Constrictive Physiology Research Articles

Propionibacterium acnes: A Treatable Cause of Constrictive Pericarditis.

In this case report we share a case of infective Pericarditis caused by Propionibacterium acnes (P. acnes) in an immune-competent, nonsurgical patient. This case and review will illustrate the importance of considering P. acnes as a cause of idiopathic pericardial effusion and effusive constrictive disease. The patient was a 61-year-old male with history of osteoarthritis of the knee. He received an intra-articular steroid injection in July 2013. Two months later, he presented with atrial fibrillation and heart failure. He was found to have pericardial and bilateral pleural effusions which grew P. acnes. This organism was initially considered to be contaminant; however, as P. acnes was isolated from both pleural and pericardial fluids, he was started on oral amoxicillin. He was noted to have recurrence of effusions within 2 weeks with evidence of constrictive physiology by echocardiography. Treatment was subsequently changed to intravenous Penicillin G with marked symptomatic improvement, resolution of pericardial/pleural effusions, and no echocardiographic evidence of constrictive pericarditis at 10 weeks follow-up. Pursuit and treatment of P. acnes could lead to prevention of constrictive pericarditis. We believe that further studies are needed to assess prevalence of P. acnes and response to intravenous Penicillin G in patients presenting with effusive constrictive disease.

A Potential Echocardiographic Classification for Constrictive Pericarditis Based on Analysis of Abnormal Septal Motion.

BackgroundConstrictive pericarditis is an uncommon condition that could be easily confused with congestive heart failure. In symptomatic patients, septal "wobble" on echocardiography may be an important sign of constrictive physiology. This study was planned to investigate the effects of constriction on septal motion as identified by echocardiography.MethodsIn this retrospective observational study, nine consecutive patients with constriction underwent careful echocardiographic analysis of the interventricular septum (IVS) with slow motion 2-dimensional echocardiography and inspiratory manoeuvres. Six patients who had undergone cardiac magnetic resonance imaging underwent similar analysis. Findings were correlated with haemodynamic data in five patients who had undergone cardiac catheterisation studies.ResultsIn mild cases of constriction a single wobble of the IVS was seen during normal respiration. In more moderate cases a double motion of the septum (termed "double wobble") was seen where the septum bowed initially into the left ventricle (LV) cavity in diastole then relaxed to the middle only to deviate again into the LV cavity late in diastole after atrial contraction. In severe cases, the septum bowed into the LV cavity for the full duration of diastole (pan-diastolic motion). We describe how inspiration also helped to characterize the severity of constriction especially in mild to moderate cases.ConclusionEchocardiography appears a simple tool to help diagnose constriction and grade its severity. Larger studies are needed to confirm whether the type of wobble motions helps to grade the severity of constrictive pericarditis.

Abstract 19169: Anakinra - A Promising New Therapy for Idiopathic Recurrent Pericarditis

BACKGROUND: Idiopathic recurrent pericarditis (IRP) is a debilitating condition that can be recalcitrant to conventional therapy. Some patients develop steroid dependency with the attendant risks of systemic side effects and increased future recurrence. Anakinra is a recombinant human interleukin-1 receptor antagonist that reduces systemic inflammatory responses. The aim of this study was to evaluate the therapeutic role of anakinra in IRP. Methods: We retrospectively studied consenting patients with treatment refractory IRP who received anakinra, between January 2009 and November 2013. The primary end points were symptom resolution and steroid discontinuation. Results: Nine patients were followed for a median of 16.8 (IQR 1.3-24) months. Study subjects were predominantly female (7 [78%]) with a median age of 53 (IQR 38 - 58) years. All 9 patients had failed maximum tolerated doses of NSAIDs, colchicine and prednisone (median dose 20 mg [IQR 15 - 22.5]). Primary symptom was chest pain in 9 (100%), with concurrent dyspnea in 5 (56%) patients. Symptom duration prior to anakinra initiation was 24 (IQR 13 - 71) months. Indication for anakinra was steroid sparing agent in 7 (78%) and symptom control in 2 (22%) patients. The dosage was 100 mg once daily via subcutaneous injection. Baseline LVEF was 62% (IQR 59% - 67%). Echocardiographic findings include pericardial effusion in 3 (33%), pericardial thickening in 6 (67%), and constrictive physiology in 4 (44%). Pericardial enhancement on cardiac MRI was seen in 7 (78%) patients. All 9 patients (100%) had symptom improvement with complete resolution in 8 (89%) and partial resolution in 1 (11%) patient. At last follow up, all 9 (100%) patients had discontinued NSAIDs and colchicine, 5 (56%) patients discontinued and 4 (44%) had reduced prednisone dosage. All patients remained on anakinra at the end of follow up. The only reported side effect was transient injection site reaction in 4 (44%) patients. In 2 (22%) patients, attempted anakinra weaning was unsuccessful due to symptomatic flare after 6 weeks. Conclusion: Anakinra is an effective alternative agent for the management of steroid dependent IRP. It provides remarkable symptomatic amelioration, limits steroid dependency, and is associated with minimal side effects.

