A heart too tightly hugged

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Case Presentation: An 83 year old male with history of uncomplicated cardiac bypass 1 year prior without pericardiectomy presented with symptoms of acute decompensated congestive heart failure despite Lasix therapy and salt- controlled diet. Following bypass, the patient had a progressive worsening of volume overload represented by progressive peripheral and pulmonary effusions despite normal ejection fraction and kidney function. Two weeks prior to admission he was hospitalized for decompensated heart failure with large transudative pleural effusions treated by thoracentesis.

On physical examination the patient was dyspneic at rest, with pulse of 64, BP of 105/64. JVD was visible to the angle of his jaw at 90 degree seated position with prominent x and y descents. Decreased breath sounds were noted halfway up posteriorly on right, with no murmurs or knock detected. 4+ edema was noted to sacrum, and liver edge was noted to be pulsatile. Chest X-ray confirmed a large right pleural effusion. BNP was 1328 pg/ml (normal: <100 pg/ml). EKG suggested a low voltage AV-dual paced rhythm. Repeat echocardiogram demonstrated a normal ejection fraction (73%) without valvular disease, similar to two prior studies. Aggressive diuresis led to hypotension and oliguric renal failure and ICU admission. MRI was not able to be performed due to severe illness and pacemaker insitu. Diagnostic Swan-Ganz catheterization in the ICU revealed Central Venous Pressure= 18 mmHg, RV pressure 22 mmHg, Pulmonary Artery mean pressure of 25 mmHg, Pulmonary Capillary Wedge pressure of 18 mmHg, demonstrating equalization of pressures consistent with constrictive pericarditis. The patient’s family elected to change patient to comfort care due to his illness and advanced dementia, and no autopsy was performed.

Discussion: Hospitalization for decompensated heart failure occurs in more than 1 million patients in the United States annually. Changes in systolic, diastolic dysfunction and valvular disease represent the majority of causes of this decompensation. CABG surgery is common in medicine, and constrictive pericarditis is an uncommon complication of this procedure (2.4%) which can masquerade as heart failure. Median time to development of symptoms is 4 weeks, with a wide range reported (3-96 weeks). Low voltage on EKG, predominantly right-sided heart failure symptoms and JVD with prominent x and y descents in patients with risks (recent prior CABG, chest irradiation, and tuberculosis) should prompt physicians to search for this difficult to diagnose condition. It is important to recognize this condition as the definitive treatment for constrictive pericarditis is pericardiectomy.

Conclusions: Rarely, pericardial constriction can present with heart failure. This is often not responsive to diuretics. If not recognized and appropriately treated, patients will not improve.

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Society of Hospital Medicine Annual Meeting


Baltimore, MD

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