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INTERESTING CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 203-205

Diffuse Constrictive Pericarditis with Focal Sparing Resulting in Multiple Ventricular Free Wall Outpouchings Mimicking Aneurysm


1 Department of Radiodiagnosis, B. Y. L Nair Ch. Hospital, Mumbai, Maharashtra, India
2 Department of Radiodiagnosis, SAIMS, Indore, Madhya Pradesh, India

Date of Submission17-Oct-2019
Date of Acceptance05-Jan-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Dr. Archit Gupta
Room No. 803, H-Building, B.Y.L Nair Ch. Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_48_19

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  Abstract 

We present a case of diffuse constrictive pericarditis (CP) with multiple right and left ventricular wall outpouchings, simulating ventricular free wall aneurysm. Few cases have been reported till date of multiple ventricular free wall aneurysm-like outpouching adjacent to surrounding regions of thickened pericardium in a patient with CP.

Keywords: Aneurysm, aneurysm-like outpouching, constrictive pericarditis


How to cite this article:
Gupta A, Varshney D. Diffuse Constrictive Pericarditis with Focal Sparing Resulting in Multiple Ventricular Free Wall Outpouchings Mimicking Aneurysm. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:203-5

How to cite this URL:
Gupta A, Varshney D. Diffuse Constrictive Pericarditis with Focal Sparing Resulting in Multiple Ventricular Free Wall Outpouchings Mimicking Aneurysm. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Oct 27];4:203-5. Available from: https://www.jiaecho.org/text.asp?2020/4/2/203/292629


  Introduction Top


Constrictive pericarditis (CP) is caused by scarring and loss of elasticity of the pericardium, resulting in external impedance to cardiac filling resulting in heart failure. The most common causes of CP include viral or idiopathic pericarditis, previous cardiac surgery, and thoracic irradiation.[1]


  Clinical Presentation Top


A 34-year-old male patient presented with dyspnea and chest pain with a history of progressive right heart failure who was referred for cardiac computed tomography (CT) considering the possibility of CP. His physical examination was notable for marked jugular venous distension, abdominal fullness with significant ascites, and peripheral edema.

The patient underwent cardiac CT which reveals diffuse pericardial thickening [Figure 1], measuring approximately 5 mm with significant pericardial calcifications except at few focal regions through which ventricular free wall outpouchings are seen. Three well-defined focal outpouchings arising from the spared portion of the pericardium mimicking ventricular aneurysm are seen. The left ventricular aneurysm-like outpouching measured 3 cm × 1.7 cm, and the right ventricular outpouching measured 2.0 cm × 1.5 cm and 1.7 cm × 1.0 cm [Figure 2], [Figure 3], [Figure 4].
Figure 1: Diffuse pericardial thickening with calcification

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Figure 2: Outpouching from the left ventricular free wall

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Figure 3: Outpouching from the right ventricle

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Figure 4: Another small outpouching from the right ventricular free wall

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The heart appeared tubular in shape. Dilated hepatic veins and inferior vena cava demonstrated changes consistent with right ventricular overload [Figure 5]. There was no evidence of pericardial contrast enhancement.
Figure 5: Dilated inferior vena cava due to the right ventricular overload

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Other imaging findings also seen in this patient included pulmonary thromboembolism with peripheral pulmonary infarcts and bilateral pleural effusion.


  Discussion Top


The pericardium is a thin, avascular sac, which composes of two layers: an inner serous and an outer fibrous collagenous layer.[2] Modalities such as CT and magnetic resonance imaging (MRI) provide excellent visualization of the pericardium. The thickness of the normal pericardium is <2 mm measured on CT or MRI.[3] Pericardial thickness of 4 mm or more indicates abnormal thickening and, when accompanied with clinical findings of heart failure, is highly suggestive of CP.[3]

CT has a high sensitivity in depicting pericardial calcification, which is also associated with CP. However, neither pericardial thickening nor calcification is diagnostic of CP unless the patient also has symptoms of heart failure.[2] Other differentials which should be considered in patients with focal aneurysm include arrhythmogenic right ventricular dysplasia, acute myocardial infarction, acute myocarditis, and iatrogenic injury.[4]


  Conclusion Top


Our case very well demonstrates diffuse pericardial involvement consistent with CP with few focal region of sparing. The ventricular free wall that was covered with normal pericardium was not constricted and the adjacent thickened pericardium was stiff enough that this normal region protruded in between the edges of the thickened pericardium, simulating an aneurysm. The region of the ventricle that appeared abnormal and showed aneurysmal outpouching was normal-functioning portion with an overlying normal pericardium.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sengupta PP, Eleid MF, Khandheria BK. Constrictive pericarditis. Circ J 2008;72:1555-62.  Back to cited text no. 1
    
2.
Bogaert J, Francone M. Cardiovascular magnetic resonance in pericardial diseases. J Cardiovasc Magn Reson 2009;11:14.  Back to cited text no. 2
    
3.
Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW, Higgins CB. CT and MR imaging of pericardial disease. Radiographics 2003;23 Spec No: S167-80.  Back to cited text no. 3
    
4.
Kayser HW, van der Wall EE, Sivananthan MU, Plein S, Bloomer TN, de Roos A. Diagnosis of arrhythmogenic right ventricular dysplasia: A review. Radiographics 2002;22:639-48.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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