PMC10351041_01
(A) Transthoracic echocardiography before cardiac surgery. (B) Transthoracic echocardiography after cardiac surgery.
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F1
The transthoracic echocardiography showed moderate dysfunction of the left ventricle (LV) (with an ejection fraction of 46%), severe desynchrony of the ventricular septum, a global longitudinal strain (GLS) of -12.9%, the right ventricle (RV) with a normal function, and no significant regurgitation of the atrioventricular valve (Figure 1A). One week after surgery, transthoracic echocardiography was repeated and showed normalization of left ventricular function (3D ejection fraction 55%), and the GLS improved (-18.3%) (Figure 1B).
Cine steady-state free precession four- and two-chamber view images show circumferential pericardial effusion (A,B), with uniform pericardial thickening at T1-weighted short-axis view image (C). There is no significant hyperintense signal on the edema-weighted image (D) while a marked late gadolinium enhancement of pericardial layers is evident (E,F), suggesting diffuse pericardial fibrosis. Short-axis real-time cine MRI sequence during operator-guided breathing (G,H) demonstrates an abnormal displacement of the interventricular septum during the onset of inspiration, due to a fixed pericardial volume with reduced ventricular compliance and consequent increase of the right ventricular filling on inspiration.
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F2
A cardiac MRI was performed also 6 months after the first one and confirmed constriction with diffuse fibrotic thickening of the pericardial sac and signs of ventricular interdependence evident in the dynamic sequences (flattening of the interventricular septum in maximal inspiration), suggestive of constrictive physiology (Figure 2).
Normally, there is a concordant fall in LV and RV pressures in inspiration. In constriction, there is discordance of LV and RV pressure changes in inspiration: the LV pressure falls, and the RV pressure rises. Also, the ventricular pressure tracings show an early diastolic dip in pressure followed by a plateau phase due to rapid early diastolic filling and subsequent restriction in filling (square root sign or dip and plateau sign).
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F3
Specimen of anterior parietal layer pericardium post-pericardiectomy.
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F4
At this point, the patient underwent anterior and posterior pericardiectomy surgery with preservation of the phrenic nerves, a procedure performed in normothermic cardiopulmonary bypass with a beating heart (Figure 4).