Clinical Features Associated With Adverse Events in Patients With Post-Pericardiotomy Syndrome Following Cardiac Surgery

Postpericardiotomy syndrome (PPS) may be associated with tamponade and pericardial constriction that may require procedural intervention. The aim of this study was to identify clinical features associated with adverse events requiring procedural intervention in patients with PPS. A total of 239 patients who developed PPS after cardiac surgery were monitored for 12months. PPS was diagnosed if 2 of the 5 following findings were present: fever without infection, pleuritic pain, friction rub, pleural effusion, and pericardial effusion (<60days after surgery). The primary end point was the development of pericardial effusion or pericardial constriction requiring procedural intervention. Among 239 patients with PPS, 75 (31%) required procedural intervention. In a univariate analysis, the odds of a procedural intervention were decreased with older age (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.96 to 0.99) and with colchicine used in combination with anti-inflammatory agents (OR 0.45, 95% CI 0.26 to 0.79). However, the odds were increased in patients with preoperative heart failure (OR 1.84, 95% CI 1 to 3.39) and early postoperative constrictive physiology (OR 5.77, 95% CI 2.62 to 12.7). After multivariate adjustment, treatment with colchicine along with anti-inflammatory agents was associated with lower odds of requiring intervention (OR 0.43, 95% CI 0.95 to 0.99). Independent positive predictors of procedural intervention included age (OR 0.97, 95% CI 0.95 to 0.99), time to PPS (OR 0.97, 95% CI 0.95 to 0.99), and early postoperative constrictive physiology (OR 6.23, 95% CI 2.04 to 19.07). In conclusion, younger age, early-onset PPS, and postoperative constrictive physiology were associated with the need for procedural intervention in patients with PPS, whereas colchicine was associated with reduced odds of adverse events and procedural intervention.

Constrictive Pericarditis: Rapid Progression of Pericardial Calcification in a Patient With Hemodialysis and Coronary Artery Bypass Surgery

A 72-year-old man, with a history of coronary artery bypass grafting (CABG) undergone19 years previously and end-stage renal disease (ESRD) on hemodialysis since 1 year before, was admitted for evaluation of dropping arterial pressure down 1 hour after starting hemodialysis. On a computed tomography on chest scan, markedly calcified pericardium on the posterior and diaphragmatic sides of the heart was revealed. Pericardium was mostly not calcified 2 years before admission, pre-initiation of hemodialysis, and the thickness of calcified pericardium was obviously increased after initiation of hemodialysis. Constrictive pericarditis (CP) was diagnosed and subsequent pericardiectomy was underwent, and dropping atrial pressure down during hemodialysis disappeared. The main cause of CP was not cardiac surgery undergone previously (postoperative CP). It is probable that secondary hyperparathyroidism in ESRD provoked dystrophic calcification of pericardium, which was injured by past CABG, subsequent rigid and thickness of pericardium, and constrictive physiology became obvious. J Med Cases. 2014;5(9):498-501 doi: http://dx.doi.org/10.14740/jmc1910w

Severe tricuspid regurgitation mimicking constrictive pericarditis.

