Entrapped Coronary Arteries in Constrictive Pericarditis

Key words: coronary artery imaging, pericarditis

A 49-year-old female patient presented with progressive shortness of breath, and abdominal and leg swelling. Her medical history was significant for stage 3 breast cancer, which was treated with multiple rounds of chemotherapy and radiation over 7 years. Electrocardiogram showed Q-waves in V1 and V2. Bedside echocardiogram showed a left ventricular ejection fraction of 25% with severe global hypokinesis. Troponin I was elevated at 1.15 ng/mL. She was taken to the cardiac catheterization lab, where a coronary angiogram showed no obstructive coronary artery disease (Figure 1), but revealed an unusual motion abnormality of the coronary arteries that is typical for pericardial constriction (Videos 1 and 2). The pericardium was unremarkable on fluoroscopy. Subsequent echocardiography revealed other signs of constrictive pericarditis with thickened pericardium, interventricular interdependence, and annulus reversus (lateral e' velocity < medical e' velocity).

Pericardial constriction can be present without pericardial calcium and often without pericardial thickening. This epicardial coronary artery motion abnormality due to entrapment in a thickened, fibrotic pericardium, is characteristic of constrictive pericarditis, and differentiates this entity from other close differential diagnoses, such as restrictive and dilated cardiomyopathy.