Abstract Body (Do not enter title and authors here): Case Presentation:
An 86-year-old woman with a history of atrial fibrillation, heart failure with preserved ejection fraction, chronic kidney disease, and prior gastrointestinal bleeding underwent left atrial appendage occlusion (LAAO) device implantation for stroke prevention. Several months post-implantation, she developed progressive dyspnea, pleuritic chest pain, and peripheral edema. Examination revealed signs of volume overload and atrial fibrillation with rapid ventricular response. Right heart catheterization showed elevated pressures (RA 28 mmHg, RV 65/32 mmHg, PA 65/28 mmHg, mean PA 37 mmHg, PCWP 30 mmHg, mean RA v-wave 39 mmHg, CO/CI 2.5/1.4) and a prominent y-descent, raising concern for constrictive physiology. Cardiac MRI revealed anterior pericardial thickening and late gadolinium enhancement consistent with active pericardial inflammation. Inflammatory markers were markedly elevated. A diagnosis of delayed inflammatory pericarditis was made, and corticosteroids were initiated with clinical improvement. However, symptoms recurred during taper. Due to underlying CKD and prior GI bleeding, colchicine and NSAIDs were avoided. Rilonacept, an interleukin-1 inhibitor, was initiated as a steroid-sparing agent, leading to sustained symptom resolution and no further hospitalizations.
Discussion:
This case highlights delayed-onset recurrent pericarditis with transient constrictive physiology as a rare but important complication following LAAO device implantation. While early pericardial effusion is well-documented, delayed pericardial inflammation remains underrecognized. Multimodal imaging, especially cardiac MRI, was critical in differentiating active inflammation from irreversible fibrosis, guiding a medical rather than surgical approach. The patient’s favorable response to rilonacept supports its emerging role in steroid-dependent pericarditis. As LAAO utilization grows, clinicians should remain vigilant for delayed pericardial complications and consider advanced imaging and immunomodulatory therapy to avoid unnecessary invasive procedures.