Diagnosis Of Constrictive Pericarditis Research Articles

Eine seltene Ursache der Rechtsherzinsuffizienz

The case of a 46-year-old male with progressive dyspnea on exertion and severe headache while having the head lowered is described. Clinically, the patient showed left-sided pleural effusion, jugular venous distension, and a congested liver. During cardiologic work-up, echocardiography, combined left/right heart catherization and magnetic resonance imaging established the diagnosis of constrictive pericarditis. Under conservative medical treatment, the patient again developed cardiac decompensation and, therefore, a pericardectomy was performed. Immediately after surgery, symptoms diminished and exercise tolerance increased. The patient is currently in cardiac rehabilitation. Constrictive pericarditis is a rare differential diagnosis of right heart failure. Especially in patients with congested inferior vena cava, but normal systolic left ventricular function and normal function of the cardiac valves, constrictive pericarditis should be considered as a differential diagnosis.

Pericardiectomy in post-traumatic suppurative constrictive pericarditis: case report

A 13-year-old male was seen at the Hospital with a 5-months history of right chest swelling, pain and recurrent fever and breathlessness on mild exertion. There was a history of gunshot to his chest two and half years before presentation.On admission he was febrile with a temperature of 39°C. The chest wall swelling measuring 6 cm/6 cm was tender and fluctuant and needle aspiration yielded purulent fluids. His blood pressure and pulse were 110/60 mmHg (14.6/8 Kpa) and 100 per minute respectively. The chest radiograph showed massive cardiomegaly with pellets lodging in the right 5th costosternal joint. Echocardiography confirmed massive pericardial effusion. The electrocardiogram showed sinus rhythm and low voltage of QRS complexes without chamber enlargement. A diagnosis of constrictive pericarditis with purulent pericardial effusion secondary to foreign body abscess was made.His clinical picture improved after an initial incision and drainage of the right anterior chest wall abscess under ketamine intravenous anaesthesia. Two weeks after, he had pericardiectomy under general anaesthesia using a nitrous/oxygen/halothane relaxant technique which was uneventful.

A difficult diagnosis - constrictive pericarditis and its treatment: a case report

The diagnosis of constrictive pericarditis requires a high degree of clinical suspicion, for the signs and symptoms of this disease can be falsely attributed to other causes. Herein, we present a case of a 70-year old retired farmer whose symptoms of right heart failure were initially attributed to co-existing pneumonia and pulmonary embolism. He was discharged. Three weeks later he presented with worsening breathlessness and ascites. Echocardiography, computed tomography and cardiac catheterization revealed the diagnosis of constrictive pericarditis. He underwent complete pericardectomy and to date has made a good recovery. This case exemplifies the difficulty in diagnosing this condition, the investigation required, and provides a discussion of the benefit and outcomes of prompt treatment.

Diagnostic Utility of Plasma N‐Terminal Pro‐B‐Type Natriuretic Peptide and C‐Reactive Protein Levels in Differential Diagnosis of Pericardial Constriction and Restrictive Cardiomyopathy

The authors investigated the diagnostic utility of plasma N-terminal pro-B-type natriuretic peptide (NT proBNP) and C-reactive protein (CRP) levels in the differential diagnosis of constrictive pericarditis (CP) and restrictive cardiomyopathy (RC). Twenty-five patients with high clinical suspicion of either CP or RC were enrolled. Mean plasma NT proBNP levels were significantly higher in patients with RC compared to those with CP (2641 +/- 2902 pg/mL vs 628 +/- 678 pg/mL; P=.003). The NT proBNP level that provided the best sensitivity and specificity for the differentiation of CP and RC was 800 pg/mL. Mean CRP levels were higher in patients with CP than with RC (1.41 +/- 1.73 mg/dL vs 0.38 +/- 0.21 mg/dL; P=.03). The CRP level that provided the best sensitivity and specificity for the differentiation of CP and RC was 0.57 mg/dL. Plasma NT proBNP and CRP levels can be useful in the differential diagnosis of RC and CP.

