Biopsy‐Proven Cirrhosis with a Third Heart Sound — a Common Presentation of Constrictive Pericarditis

1Henry Ford Hospital, Detroit, MI
2Wayne State University, Detroit, MI
3Henry Ford Hospital, Detroit, MI
4Henry Ford Hospital, Detroit, MI

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 452

Case Presentation:

A 48‐year‐old man with history of hypertension, hyperlipidemia, congestive obstructive pulmonary disease, heart failure with preserved ejection fraction, and cirrhosis presented complaining of progressive shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea, slowly worsening over the last 4 years. He was diagnosed with cirrhosis by biopsy at an outside hospital. During this time, he was admitted multiple times for volume overload, multiple diagnostic studies were done concluding that liver cirrhosis was the main etiology for his symptoms. He was referred to our hospital for liver transplant evaluation. His physical exam was consistent with signs of fluid overload. Laboratory workup was unremarkable, except for mildly elevated liver function tests. Given the etiology of his liver cirrhosis was unknown, and his symptoms pointed to a cardiovascular etiology, our cardiology department evaluated the case and a transthoracic echocardiogram looking for specific findings was done, showing signs of ventricular interdependence, suggestive of constrictive physiology. To confirm the diagnosis, a simultaneous left and right heart catheterization was done, showing elevated filling pressures, classic findings of constriction were not seen. Given that the diagnosis was still strongly suspected, the patient was aggressively diuresed and catheterization was repeated 5 days later, showing ventricular discordance and early diastolic filling, confirming the diagnosis of constrictive pericarditis. Patient went for pericardiectomy, showing a thick, fibrotic pericardium, pathology confirmed the diagnosis. After surgery, for the first time in years, the patient felt his swelling was coming down and his shortness of breath was improving, later his orthopnea and paroxysmal nocturnal dyspnea disappeared. An interval echocardiogram showed no signs of ventricular interdependence. He lost around 40 pounds, his edema resolved, and his symptoms of shortness of breath are almost fully gone by now.

Discussion:

Constrictive pericarditis is a disease characterized by the encasement of the heart by a rigid nonpliable pericardium, most of the time idiopathic. The presentation is the typical of diastolic heart failure with congestive symptoms, making the diagnosis challenging and confusing, frequently missed, as in our case. The most interesting feature is that it is a potentially reversible condition, and patients undergoing surgery have great improvement in their quality of life. The prevalence of constrictive pericarditis may be higher than thought, and considering the large number of patients that are admitted for heart failure every year to hospitals across the country, it is important to recognize this potentially reversible condition.

Conclusions:

This case highlights the importance of recognizing a potentially reversible condition in our inpatient heart failure population.

To cite this abstract:

Calle‐Muller C, Morris M, Njeim M, Baker‐Genaw K. Biopsy‐Proven Cirrhosis with a Third Heart Sound — a Common Presentation of Constrictive Pericarditis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 452. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/biopsyproven-cirrhosis-with-a-third-heart-sound-a-common-presentation-of-constrictive-pericarditis/. Accessed November 13, 2019.

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