Images in cardiovascular medicine
Constrictive pericarditis: an underdiagnosed cause of chest pain Caroline J. Magri, Sarah Grixti and Herbert Felice Constrictive pericarditis is an underdiagnosed condition characterized by a rigid pericardium leading to restriction in cardiac filling with consequent fluid overload and decreased cardiac output. The authors provide classic echocardiographic and cardiac catheterization images which, in addition to good clinical acumen, assist in making the correct diagnosis. J Cardiovasc Med 2014, 15:515–516
Constrictive pericarditis is characterized by a rigid, thickened pericardium, leading to a restriction in cardiac filling in late diastole. Symptoms are either related to fluid overload or decreased cardiac output. It is an underdiagnosed condition; its diagnosis depends mainly on good clinical acumen and imaging techniques, as outlined in this case. A 62-year-old lady with no known medical problems presented to her general practitioner with a 6-week history of intermittent retrosternal compressive discomfort. An echocardiogram showed a small pericardial effusion. She was treated with analgesics and antibiotics. However, she remained unwell with increasing lethargy, dyspnoea on minimal exertion and dry persistent cough. The patient was referred for a cardiology opinion 2 months after the initial presentation. On examination, she was tachycardic, had a raised jugular
Keywords: catheterization studies, echocardiography, pericarditis Department of Cardiac Services, Mater Dei Hospital, Msida, Malta Correspondence to Dr Caroline J. Magri, ‘Jesmel’, Imdina Road, Zebbug, ZBG05, Malta Tel: +356 79258763; fax: +356 25454154; e-mail: [email protected] Received 16 March 2013 Revised 28 May 2013 Accepted 30 June 2013
venous pressure which increased paradoxically with inspiration, and lower limb oedema. Blood investigations revealed elevated erythrocyte sedimentation rate (ESR, 72 mm in the first hour) with normal C-reactive protein (CRP); virology, microbiology and rheumatology screen were negative. Computed tomography (CT) of the thorax showed a small left pleural effusion and small pericardial effusion without mediastinal/axillary lymph node enlargement. Ultrasound abdomen was unremarkable. A repeat echocardiogram showed thickened pericardium and a small pericardial effusion, together with Doppler evidence of constriction (Fig. 1) and septal bounce. Right and left catheterization studies showed equalization of right and left ventricular diastolic pressures (square root sign; Fig. 2). Idiopathic constrictive pericarditis was diagnosed, based on symptomatology, echocardiographic and
Fig. 1
Doppler studies showing (a) mitral flow increase during expiration, (b) tricuspid flow increase during inspiration and (c) increased diastolic flow reversal in the hepatic vein with expiration. These changes occur because of failure of transmission of intrathoracic pressures to intracardiac chambers. Thus, in constrictive pericarditis, the inspiratory decrease in intrathoracic pressure is transmitted to the pulmonary vein and left atrium but not to the left ventricle, resulting in a reduced gradient that drives left ventricular filling during inspiration, allowing increased right ventricular filling and shift of the interventricular septum to the left. The opposite occurs in expiration.
1558-2027 ß 2014 Italian Federation of Cardiology
DOI:10.2459/JCM.0b013e328364bf12
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
516 Journal of Cardiovascular Medicine 2014, Vol 15 No 6
Fig. 2
Cardiac catheterization studies showing equal right ventricular and left ventricular end-diastolic pressures during (a) expiration and (b) inspiration, indicating ventricular interdependence, whereby filling of one ventricle limits the simultaneous filling of the other ventricle owing to the shared mechanical constraint. The typical ‘dip-and-plateau pattern’ or the ‘square root sign’ is also seen; the dip represents unrestrained early diastolic filling, whereas the plateau occurs at the end of the first third of diastole, whereby the stiff pericardium reaches its limit of distension and abruptly restricts ventricular filling.
