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Missing the diagnosis of atrial septal defect (ASD) increases morbidities to patient and may require second surgery or intervention. Chronic constrictive pericarditis produces thickening and calcification of pericardium. The detection of any intracardiac lesion may be difficult by echocardiography due to the masking or shadowing effect of calcified pericardium. We report a case of 30-year-old male presented with congestive heart failure, dyspnea and abdominal swelling. Transthoracic echocardiography diagnosed constrictive pericarditis with no evidence of ASD. The contrast enhanced computed tomography (CECT) showed extensive diffuse pericardial calcification with a large ASD. In the operating room initial transesophageal echocardiography (TEE) examination was not able to detect any ASD. Agitated saline injected through the central venous line into right atrium showed bubbles in the left atrium under TEE monitoring. Subsequent movement of TEE probe in deeper position detected the ASD. It is recommended that all the views and methods of echocardiography examination may be practiced in difficult moments to avoid missing the presence of ASD.

Coexistence of Chronic Constrictive Pericarditis can make the Echocardiographic Diagnosis of Atrial Septal Defect Challenging