Constrictive pericarditis, still a diagnostic challenge: comprehensive review of clinical management

The diagnosis of constrictive pericarditis (CP) continues to be a challenge in the modern era. Understanding the pathophysiology and integrating the results of invasive and non-invasive techniques are important in the differential diagnosis of CP and e.g. restrictive cardiomyopathy. New echocardiographic techniques such as tissue Doppler imaging (TDI) and 2D-speckle tracking, dual-source CT (computed tomographic imaging) and especially tagged cine-MRI (magnetic resonance imaging) with the analysis of phase contrast angiography sequences are promising novel approaches. Pericardiectomy in experienced centers with complete decortication (if technically feasible) is the treatment of choice for CP and it results in symptomatic relief in most patients. However, some patients may not benefit from pericardiectomy and this may be due to myocardial compliance abnormalities, myocardial atrophy after prolonged constriction, residual constriction or other myocardial processes. An important predictor of long-term outcome after pericardiectomy is the etiology of the pericardial disease. The overall mortality in the current literature is nearly 5-6%. Survival with post-surgical CP is worse than with idiopathic CP, but significantly better than with post-radiation CP.

Constrictive Pericarditis Presenting as a Calcified Anterior Cardiac Mass

Constrictive pericarditis is an infrequent disorder. We report the case of a 52-year-old man with constrictive pericarditis with an uncommon anterior associated pericardial mass. Upon diagnosis of constrictive pericarditis, the patient underwent pericardectomy and resection of the mass. He is well 6 months postoperatively, with complete resolution of his heart failure symptoms.

Massive pericarditis constrictiva calcarea with compression of the right ventricle and consecutive pulmonary embolism

A 40-year-old man was admitted with a massive pericarditis constrictiva calcarea. Transthoracic and transoesophageal echocardiography demonstrated a double-layered pericardial calcification with interspacial effusion, a massive compression of the right ventricle, and a thrombus formation in the ventricle. In addition, severe pulmonary embolism due to this right ventricular thrombus formation was diagnosed by CT. This case demonstrates the importance of a multimodal imaging approach (echocardiography, TDI, MRI, CT) in the diagnosis of constrictive pericarditis and pericardial masses. In respect to the severe pericardial calcification with the massive interspacial mass, and the compression of the right ventricle with thrombus formation and consecutive pulmonary embolism, this case appears to be a very rare and uncommon clinical finding.

CME Test for Role of Echocardiography in the Diagnosis of Constrictive Pericarditis: Volume 22 • Issue 1

CME Test for Role of Echocardiography in the Diagnosis of Constrictive Pericarditis: Volume 22 • Issue 1

Diagnosis of constrictive pericarditis by quantitative tissue Doppler imaging

Objectives To observe the motion of pericardium and myocardium in patients with constrictive pericarditis (CP) and normal subjects using two-dimensional (2D) echocardiography and quantitative tissue Doppler imaging (QTDI), and to investigate the value of this echocardiographic approach in the diagnosis of pericardial adhesion in CP. Background The relationship of the motion of pericardium and myocardium in CP has not been investigated by QTDI. Methods The motions of pericardium and myocardium and the difference between them were investigated using 2D echocardiography combined with QTDI technique in 20 patients with CP and 20 age- and sex-matched normal subjects. Systolic peak displacements of pericardium ( D 1), outer-layer myocardium ( D 2) and inner-layer myocardium ( D 3) were measured from quantitative tissue displacement curves. The ratios of ( D 3– D 2)/( D 2– D 1) were then calculated. Results In normal subjects, the motion of myocardium was found to be stronger than that of pericardium, but the motions of outer-layer and inner-layer myocardium were virtually identical. However, in patients with CP, the motion of outer-layer myocardium was significantly reduced approaching that of pericardium, while the motion of inner-layer myocardium was stronger than that of outer-layer myocardium. The ratios of ( D 3– D 2)/( D 2– D 1) were significantly higher in patients with CP than those in normal subjects (5.0 ± 4.7 vs 0.6 ± 0.7, P < 0.05). Conclusions Obvious differences exist in the motion of pericardium and myocardium between normal subjects and patients with CP; observations of these differences using 2D echocardiography and QTDI provide a new and sensitive method in the diagnosis of pericardial adhesion in CP.