haemodynamic findings. These findings occur secondary to the increased pericardial restraint, resulting in marked restriction of filling, ventricular interdependence and failure of transmission of intrathoracic pressures to
intracardiac chambers. The patient was given a trial of steroids with improvement in the symptoms. She is being followed up regularly with a view for elective pericardiectomy.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
Constrictive pericarditis: an underdiagnosed cause of chest pain Caroline J. Magri, Sarah Grixti and Herbert Felice Constrictive pericarditis is an underdiagnosed condition characterized by a rigid pericardium leading to restriction in cardiac filling with consequent fluid overload and decreased cardiac output. The authors provide classic echocardiographic and cardiac catheterization images which, in addition to good clinical acumen, assist in making the correct diagnosis. J Cardiovasc Med 2014, 15:515–516
Constrictive pericarditis is characterized by a rigid, thickened pericardium, leading to a restriction in cardiac filling in late diastole. Symptoms are either related to fluid overload or decreased cardiac output. It is an underdiagnosed condition; its diagnosis depends mainly on good clinical acumen and imaging techniques, as outlined in this case. A 62-year-old lady with no known medical problems presented to her general practitioner with a 6-week history of intermittent retrosternal compressive discomfort. An echocardiogram showed a small pericardial effusion. She was treated with analgesics and antibiotics. However, she remained unwell with increasing lethargy, dyspnoea on minimal exertion and dry persistent cough. The patient was referred for a cardiology opinion 2 months after the initial presentation. On examination, she was tachycardic, had a raised jugular
Keywords: catheterization studies, echocardiography, pericarditis Department of Cardiac Services, Mater Dei Hospital, Msida, Malta Correspondence to Dr Caroline J. Magri, ‘Jesmel’, Imdina Road, Zebbug, ZBG05, Malta Tel: +356 79258763; fax: +356 25454154; e-mail: [email protected] Received 16 March 2013 Revised 28 May 2013 Accepted 30 June 2013
venous pressure which increased paradoxically with inspiration, and lower limb oedema. Blood investigations revealed elevated erythrocyte sedimentation rate (ESR, 72 mm in the first hour) with normal C-reactive protein (CRP); virology, microbiology and rheumatology screen were negative. Computed tomography (CT) of the thorax showed a small left pleural effusion and small pericardial effusion without mediastinal/axillary lymph node enlargement. Ultrasound abdomen was unremarkable. A repeat echocardiogram showed thickened pericardium and a small pericardial effusion, together with Doppler evidence of constriction (Fig. 1) and septal bounce. Right and left catheterization studies showed equalization of right and left ventricular diastolic pressures (square root sign; Fig. 2). Idiopathic constrictive pericarditis was diagnosed, based on symptomatology, echocardiographic and
Fig. 1
Doppler studies showing (a) mitral flow increase during expiration, (b) tricuspid flow increase during inspiration and (c) increased diastolic flow reversal in the hepatic vein with expiration. These changes occur because of failure of transmission of intrathoracic pressures to intracardiac chambers. Thus, in constrictive pericarditis, the inspiratory decrease in intrathoracic pressure is transmitted to the pulmonary vein and left atrium but not to the left ventricle, resulting in a reduced gradient that drives left ventricular filling during inspiration, allowing increased right ventricular filling and shift of the interventricular septum to the left. The opposite occurs in expiration.
1558-2027 ß 2014 Italian Federation of Cardiology
DOI:10.2459/JCM.0b013e328364bf12
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
516 Journal of Cardiovascular Medicine 2014, Vol 15 No 6
Fig. 2
Cardiac catheterization studies showing equal right ventricular and left ventricular end-diastolic pressures during (a) expiration and (b) inspiration, indicating ventricular interdependence, whereby filling of one ventricle limits the simultaneous filling of the other ventricle owing to the shared mechanical constraint. The typical ‘dip-and-plateau pattern’ or the ‘square root sign’ is also seen; the dip represents unrestrained early diastolic filling, whereas the plateau occurs at the end of the first third of diastole, whereby the stiff pericardium reaches its limit of distension and abruptly restricts ventricular filling.
haemodynamic findings. These findings occur secondary to the increased pericardial restraint, resulting in marked restriction of filling, ventricular interdependence and failure of transmission of intrathoracic pressures to
intracardiac chambers. The patient was given a trial of steroids with improvement in the symptoms. She is being followed up regularly with a view for elective pericardiectomy.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
