The Heterogeneous Expressions of Pericardial Disease: A Case Report/Series

Introduction: The pericardium may have various phenotypic manifestations in assorted disease states, such as acute pericarditis, effusive constrictive pericarditis, and constrictive pericarditis. The variety in the phenotypic expressions of pericardial inflammation requires unique clinical and physical examinations and is associated with specific imaging features. The present study aimed to review the normal pericardium and variations of the pericardial disease based on the previously described cases and discuss the clinical manifestations, etiology, diagnostic tools, and treatment methods.Case Series: A case series of three patients with various phenotypic expressions of pericardial disease have been described. The first patient presented with chest and abdominal pain for three hours. Electrocardiography (ECG) revealed inferior-lateral ST elevation, which was interpreted as an acute coronary syndrome. However, coronary arteriography revealed no obstructive coronary artery disease. Blood tests and ECG post-cardiac catheterization confirmed pericarditis. The second patient had ablation of the cavotricuspid isthmus on the right side of the atrial flutter. After the procedure, the patient had cardiac tamponade and required pericardiocentesis. After two months, the patient presented with tachycardia and hypotension, as well as cardiac tamponade; therefore, pericardiocentesis was performed again. Two years after the second pericardiocentesis, the patient presented with progressive dyspnea. Perfusion imaging revealed anterior wall ischemia, and coronary arteriography revealed three-vessel coronary artery disease. During the bypass surgery, the surgeon was unable to dissect the right and circumflex coronary arteries due to the densely thickened pericardium of the patient. In addition, CT-scan revealed a fibrotic pericardium (thickness: 12 mm). The third patient received chemotherapy and radiation for breast cancer, which resulted in a cancer-free state. However, breast cancer was recurrent, and the patient received treatment with biological Optivo, resulting in cancer remission. After several months, the patient presented with palpitations, dyspnea, and abdominal and leg swelling. Moreover, she had elevated troponin and ECG changes leading to cardiac catheterization with normal coronaries, which were fixed in a dense, thickened serosal pericardium. Subsequent echocardiography revealed evident signs of constrictive pericarditis, and cardiac MRI showed a densely thickened pericardium with diffuse late gadolinium enhancement.Conclusion: The Phenotypic expressions of pericardial disease are enigmatic and challenging diagnostically. Various forms of pericardial disease may mimic acute coronary syndrome and acute/chronic heart failure. Since each phenotypic presentation of the disease is unique, a rational, linear approach is considered essential to the accurate diagnosis.