(Figure 5)
Indications for ASD closure in childhood are well documented, and treatment is known to be effective.3 Complications including development of cardiac tamponade, recurrent pericardial effusion or pericardial effusions requiring drainage after ASD closure are rare.1,4–6 Furthermore, these pericardial complications are usually reported in the peri-procedure period, as compared to our patient who developed symptoms several months after surgery.7 RP concomitantly with constrictive physiology in these patients after a latent period has been sporadically reported in the literature. A prior study of 15 cases on RP in children and adolescents concluded that surgical ASD closure (n=6) was the predominant underlying etiology .6 Interestingly, the risk of development of PCIS presenting as RP is similar between pediatric and adult populations.8
Echocardiogram and CMR supplemented clinical information to attain diagnosis in our patient. CMR findings: mild LGE, right ventricular tethering, diastolic septal bounce, and respirophasic shift supported the diagnosis of recurrent pericarditis complicated by constrictive physiology in our case.1 Short courses or abrupt cessation of anti-inflammatory therapy without adequate tapering may have resulted in residual pericardial inflammation, increasing his risk of further flares. Treatment of pericarditis requires NSAIDs and colchicine (as first line), steroids (second line), biologics such as interleukin-1 receptor blockers or disease modifying anti-rheumatic drugs (third line) and pericardiectomy (fourth line in refractory cases).9,10
Our case represents a rare occurrence of RP with constrictive physiology treated with pericardiectomy in an adolescent patient with prior surgical ASD repair. Medical management of PCIS can be complicated due to its prolonged duration and notable side effects. Further, it can be an underdiagnosed or under-reported condition among adolescents. Patients with ASD repair are living longer and require monitoring for complications.11 Therefore, in order to improve their outcomes it is imperative to timely identify the development of PCIS and adequately manage it.