Níveis séricos de NT pro-BNP: relação com função sistólica e diastólica nas miocardiopatias e pericardiopatias

NT pro-BNP is a marker of systolic and diastolic dysfunction. To determine NT pro-BNP levels in patients with chagasic, hypertrophic, and restrictive heart diseases, as well as with pericardial diseases, and their relation to echocardiographic measurements of systolic and diastolic dysfunction. A total of 145 patients were divided into the following groups: 1) Chagas' heart disease (CHD)--14 patients; 2) hypertrophic cardiomyopathy (HCM)--71 patients; 3) endomyocardial fibrosis (EMF)--26 patients; 4) pericardial effusion (PE)--18 patients; and 5) constrictive pericarditis (CP)--16 patients. The control group was comprised of 40 individuals with no heart disease. The degree of myocardial impairment and pericardial effusion were assessed by two-dimensional echocardiography and the degree of restriction by pulsed Doppler transmitral flow. The diagnosis of CP was confirmed through magnetic resonance imaging. NT pro-BNP levels were determined through electrochemiluminescence immunoassay. NT pro-BNP was increased (p < 0.001) in CHD (median = 513.8 pg/ml), HCM (median = 848 pg/ml), EMF (median = 633 pg/ml), CP (median = 568 pg/ml), and PE (median = 124 pg/ml), when compared with the control group (median = 28 pg/ml). No statistically significant differences were found between CP and EMF (p = 0.14). In the hypertrophic group, NT pro-BNP was correlated with left atrial size (r = 0.40; p < 0.001) and with E/Ea ratio (p < 0.01). In the restrictive group, there was a trend of correlation with E-wave peak velocity (r = 0.439; p = 0.06). NT pro-BNP is increased in the different cardiomyopathies and pericardial diseases and is correlated with the degree of systolic and diastolic dysfunction.

Constrictive Pericarditis

Constrictive pericarditis (CP) is characterized by scarring and loss of elasticity of the pericardium, resulting in external impedance of cardiac filling. In the developed world, CP is most frequently encountered as a consequence of previous cardiac surgery, thoracic irradiation, viral or idiopathic causes. Tuberculosis still remains a common cause of CP in the developing world, immigrants from underdeveloped nations, and immunosuppressed patients. Clinical signs and symptoms of right heart failure coupled with risk factors for pericardial disease should raise suspicion for CP. Echocardiographic evaluation and often cardiac catheterization are essential components of accurate diagnosis of CP. Enhanced interventricular dependence, with respiratory variation in the ventricular pressures, and ventricular discordance are the pathophysiologic hallmarks of CP. Imaging findings such as increased pericardial thickness or pericardial calcification on computed tomography can be supportive, but are not necessary for the diagnosis of CP. Pericardiectomy remains the most effective therapy for symptomatic CP.

The Constricted Heart

Often indistinguishable from restrictive cardiomyopathy and hepatic cirrohis, clinical acumen is essential in the recognition and diagnosis of constrictive pericarditis. A thorough medical history should rule out infectious disease exposure. A physical examination may include variable signs such as Kussmaul's sign, pulsus paradoxus, and pericardial knock, while jugular venous distention is of cardinal significance in eliminating liver cirrhosis as the cause of ascites. A complete physical examination, appropriate imaging studies, and cardiac catheterizaiton are crucial for proper diagnosis and prompt treatment of constrictive pericarditis.

Constrictive Pericarditis in the Modern Era: Novel Criteria for Diagnosis in the Cardiac Catheterization Laboratory

This study sought to determine the clinical utility of a new catheterization criterion for the diagnosis of constrictive pericarditis (CP). The finding of early rapid filling and equalization of end-diastolic pressures obtained by cardiac catheterization are necessary for the diagnosis of CP, but these findings are also present in patients with restrictive myocardial disease (RMD). Enhanced ventricular interaction is unique to CP. High-fidelity intracardiac pressure waveforms from 100 consecutive patients undergoing hemodynamic catheterization for diagnosis of CP versus RMD were examined. Fifty-nine patients had surgically documented CP and comprised group 1; the remaining 41 patients with RMD comprised group 2. The ratio of the right ventricular to left ventricular systolic pressure-time area during inspiration versus expiration (systolic area index) was used as a measurement of enhanced ventricular interaction. There were statistically significant differences in the conventional catheterization criteria between CP and RMD, but the predictive accuracy of any of the criteria was <75%. The systolic area index had a sensitivity of 97% and a predictive accuracy of 100% for the identification of patients with surgically proven CP. The ratio of right ventricular to left ventricular systolic area during inspiration and expiration is a reliable catheterization criterion for differentiating CP from RMD, which incorporates the concept of enhanced ventricular interdependence.

