Diagnostic pitfalls in constrictive pericarditis coexisting with right ventricular outflow tract obstruction and coronary artery anomaly

Constrictive pericarditis associated with an anomalous left anterior descending artery is a very rare and complex condition. The aim of this report is to highlight the diagnostic challenges and surgical management in this disease. A 40-year-old man with right heart failure, dyspnea, and ascites, underwent comprehensive cardiac evaluation and surgery. The pulmonary valve was dysplastic, causing severe right ventricular outflow tract (RVOT) obstruction. During resection, the left anterior descending artery was inadvertently transected and bypassed with a saphenous vein graft. RVOT reconstruction, pulmonary valve replacement, and tricuspid valve repair were performed. Postoperative follow-up showed satisfactory ventricular and valve function; however, structural changes and reduced right ventricular function persisted. Non-invasive coronary imaging is necessary when angiography is not feasible, and the limitations of transesophageal echocardiography should be considered. Chronic right ventricular changes may not be fully reversible, emphasizing the need for long-term follow-up.