Patient: Female, 62Final Diagnosis: Tricuspid regurgitationSymptoms: Dyspnea exertional • fatigue • leg edemaMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Challenging differential diagnosisBackground:Tricuspid regurgitation (TR) can mimic some hemodynamic findings of constrictive pericarditis (CP), due to the restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. In this article, we report a case of severe tricuspid regurgitation in which hemodynamic findings were consistent with CP.Case Report:A 62-year-old Caucasian woman presented with right heart failure symptoms. Echocardiography showed enlarged right heart chambers and severe tricuspid regurgitation. Right heart catheterization surprisingly demonstrated a constrictive physiology. Diastolic pressures of both ventricles were elevated and equalized, with a prominent deep and plateau pattern. The patient was re-evaluated with a further focus on constrictive pericarditis. However, echocardiography, thorax CT, and cardiac MRI did not demonstrate any pathological finding related to pericardium. The remaining explanation was that the severe TR itself and secondary right heart enlargement caused the restraining effect on the intact pericardium and on the left ventricle. The pericardium was normal and tricuspid annulus was severely dilated on surgical inspection. The tricuspid valve was replaced with a bioprosthetic valve. The patient did well just after the surgery, with a rapid decrease in cardiac pressures; however, she died due to respiratory failure on the 15th postoperative day.Conclusions:This was a case with right heart failure symptoms in which invasive hemodynamic findings were consistent with constrictive pericarditis and the noninvasive imaging modalities were not. This case illustrates that severe TR can mimic some hemodynamic findings of constrictive pericarditis, due to restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. Lack of significant respiratory changes in hemodynamic parameters that can safely be demonstrated by echocardiography and cardiac MRI suggest a normal pericardium.

Heart Failure due to Tension Hydrothorax after Left Pneumonectomy

Tension hydrothorax is a rare complication of pneumonectomy for pleural mesothelioma and an exceptionally rare cause of heart failure. We describe a patient who had undergone extrapleural pneumonectomy, chemotherapy, and radiation for pleural mesothelioma and who developed heart failure symptoms within months of the completion of treatment. Investigation showed a massive left pleural effusion resulting in tension hydrothorax, mediastinal shift, and evidence of right heart failure with constrictive physiology and low cardiac output. Therapeutic thoracentesis resulted in increase in cardiac output and symptomatic improvement.

“Adhesive Pericarditis:” Intraoperative Transesophageal Echocardiographic Diagnosis of Combined Impairment of Systolic and Diastolic Function Secondary to Mycobacterium Tuberculosis

Mycobacterium tuberculosis is a well known cause of pericarditis.1 The disease may manifest echocardiographically as effusion with or without tamponade, constriction, effusion-constriction, and associated cardiomyopathy.2 Constrictive pericarditis is characterized by normal or enhanced early diastole followed by abrupt termination of ventricular filling as the maximum intrapericardial capacity is reached.3 The term effusive-constrictive pericarditis refers to pericarditis and associated effusion causing tamponade upon which drainage of the compressing fluid reveals pericardial constrictive physiology.

Protocolo diagnóstico y diagnóstico diferencial de la pericarditis constrictiva

Constrictive pericarditis should be considered in any patient with an unexplained elevated jugular venous pressure and fluid overload. Complementary test findings as relatively low plasma concentrations of brain natriuretic peptide (BNP), electrocardiogram with low voltage and nonspecific T-wave repolarization abnormalities may support the clinical suspicion. Pericardial calcifications may be noted on the chest radiograph, although absence of calcification does not exclude constrictive pericarditis. The diagnosis is confirmed with: constrictive physiology proved by echocardiography or invasive hemodynamic study, or pericardial thickening with or without calcification by cardiac computed tomography and cardiac magnetic resonance imaging. Results of both imaging modalities will help plan surgery.

Effect of Postoperative Constrictive Physiology on Early Outcomes after Off-Pump Coronary Artery Bypass Grafting

BackgroundConstrictive pericarditis after coronary artery bypass surgery has been known to affect cardiac output by limiting diastolic ventricular filling. We aimed to assess the influence of postoperative constrictive physiology on the early outcomes of patients undergoing off-pump coronary artery bypass grafting (OPCAB).Materials and MethodsBetween January 2008 and July 2011, 903 patients underwent an isolated OPCAB and postoperative transthoracic-echocardiography. The patient cohort was classified into two groups: group A, constrictive physiology and group B, control group without constrictive physiology. Early outcomes were analyzed between the two groups.ResultsOf the total 903 patients, group A consisted of 153 patients (16.9%). The amount of blood loss in group A during the postoperative 24 hours was greater than that of group B, but this was not statistically significant (p=0.20). No significant differences were found in the mortality rates (group A, 0.6%; group B, 1.4%; p=0.40) and 30-day major adverse cardiac and cerebrovascular events (MACCEs; group A, 3.3%; group B, 6.1%; p=0.42).ConclusionPostoperative constrictive physiology does not affect 30-day MACCEs or other major complications after OPCAB. The results of this study suggest that patients with early postoperative constrictive physiology do not need medical or surgical treatment, and that conservative care is sufficient.

