A complicated diagnosis of constrictive pericarditis in a patient with atrial fibrillation - The importance of temporary pacing inducing regular heart rhythm during invasive hemodynamic study
Abstract
Background: Constrictive pericarditis (CP) is a rare disease frequently with nonspecific initial clinical manifestations. Transthoracic echocardiography (TTE) is a key imaging method for the CP diagnosis.
However, concomitant atrial fibrillation (AFib) may complicate the correct diagnosis, since some typical echocardiographic CP markers, especially those based on their respiratory changes may not be obvious or routinely evaluated. Case report: We present a case of initially asymptomatic 61-year-old male with elevated cholestatic enzymes of unclear etiology detected repeatedly over a period of 3 years, with chronic AFib but without signs of heart failure.
Prior to planned liver biopsy, a comprehensive TTE was performed showing some signs indicative of CP (including septal bounce and shift, annulus reversus and paradoxus and inferior fixed caval vein dilatation). Other TTE parameters based on respiratory variation, which are typically observed in CP with sinus rhythm, were unreliable in AFib.
Cardiac computer tomography and magnetic resonance showed pericardial thickening and calcification supporting but not confirming the CP diagnosis. Only after right ventricular pacing during catheterization, the typical discordance of peak systolic right and left ventricular pressure during respiration confirmed CP diagnosis.
After pericardiectomy, cholestatic enzymes decreased supporting the CP causal role. Conclusions: CP should be considered in unexplained increase of cholestatic enzymes.
In AFib, the TTE parameters based on respiratory variation may not be useful. However, a combination of the remaining TTE parameters can indicate CP and trigger further investigation.
Temporary pacing to avoid beat-to-beat variability in AFib can ''unmask'' the ventricular pressures discordance, and thus be helpful in unclear CP cases.