Introduction:

Based on the clinical presentation and multimodality imaging findings, a diagnosis of constrictive pericarditis was established. No clear underlying aetiology was identified.

Following multidisciplinary team discussion, treatment options—including surgical pericardiectomy and conservative management—were considered. Given the patient’s advanced age and estimated surgical risk, he opted for conservative medical management. Invasive haemodynamic assessment with right heart catheterisation was therefore not pursued.

The patient was discharged on bumetanide 3 mg daily and spironolactone 37.5 mg daily. At six-week follow-up, his dyspnoea had improved, although peripheral oedema persisted. Metolazone 2.5 mg on alternate days was subsequently initiated to optimise diuretic therapy.

3. Discussion

Constrictive pericarditis (CP) is an uncommon but important cause of heart failure in developed countries, accounting for fewer than 0.5% of cases of heart failure presentations. The aetiology is heterogeneous and includes idiopathic disease, prior cardiac surgery, mediastinal radiation therapy, and infectious causes, particularly tuberculosis in endemic regions. [2,5] Despite advances in imaging and clinical recognition, CP remains diagnostically challenging because its clinical manifestations frequently overlap with other forms of heart failure, particularly heart failure with preserved ejection fraction (HFpEF).

The fundamental pathophysiological feature of CP is the presence of a rigid, non-compliant pericardium that restricts normal diastolic expansion of the cardiac chambers. This leads to impaired ventricular filling, dissociation between intrathoracic and intracardiac pressures, and exaggerated ventricular interdependence. Consequently, ventricular filling becomes limited and cardiac output may be reduced, while systemic venous congestion results in clinical features predominantly related to right-sided heart failure, including peripheral oedema, ascites, and elevated jugular venous pressure. [6]

Accurate diagnosis requires careful integration of clinical findings with multimodality imaging. [4,7,8] Transthoracic echocardiography is usually the initial imaging modality and may demonstrate characteristic findings such as abnormal interventricular septal motion (“septal bounce”), respiratory variation in transvalvular flow velocities, and features suggesting elevated right atrial pressure. [6,9] However, echocardiography alone may not always provide definitive diagnostic information, particularly in patients with limited acoustic windows or atypical haemodynamic features. [7,8]

Advanced imaging modalities therefore play a central role in the evaluation of suspected constrictive physiology. Cardiac magnetic resonance (CMR) provides detailed assessment of pericardial morphology and ventricular interaction, enabling visualisation of septal bounce, respiratory variation in ventricular filling, and ventricular interdependence. In addition, CMR allows assessment of myocardial tissue characteristics and can identify concomitant myocardial disease, which is important in differentiating constrictive pericarditis from restrictive cardiomyopathy. [10,11] As highlighted in recent reviews of pericardial imaging, CMR has emerged as a powerful non-invasive tool for characterising pericardial disease and evaluating associated myocardial pathology. [3,6]

Computed tomography (CT) provides excellent spatial resolution for anatomical assessment of the pericardium and is particularly sensitive for detecting pericardial thickening and calcification. CT is therefore especially valuable in chronic calcific pericarditis, where dense circumferential calcification may be readily demonstrated. Contemporary multimodality imaging strategies integrating echocardiography, CMR, and CT have significantly improved the diagnostic accuracy of CP while reducing the need for invasive haemodynamic assessment in many patients. [3]

Distinguishing constrictive pericarditis from heart failure with preserved ejection fraction (HFpEF) remains a common clinical challenge because both conditions may present with similar symptoms of exertional dyspnoea and systemic venous congestion. However, certain clinical and biochemical features may aid differentiation. In patients with CP, natriuretic peptide levels are often normal or only mildly elevated despite significant clinical congestion, reflecting the relatively preserved myocardial wall stress compared with myocardial causes of heart failure. In contrast, HFpEF is typically associated with elevated natriuretic peptide concentrations. Imaging findings such as septal bounce, exaggerated ventricular interdependence, and dissociation between intrathoracic and intracardiac pressures are characteristic of constrictive physiology and help distinguish CP from myocardial disease. [3,12]

