**Introduction/Hypothesis:**
Constrictive pericarditis can be a challenging diagnosis with clinical findings that overlap with other conditions such as liver disease.

**Methods**
Case presentation:
A 70-year-old male was referred to cardiology for pre-operative evaluation for liver transplantation due to an abnormal stress test. His past medical history is significant for cirrhosis secondary to metabolic dysfunction associated steatotic liver disease (MASLD) complicated by recurrent ascites requiring regular paracentesis, Type 2 diabetes mellitus, chronic kidney disease, hyperlipidemia, hypertension, atrial fibrillation, and heart failure with preserved ejection fraction. The single-photon emission computerized tomography (SPECT) showed a moderate size, mild reversible defect in the apex including the apical cap, at the anterior and lateral walls.
Given the abnormal SPECT findings, left and right heart catheterization for a pre-transplant evaluation were performed, which revealed mild pulmonary hypertension, non-obstructive coronary artery disease and findings of concerning for constriction (prominent x and y descents, ventricular interdependence, and tethered coronary vessels). Subsequently, a transthoracic echocardiogram (TTE) confirmed findings of constrictive pericarditis with typical signs of annulus reversus, respirophasic abnormal ventricular septal motion, dilated IVC with diastolic end-expiratory reversals in the hepatic veins.

**Results**
Chest computed tomography (CT) described diffuse pericardial thickening with sparing of the apex that was suspicious for partial absence of the pericardium and herniation (figure 1). Cardiac magnetic resonance imaging (CMR) confirmed thickening of the pericardium involving the base and mid pericardium with sparing around the apex. Notably, no prominent delayed enhancement seen, suggestive of a chronic pericardial process without active inflammation (Figure 2).

**Conclusion**
Constrictive pericarditis is a challenging diagnosis, especially in the setting of confounding conditions with symptoms that overlap like ESLD. Multimodality imaging combining TTE, Cardiac CT and CMR are complimentary studies when these challenging cases present and can lead to a non-invasive diagnosis of pericardial constriction.



**Introduction/Hypothesis:**
Constrictive pericarditis can be a challenging diagnosis with clinical findings that overlap with other conditions such as liver disease.

**Methods**
**Case presentation:**
A 70-year-old male was referred to cardiology for pre-operative evaluation for liver transplantation due to an abnormal stress test. His past medical history is significant for cirrhosis secondary to metabolic dysfunction associated steatotic liver disease (MASLD) complicated by recurrent ascites requiring regular paracentesis, Type 2 diabetes mellitus, chronic kidney disease, hyperlipidemia, hypertension, atrial fibrillation, and heart failure with preserved ejection fraction. The single-photon emission computerized tomography (SPECT) showed a moderate size, mild reversible defect in the apex including the apical cap, at the anterior and lateral walls.
Given the abnormal SPECT findings, left and right heart catheterization for a pre-transplant evaluation were performed, which revealed mild pulmonary hypertension, non-obstructive coronary artery disease and findings of concerning for constriction (prominent x and y descents, ventricular interdependence, and tethered coronary vessels). Subsequently, a transthoracic echocardiogram (TTE) confirmed findings of constrictive pericarditis with typical signs of annulus reversus, respirophasic abnormal ventricular septal motion, dilated IVC with diastolic end-expiratory reversals in the hepatic veins.

**Results**
Chest computed tomography (CT) described diffuse pericardial thickening with sparing of the apex that was suspicious for partial absence of the pericardium and herniation (figure 1). Cardiac magnetic resonance imaging (CMR) confirmed thickening of the pericardium involving the base and mid pericardium with sparing around the apex. Notably, no prominent delayed enhancement seen, suggestive of a chronic pericardial process without active inflammation (Figure 2).

**Conclusion**
Constrictive pericarditis is a challenging diagnosis, especially in the setting of confounding conditions with symptoms that overlap like ESLD. Multimodality imaging combining TTE, Cardiac CT and CMR are complimentary studies when these challenging cases present and can lead to a non-invasive diagnosis of pericardial constriction.



Refractory ascites, a shared manifestation of the liver and the heart: The use of multimodality cardiac imaging to aid in diagnosis.