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case_images: Left ventricular (blue arrow) and right ventricular (red arrow) pressure tracings demonstrating discordant respiratory variation and square root sign (green arrow).
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case_images: In addition, there was an equilibration of diastolic pressures across all cardiac chambers, square root sign (dip and plateau pattern of right ventricular and left ventricular diastolic tracing), and discordant respiratory variation (Fig. 1).
case_images: TEE images showing: A) Increased echodensity of the pericardium (arrow), B) Bi-atrial dilation, C-D) Significant respiratory variation of Mitral (C) and Tricuspid (D) inflow. RA = Right Atrium, LA = Left Atrium.
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case_images: The TEE (Fig. 2) showed an LVEF of 55% with respirophasic abnormal septal motion, bi-atrial dilation, significant respiratory variation of the mitral and tricuspid valve inflow, and increased echodensity of the pericardium with no pericardial effusion, all of which again pointed towards constrictive physiology.
case_images: CT chest from this admission (right) and from one month prior (left) demonstrating interval improvement in the pericardial effusion (arrows).
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case_images: However, she was found to have a moderate pericardial effusion on a CT scan of her chest one month after systemic thrombolysis for her massive PE, which was noted to be only trace on CT scan at this admission (Fig. 3). Her pericardial biopsy revealed marked fibrosis, mild acute and chronic inflammation with hemosiderinladen macrophages, and no malignancy (Figs. 3 & 5).
case_images: Gadolinium enhanced CMRI (transverse section) showing mild diffuse thickening of the pericardium (arrow).
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case_images: A gadolinium enhanced Cardiac Magnetic Resonance Imaging (CMRI, Fig. 4) was performed to rule out restrictive cardiomyopathy that showed mild diffuse thickening of up to 4 mm and subtle enhancement of the pericardium with a positive septal bounce.
case_images: Pericardial biopsy showing marked fibrosis, mild acute and chronic inflammation with hemosiderin-laden macrophages (arrow).
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case_images: Her pericardial biopsy revealed marked fibrosis, mild acute and chronic inflammation with hemosiderinladen macrophages, and no malignancy (Figs. 3 & 5).