Management of CP should be individualised according to symptom severity, comorbidities, and operative risk. In patients with mild symptoms or significant comorbid conditions that increase surgical risk, conservative treatment with diuretics may provide symptomatic relief by reducing systemic congestion. [12] However, medical therapy does not address the underlying mechanical constraint imposed by the diseased pericardium. For patients with advanced symptoms and acceptable surgical risk, pericardiectomy remains the definitive treatment and can lead to substantial haemodynamic and symptomatic improvement. [13]

The present case highlights the clinical challenges encountered when managing elderly patients with CP. In this instance, the patient elected conservative therapy because of advanced age and perceived operative risk. Although medical therapy improved symptoms, the underlying constrictive physiology remained untreated, and careful clinical follow-up was required.

An additional noteworthy aspect of this case is the incidental identification of extensive pericardial calcification during invasive coronary angiography performed to evaluate suspected coronary artery disease. Fluoroscopic recognition of extra-coronary findings, such as curvilinear pericardial calcification outlining the cardiac silhouette, can provide an important diagnostic clue. In this patient, the angiographic observation prompted further targeted multimodality imaging that ultimately established the diagnosis of CP. This emphasises the importance of maintaining diagnostic vigilance and recognising extracardiac and extra-coronary findings during invasive procedures

Overall, this case highlights the growing importance of multimodality imaging in the evaluation of suspected constrictive pericarditis. Integrating echocardiography, CMR, and CT allows comprehensive non-invasive assessment of both pericardial anatomy and cardiac physiology, facilitating accurate diagnosis even in complex or atypical presentations. [3,4,6]

4. Conclusions

Constrictive pericarditis is an uncommon but clinically important and potentially treatable cause of heart failure that may mimic HFpEF. Accurate diagnosis requires a high index of suspicion and careful integration of clinical findings with multimodality imaging. Echocardiography, cardiac magnetic resonance, and computed tomography provide complementary information regarding pericardial structure and constrictive physiology.

Although diuretic therapy may provide symptomatic relief in selected patients, surgical pericardiectomy remains the only definitive treatment. Patients managed conservatively require careful follow-up due to the persistent underlying constrictive pathology.

5. Key Learning Points

• Constrictive pericarditis is an uncommon but important reversible cause of heart failure that frequently mimics HFpEF.
• Incidental pericardial calcification detected during coronary angiography may provide a crucial diagnostic clue.
• Multimodality imaging—including echocardiography, cardiac CT, and cardiac magnetic resonance—is central to establishing the diagnosis.
• Septal bounce and ventricular interdependence on imaging are key physiological markers of constrictive physiology.
• Surgical pericardiectomy remains the definitive therapy; however, management must be individualised in elderly patients with significant operative risk.

6. Abbreviations:

AL1:                     Amplatz Left 1

CMR:                   Cardiac Magnetic Resonance Imaging

CP:                       Constrictive pericarditis

CT:                       Computed tomography

HFpEF:  Heart Failure with preserved Ejection Fraction

IVS:                      Interventricular septum.

LA:                       Left atrium,

LV:                        Left ventricle

NYHA:   New York Heart Association

RA:                       Right atrium,

RV:                       Right ventricle

SSFP:                   Steady-state free precession

7. Declarations

Authors’ contributions

ASS, HK, BS: Conceptualization, Writing—original draft, Writing—review & editing. ASS, HK, BS: Writing—original draft, Writing—review & editing. ASS, HK, BS, MF, AS: Writing—review & editing. All authors read and approved the submitted version.

Conflicts of interest

The authors declare that there are no conflicts of interest.

Ethical approval

The study was conducted in accordance with institutional guidelines and the principles of the Declaration of Helsinki. A formal ethical approval was not required for this retrospective case report.

Consent to participate

Informed consent to participate in the study was obtained from the patient.

Consent to publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Funding Statement

This research work did not receive any external funding.

Availability of Data and Materials

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declaration of generative AI and AI-assisted technologies in the writing process

The authors declare that ChatGPT was used solely to assist with language editing and improving clarity of expression. The tool was not used to generate scientific content, analyse data, or develop conclusions. All intellectual contributions are entirely those of the authors. The manuscript was carefully reviewed and revised by the authors, who take full responsibility for its content and integrity.