Introduction: Despite the increasing use of alternative techniques, endomyocardial biopsy (EMB) remains the primary method for diagnosing cardiac allograft rejection, and is considered a safe procedure, with a very low complication rate when performed by experienced operators. Major complications include cardiac perforation, tamponade and endocarditis. (1, 2)

Case report: We present a case of a 65-year-old male patient who underwent heart transplantation in August 2014 due to dilative cardiomyopathy. The early postoperative course was complicated with pneumonia and ulcers of sacral region. The last scheduled biopsy was performed in December 2015 and the control transthoracic echocardiography (TTE) was unremarkable. By April 2016 a gradual clinical deterioration was observed, with loss of appetite, weight loss, shortness of breath, effort intolerance and swelling of the abdomen and legs. TTE showed a moderate pericardial effusion around the inferior wall and in front of the right ventricle. Mitral inflow velocities suggested ventricular interdependence, but chamber collapse was not evident. Dense collection of 3.4 cm in the pericardium and pericardial thickening of 1.3 cm was noted on. Therefore, a localized parietal and visceral pericardiectomy was preformed via sternotomy with intraoperative transesofageal echocardiogram confirming better kinetics of the inferior wall of the left ventricle and the anterior wall of the right ventricle following procedure. The patient was discharged after 3 weeks and was seen in an out-patient clinic a month later with significant improvement in his symptoms. Repeat TTE showed no pericardial effusion.

Conclusion: The diagnosis of effusive-constrictive pericarditis as a late complication of EMB is possible and should considered in new onset worsening of heart transplant recipient. Pericardiectomy should be considered in patients with evolution to constrictive pericarditis and clinical features of severe and persistent heart failure.