• Images in cardiology

A 43 year old man with constrictive pericarditis underwent pericardiectomy with good results. Surgical pathology showed thickened pericardium with mild non-specific acute and chronic inflammation, and no granulomas. On postoperative day 2, he was asymptomatic and haemodynamically stable, but was noted to have pronounced PR depression on ECG in comparison with baseline (upper panel). Drainage of 135 ml of mediastinal fluid occurred and normalisation of the PR segment was noted instantaneously (lower panel). Repeated physical examination on subsequent days revealed friction rub. The patient was treated with naproxen and was eventually discharged from hospital. The most likely explanation for the dynamic PR segment change is transient accumulation of mediastinal fluid around the heart in the setting of residual inflammation post-pericardiectomy.