Constrictive Pericarditis: A Cause of Exertion-Induced Dyspnea in a Soldier with a Prior Sternotomy

Diagnosing the underlying etiology of dyspnea on exertion in adults can be challenging, often requiring the clinician to distinguish cardiac or pulmonary pathological conditions from metabolic, neurological, or hematological conditions or from chest wall abnormalities. We report such a case involving a 29-year-old, male, active duty Army soldier. With a history of a median sternotomy, symptoms of right- and left-side heart failure, and examination findings suggesting elevated right atrial pressure, pericardial disease was pursued. Echocardiography and cardiac catheterization revealed constrictive physiological features, namely, elevation and near-equalization of right- and left-side pressures and ventricular interdependence, whereas computed tomography illustrated pericardial thickening, ultimately leading to the diagnosis of constrictive pericarditis. The patient was treated with a complete pericardiectomy, leading to symptom resolution and improved exercise capacity. This case report of a rare condition offers a concise etiological and physiological overview of constrictive pericarditis and demonstrates an effective multimodal diagnostic approach. The scientific evidence provided may assist general practitioners in making decisions to differentiate this clinical condition from similar cardiac or cardiopulmonary conditions.

A young man with intractable ascites and effort dyspnoea without echocardiographic signs of pericardial thickening: The importance of clinical investigation, CT scan and MRI in the diagnosis of constrictive pericarditis

A 35-year-old male patient suffering from dyspnoea on effort for 8 months, with abdominal and jugular venous distension, was previously studied in another hospital and discharged with a diagnosis of restrictive cardiomyopathy. Physical examination revealed a blood pressure of 110/60 mm Hg and absence of pericardial knock and also of paradoxical pulse. Chest X-ray showed no cardio-pulmonary alterations. Transthoracic echocardiography showed mild LV dysfunction (LVEF 46%) and lack of pericardial effusion and thickening. Doppler interrogation of transmitral flow showed a restrictive pattern. Computed tomography showed diffusely thickened pericardium, with the absence of calcification and of pericardial effusion. Cardiac magnetic resonance confirmed pericardial thickening and showed lack of myocardial alterations. Mild LV dysfunction was noted with dyskinesia of interventricular septum. The patient underwent cardiac catheterization, demonstrating an equalisation of RV and LV diastolic pressures with “square root” sign. The patient underwent pericardiectomy with consequent resolution of his symptoms and improvement of LV function.

Experience of Pericardiectomy in Tikur Anbessa University Hospital, Ethiopia

Background: Pericardiectomy is the only accepted curative treatment for improving cardiac haemodynamics in chronic constrictive pericarditis (CCP). This study was aimed at reviewing the experience and functional outcome of patients undergoing Pericardiectomy in Tikur Anbessa Hospital between January 1996 and December 2005. Methods: This was a retrospective Analysis done at the Thoracic Surgical unit, Tikur Anbessa Hospital, Department of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa, Ethiopia. During the period under review, 26 patients underwent Pericardiectomy for CCP. Medical records and operation theatre registers of 19 patients were retrieved and analysed. Results: Thirteen of the patients were males and six were females (M: F=2.2:1) The ages ranged from 14 to 42 years (mean 24.3±7). The duration of illness ranged between 2 and 36 months with a mean of 15.2±10.8). Diagnosis of constrictive pericarditis was based on the clinical picture of right sided heart failure along with chest roentgenogram, electrocardiogram, echocardiography and histological examinations. The most common presenting symptoms were dyspnea in 19 (100%) patients, abdominal discomfort in 14 (73.7%) and abdominal distension in 11 (68.4%) patients. Onphysical examination raised JVP, peripheral edema, hepatomegaly and ascites w 63.2%) patients, enlarged cardiac silhouette in 9 (47.4%) and pericardial calcification in 7 (36.8%). ECG showed low QRS voltage and T wave abnormality in 10 (52.6%) and 9 (42.1%) cases respectively. Pericardial thickening/calcification (52.6%), left ventricular septa motion abnormality (42.1%) and pericardial effusion (36.8%) were seen by echocardiography. The surgical approach was mainly median sternotomy in 15 (79%) patients, and the mean operation time was 112 (range 90-135±18.9) minutes. Fifteen (79%) patients had uneventful postoperative course. Two patients developed pneumonia and one a hydropneumothorax. There was one death in the immediate postoperative period. Long–term mortality of 10.5% was noted. Mean hospital stay and follow-up time were 14.3±5.3 (range 7-24) days and 12.8±6.9 (range 3-24) months respectively. Conclusion: Pericardiectomy can be performed without the use of CPB and with low mortality, and can result in an improved functional capacity in the majority of the patients.