Constrictive pericarditis: Insights from cardiac computed tomography

a v d d c r w c t e Constrictive pericarditis is a rare disease, usually the result of long-standing pericardial inflammation leading to pericardial scarring with thickening, fibrosis, and calcification. The most frequent causes are mediastinal radiation, chronic idiopathic pericarditis, cardiac surgery, and tuberculous pericarditis. Nearly 9% of patients with acute pericarditis for any reason go on to develop constrictive physiology. We report the case of a 52-year-old man with a history of acute pericarditis 30 years ago, with a three-year evolution of fatigue, dyspnea and palpitations. Physical examination revealed jugular venous distension and hepatomegaly and a pericardial knock was audible on cardiac auscultation. The 12-lead electrocardiogram revealed atrial flutter

Respiratory ventricular area changes measured with real-time cardiac magnetic resonance: A new, accurate, and reproducible approach for the diagnosis of pericardial constriction

Demonstration of pericardial pathology and/or constrictive physiology remains the basis for the diagnosis of pericardial constriction (PC). Cardiovascular magnetic resonance (CMR) is increasingly used to depict pericardial abnormalities [1–6]. Moreover, the Society of CMR endorses visual determination of abnormal respiratory septal motion characteristic of constrictive physiology on real-time cine imaging [7], and preliminary CMR studies have attempted to quantify this sign of increased ventricular interdependence [8,9] (Fig. 1).

IgG4-Related Systemic Disease Presenting With Lung Entrapment and Constrictive Pericarditis

We describe a 29-year-old woman who presented with chronic pleuropericarditis complicated by lung entrapment and constrictive pericarditis. Pleural biopsy performed during the decortication procedure revealed fibrinous pleuritis with lymphoplasmacytic inflammation including IgG4-positive plasma cells. The patient responded favorably to corticosteroid therapy with resolution of pleural effusion and constrictive physiology. To our knowledge, this is the first reported case of IgG4-related systemic disease manifesting as lung entrapment and constrictive pericarditis.

Successful application of a PressureWire retrogradely across an ATS prosthetic aortic valve to diagnose constrictive pericarditis

Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasionally necessary when noninvasive imaging and Doppler echocardiographic data are inconclusive or differ from the clinical findings for specific scenarios, such as diagnosing constrictive or restrictive physiology. We present a case in which we safely and effectively replicate the previous successful application of a PressureWire in diagnosing constrictive pericarditis in a patient with a bileafltet mechanical aortic and mitral valves.

A case of refractory rheumatoid pericarditis

A case of refractory rheumatoid pericarditis

Presentation pattern and management of effusive-constrictive pericarditis in Ibadan

Effusive-constrictive pericarditis is a syndrome in which constriction by the visceral pericardium occurs in the presence of a dense effusion in a free pericardial space. Treatment of this disease is problematic because pericardiocentesis does not relieve the impaired filling of the heart and surgical removal of the visceral pericardium is challenging. We sought to provide further information by addressing the evolution and clinico-pathological pattern, and optimal surgical management of this disease. We conducted a prospective review of a consecutive series of five patients managed in the cardiothoracic surgery unit of University College Hospital, Ibadan, in the previous year, along with a general overview of other cases managed over a seven-year period. This was followed by an extensive literature review with a special focus on Africa. The diagnosis of effusive-constrictive pericarditis was established on the basis of clinical findings of features of pericardial disease with evidence of pericardial effusion, and echocardiographic finding of constrictive physiology with or without radiological evidence of pericardial calcification. A review of our surgical records over the previous seven years revealed a prevalence of 13% among patients with pericardial disease of any type (11/86), 22% of patients presenting with effusive pericardial disease (11/50) and 35% who had had pericardiectomy for constrictive pericarditis (11/31). All five cases in this series were confirmed by a clinical scenario of non-resolving cardiac impairment despite adequate open pericardial drainage. They all improved following pericardiectomy. Effusive-constrictive pericarditis as a subset of pericardial disease deserves closer study and individualisation of treatment. Evaluating patients suspected of having the disease affords clinicians the opportunity to integrate clinical features and non-invasive investigations with or without findings at pericardiostomy, to derive a management plan tailored to each patient. The limited number of patients in this series called for caution in generalisation. Hence our aim was to increase the sensitivity of others to issues raised and help spur on further collaborative studies to lay down guidelines with an African perspective.

