditis is primarily a pericardial inflammatory syndrome occurring when clinical diagnostic criteria for pericarditis are satisfied and concurrent mild myocardial involvement is documented by elevation of biomarkers of myocardial damage (i.e. increased troponins). Limited clinical data on the causes of myopericarditis suggest that viral infections are among the most common causes in developed countries. Cardiotropic viruses can cause pericardial and myocardial in!ammation via direct cytolytic or cytotoxic effects and/or subsequent immune-mediated mechanisms. Many cases of myopericarditis are subclinical. In other patients, cardiac symptoms and signs are over shadowed by systemic manifestations of infection or inflammation. The increased sensitivity of troponin assay and contemporary widespread use of troponins has greatly increased the reported number of cases. Management is similar to that reported for pericarditis, generally with a empiric anti-inflammatory drugs mainly aimed to control symptoms. Rest and avoidance of physical activity beyond normal sedentary activities has been recommended for 6 months is recommended as for myocarditis. At present, there is no evidence that troponin elevation confers worse prognosis (i.e. a greater risk of recurrence, death or transplantation) in patients with preserved left ventricular function. Usually complete remission is seen in 3 to 6 months. We report here a case of a 18 year young man with acute myopericarditis who presented with transient effusive-constrictive pericarditis.Bangladesh Med J. 2015 Sep; 44 (3): 165-167