Constrictive Pericarditis Diagnosed by Cardiac Magnetic Resonance Imaging in a Pacemaker Patient

A 71-year-old male was referred for evaluation of 6 months of progressively worsening dyspnea on exertion and peripheral edema, mainly of the legs. During the symptomatic period, he had undergone 3 thoracentesis procedures, each draining more than 1500 mL of transudative fluid. His functional impairment was so severe that he contemplated suicide. His cardiac history was significant for syncope attributable to sinus node dysfunction 19 years earlier, requiring implantation of an atrioventricular pacing system. Because of atrial lead fracture, a second atrial lead had been placed 1 month before the onset of the dyspnea and leg edema. Physical examination revealed diminished breath sounds over both lung fields and moderate (2+) edema of both lower extremities to the level of the knee. The 12-lead ECG demonstrated normal sinus rhythm at 79 bpm with low-voltage and diffuse ST and T-wave abnormalities (Figure 1). A chest x-ray revealed a dual-chamber permanent cardiac pacemaker, 2 retained leads, and bilateral pleural effusions (Figure 2). Transthoracic and transesophageal echocardiography and …

Diagnosis of Constrictive Pericarditis by Using Doppler Tissue Echocardiography

Diagnosis of constrictive pericarditis(CP) is difficult using conventional Doppler echocardiography. Gracia et al. (1996 JACC) measured mitral annular velocities, and found that early diastolic myocardial velocity(Em) was significantly higher in normals and patients with CP, compared to those with restrictive cardiomyopathy. But only latest echocardiography equipment can be used to measure Em. We experienced two patients with CP. Case I was 67y.o.male two years after CABG and Case II was 66y.o.male who had the history of lung tuberculosis.

Doppler Echocardiographic Evaluation of Pulmonary Regurgitation Facilitates the Diagnosis of Constrictive Pericarditis

Diagnosing constrictive pericarditis (CP) remains a clinical challenge. Ventricular interdependence and dissociation of intrathoracic and intracardiac pressures are hallmark features that are readily recognized by invasive and noninvasive hemodynamics. The Doppler echocardiographic signal from pulmonic valve regurgitation depends on the relationship between pulmonary artery (intrathoracic) and right ventricular (intracardiac) pressure. Respiration-associated changes in this signal may aid in the evaluation of pericardial constriction. We demonstrate here that early diastolic cessation with inspiration can indicate a CP process. Early diastolic cessation with inspiration was shown to have correctly diagnosed CP in 70% of the patients in this study, with a sensitivity of 77%, specificity of 64%, positive predictive value of 67%, and negative predictive value of 75%. This noninvasive insight into dissociation of intracardiac and intrathoracic pressures, although not sufficient on its own, may be a valuable tool for aiding in the diagnosis of CP.

Continuous Intraoperative Transesophageal Echocardiography during Pericardiectomy for Constrictive Pericarditis Revealing Dynamic Change in Chamber Size

We review a case of a 50-year-old man with diagnosis of constrictive pericarditis, who underwent pericardial stripping with continuous intraoperative transesophageal echocardiography (TEE). This patient demonstrates the immediate dynamic changes in chamber size after successful surgical removal of pericardium as demonstrated by TEE.