Constrictive Pericarditis Caused by Immunoglobulin G4-Related Disease

Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized systemic fibroinflammatory disease associated with elevated serum level of IgG4. It was initially described as autoimmune pancreatitis; however, in recent years, there have been reports describing a broadening spectrum of organ involvements. We report a case of IgG4-RD manifesting as constrictive pericarditis. ### Case Presentation A 76-year-old former smoker was admitted to an outside hospital with a 2-year history of progressive exertional dyspnea and lower extremity edema. Initial evaluation revealed the presence of bilateral pleural effusions and ascites. He was diagnosed with congestive heart failure. He was treated with diuretics and an afterload-reducing agent. Subsequent hemodynamic cardiac catheterization revealed findings suggestive of constrictive physiology (Figure 1). Despite aggressive management that included multiple paracenteses and thoracenteses, his overall clinical status did not improve. He was referred to our clinic for further evaluation. Figure 1. Hemodynamic cardiac catheterization. During …

Asymmetric focal pericardial thickening causing physiologically significant constrictive pericarditis

A 34-year-old woman presented with refractory ascites and edema. Echocardiography revealed normal left ventricular function with a restrictive diastolic filling pattern. Tissue Doppler velocities of the mitral annulus were normal. Cardiac magnetic resonance imaging (MRI) revealed a focal region of pericardial thickening anterior to the right ventricle and normal thickness pericardium in the other segments. However, abnormal delayed enhancement MRI (consistent with inflammation) was present in both the thickened and the normal pericardial segments. Invasive hemodynamics confirmed constrictive physiology and the patient underwent successful pericardiectomy. This case highlights the utility of multimodality imaging in the diagnosis of constrictive pericarditis and the underappreciated fact that the pericardium need not be globally thickened to cause hemodynamically significant constrictive physiology.

Acute Viral Myopericarditis Presenting as a Transient Effusive-Constrictive Pericarditis Caused by Coinfection with Coxsackieviruses A4 and B3

Acute myopericarditis is usually caused by viral infections, and the most common cause of viral myopericarditis is coxsackieviruses. Diagnosis of myopericarditis is made based on clinical manifestations of myocardial (such as myocardial dysfunction and elevated serum cardiac enzyme levels) and pericardial (such as inflammatory pericardial effusion) involvement. Although endomyocardial biopsy is the gold standard for the confirmation of viral infection, serologic tests can be helpful. Conservative management is the mainstay of treatment in acute myopericarditis. We report here a case of a 24-year-old man with acute myopericarditis who presented with transient effusive-constrictive pericarditis. Echocardiography showed transient pericardial effusion with constrictive physiology and global regional wall motion abnormalities of the left ventricle. The patient also had an elevated serum troponin I level. A computed tomogram of the chest showed pericardial and pleural effusion, which resolved after 2 weeks of supportive treatment. Serologic testing revealed coxsackievirus A4 and B3 coinfection. The patient received conservative medical treatment, including nonsteroidal anti-inflammatory drugs, and he recovered completely with no complications.

Primary Malignant Pericardial Mesothelioma Presenting as Acute Pericarditis

We report on a 21-year-old man with fever, dyspnea, and pleuritic chest pain. An electrocardiography showed ST elevation in multiple lead and thoracic echocardiography revealed moderate pericardial effusion. He was initially diagnosed with acute pericarditis, and treated with nonsteroidal anti-inflammatory drugs and colchicines with clinical and laboratory improvement. After 1 month of medication, his symptoms recurred. An echocardiography showed constrictive physiology and the patient was treated with steroid on the top of current medication. The patient had been well for 7 months until dyspnea and edema developed, when an echocardiography showed marked increased pericardial thickness and constriction. Pericardial biopsy was performed and primary malignant pericardial mesothelioma was diagnosed. Malignancy should be considered in the differential diagnosis of recurrent pericarditis.