Constrictive pericarditis remains a rare but clinically critical condition, often emerging months or years after an initiating insult. In the post‑pandemic landscape, growing evidence points to SARS‑CoV‑2 as a potential trigger for delayed pericardial pathology. The presented case illustrates constrictive pericarditis manifesting 3 years after mild COVID‑19, with histopathological confirmation of viral persistence in the pericardium, emphasizing the need for heightened diagnostic vigilance in young patients with unexplained heart failure and demonstrating the efficacy of pericardiectomy in restoring hemodynamic stability.

A 28‑year‑old male with a history of mild SARS‑CoV‑2 infection in 2021, characterized solely by anosmia and ageusia without pulmonary involvement, presented with progressive signs of right‑sided heart failure. Diagnosis was established through a multimodal approach comprising transthoracic echocardiography with assessment of left ventricular ejection fraction, TAPSE, inferior vena cava dynamics, and septal motion patterns, complemented by chest multislice computed tomography (MSCT), chest radiography, and coronary angiography. Definitive confirmation relied on histological and immunohistochemical analysis of the resected pericardial tissue.

Echocardiography revealed hallmark features of cardiac constriction, including septal bounce, absence of inferior vena cava collapse on inspiration, biatrial enlargement, reduced right ventricular systolic function with TAPSE of 8 mm, and fluid accumulations manifesting as pericardial effusion, bilateral pleural effusions, and ascites. MSCT confirmed pericardial thickening and calcification, while immunohistochemical testing detected SARS‑CoV‑2 antigens within the inflammatory infiltrate, providing direct evidence supporting a post‑viral etiology.

The patient underwent subtotal pericardiectomy performed in the off‑pump setting. Postoperative evaluation demonstrated substantial improvement across structural and functional parameters: left ventricular ejection fraction increased from 38 % to 53 %, TAPSE improved from 8 mm to 15 mm, and left atrial volume decreased from 189 mL to 99 mL. Concomitantly, the inferior vena cava exhibited reduced diameter with partial restoration of respiratory collapse, quantified as a 22 % reduction on inspiration. Clinically, pleural effusions and ascites regressed completely, and symptoms of heart failure were fully alleviated.

This case underscores several important clinical implications. Constrictive pericarditis should be included in the differential diagnosis of unexplained heart failure even years after a seemingly mild SARS‑CoV‑2 infection, particularly in younger individuals. The combined use of echocardiography and MSCT offers a robust non‑invasive strategy to detect pericardial abnormalities and confirm constrictive physiology, facilitating timely diagnosis. The identification of SARS‑CoV‑2 antigens in the pericardial tissue supports the hypothesis of either direct viral involvement or persistent immune activation as underlying mechanisms driving delayed constriction.

Pericardiectomy proved to be a highly effective intervention in this instance, yielding marked hemodynamic recovery and significant symptomatic relief. These results are consistent with existing literature recognizing pericardiectomy as the definitive treatment for chronic constriction and extend the evidence base to include post‑COVID presentations. In the broader context of post‑acute sequelae of SARS‑CoV‑2 infection, maintaining a high index of suspicion for constrictive pericarditis is essential. Incorporating pericardial assessment into the standard diagnostic algorithm for right‑sided heart failure enables earlier detection, while prompt referral to specialized cardiac surgery centers optimizes patient outcomes. Integration of advanced imaging modalities with histopathological evaluation remains crucial for confirming the diagnosis and guiding appropriate management strategies.

Aleksandra Andreevna Aivaziants is a 5th‑year student at the Almazov National Medical Research Centre (Ministry of Health of the Russian Federation), Saint Petersburg (197341); she is expected to graduate next year.

Her scientific work has already been recognized with a publication in a reputable Russian journal: in 2026, her article “COVID‑19‑associated constrictive pericarditis with delayed manifestation requiring pericardiectomy” was published in Cardiology: News, Opinions, Training. The paper describes a clinical case of COVID‑19‑associated constrictive pericarditis and substantiates the need for surgical treatment. The study was carried out under the supervision of leading experts in cardiology and cardiac surgery at the Almazov Centre:

● Vadim Konstantinovich Grebennik, Head of Cardiovascular Surgery Department No. 3;

● Yuriy Anatolyevich Kudaev, Candidate of Medical Sciences, Senior Researcher at the Research Laboratory of Ischemic Heart Disease;

● Aleksey Vladimirovich Panov, Doctor of Medical Sciences, Professor, Chief Researcher at the Research Laboratory of Ischemic Heart Disease.

Currently, she continues in‑depth research in the field of cardiology under the guidance of Professor Aleksey Vladimirovich Panov. Under his mentorship, she plans to further develop her scientific career, focusing on current issues in the diagnosis and treatment of cardiovascular diseases.