A middle-aged male presented with symptoms of exertional shortness of breath and leg swelling for the past six months. Examination revealed raised jugular venous pressure (JVP), pitting pedal oedema, muffled heart sounds, bilateral pleural effusion and hepatomegaly. Echocardiogram showed features of constrictive pericarditis with heavily thickened pericardium, which was confirmed by cardiac computed tomography (CT). The patient underwent pericardiectomy following which echocardiographic features of constriction were reversed and the patient became asymptomatic

Laghari, Abid

Tai, Javed

English

eCommons@AKU

eCommons@AKUDepartment of Medicine Department of MedicineMay 2013Heavily thickened pericardium with constrictivepericarditis.Abid LaghariAga Khan University, abid.laghari@aku.eduJaved TaiAga Khan University, javed.tai@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Cardiology CommonsRecommended CitationLaghari, A., Tai, J. (2013). Heavily thickened pericardium with constrictive pericarditis.. JPMA. The Journal of the Pakistan MedicalAssociation, 63(5), 639-641.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/261AbstractA middle-aged male presented with symptoms ofexertional shortness of breath and leg swelling for thepast six months. Examination revealed raised jugularvenous pressure (JVP), pitting pedal oedema, muffledheart sounds, bilateral pleural effusion andhepatomegaly. Echocardiogram showed features ofconstrictive pericarditis with heavily thickenedpericardium, which was confirmed by cardiac computedtomography (CT). The patient underwentpericardiectomy following which echocardiographicfeatures of constriction were reversed and the patientbecame asymptomatic.Keywords: Pericarditis, Constrictive, Echocardiography,Pericardiectomy.IntroductionConstrictive pericarditis is a rare condition characterisedby clinical signs of right heart failure subsequent to loss ofpericardial compliance. The aetiology of constrictivepericarditis has changed during the last decades in thedeveloped countries. Tuberculosis (TB) accounted for 49%of the cases of constrictive pericarditis in a series reportedin 19621 but cardiac surgery has become one of the mainreasons for its development in recent years. TB is still thefrequent cause of constrictive pericarditis in developingcountries because the relative incidence of TB as a causeof pericardial disease is associated with the overallprevalence of TB in a given population. TB pericarditisoccurs in 1 to 2% of patients with pulmonary TB.2However, cases defined as idiopathic constrictivepericarditis are still seen. Case ReportA 64-year-old male, with known history of diabetesmellitus and hypertension, presented in the cardiologyclinic with complaints of progressively increasingshortness of breath on exertion for the past 6 months, butno history of chest pain, fever or cough. On examination,he had a pulse of 96 beats/minute regular, blood pressureof 115/75 mmHg, raised jugular venous pressure (JVP),and pitting pedal oedema. His heart sounds were muffled.There was dull percussion note and bilateral decreasedbreath sounds at lung bases along with enlarged liver butno ascites. Bilateral pleural effusion was found on chest x-ray and low voltage was found on electrocardiography(ECG).  The echocardiogram showed abnormallythickened pericardium (18 mm) with trace circumferentialpericardial effusion, biatrial enlargement and normal leftventricular systolic function. Septal bounce was noted,along with non-collapsing dilated inferior vena cava andexpiratory diastolic reversal in hepatic vein. A cardiac CTVol. 63, No.5, May 2013639CASE REPORTHeavily thickened pericardium with constrictive pericarditisAbid Hussain Laghari, Javed Majid TaiSection of Cardiology, Department of Medicine, Aga Khan University Hospital,Karachi.Correspondence: Javed Majid Tai. Email: javed.tai@aku.eduFigure-1: Echocardiographic image, 4 chamber view pulse wave Doppler at mitralinflow showing significant respiratory variability.Figure-2: Echocardiographic image, pulse wave Doppler of hepatic vein showingdiastolic flow reversal which is more prominent during expiratory phase.angiogram was performed which reconfirmed the findingof a heavily thickened pericardium and normal coronaries.Autoimmune workup was negative. The patientunderwent pericardiectomy, and pericardial tissue acid-fast bacilli (AFB) smear and culture were found to benegative. Histopathology of pericardial tissue wasinconclusive and did not show any caseous granulomas.After pericardiectomy, the echocardiographic features ofpericardial constriction were reversed and the patientbecame asymptomatic. DiscussionThe clinical presentation of constrictive pericarditis mayvary, as noted in a series of 135 patients, in which 67% ofthe patients presented with heart failure, 8% with chestpain, 6% with abdominal symptoms, 4% with atrialarrhythmia, and only 5% with cardiac tamponade.3 Therisk of developing constrictive pericarditis following thefirst episode of acute pericarditis was evaluatedprospectively in 500 patients over a mean follow-up timeof 6 years (24 to 120 months).4 Constrictive pericarditisdeveloped in 1.8% of the total patients.4 Case reports ofconstrictive pericarditis following orthotopic hearttransplants have also been published.5 Tuberculosisaccounted for 49% of the patients of constrictivepericarditis in a case series reported in 1962.1 TB is still acommon cause of constrictive pericarditis in endemicareas and in patients with human immunodeficiency virus(HIV) infection, but only a rare cause in developedcountries. Effusive constrictive pericarditis, though itselfrelatively uncommon, is mostly caused by tuberculosis.Chest x-ray showing calcification around the heart isstrongly favourable for constrictive pericarditis in patientswith signs and symptoms of right-sided heart failure.6Transthoracic echocardiography is a very importantdiagnostic test for constrictive pericarditis evaluation —2D and M-mode for structural visualization and Dopplerechocardiography for haemodynamic assessment.6 In areported series of 143 surgically confirmed cases,increased pericardial thickness was seen in 37% of thecases, abnormal septal motion in 49%, and atrialenlargement in 61%.7 Cardiac CT is superior to cardiacmagnetic resonance (CMR) in detecting calcification, butCMR better differentiates small effusions from pericardialthickening. CMR can assess haemodynamic events likeseptal bounce, as well as identify pericardial inflammationand pericardial-myocardial adherence.8 The lategadolinium enhancement (LGE) of the pericardium seenon CMR is fairly common but not universal in constrictivepericarditis and might be a predictor of reversibilityfollowing treatment.9 Invasive haemodynamicassessment is rarely needed to confirm the diagnosis ofconstrictive pericarditis, otherwise it is mainly used insituations of suboptimal or non-diagnosticechocardiographic findings, or for evaluation of coronaryanatomy prior to pericardiectomy. The signs andsymptoms of constrictive pericarditis are usuallyprogressive in majority of the patients unless treatedsurgically with pericardiectomy. Sometimes, the signs andsymptoms of constriction are transient or reversible in aminority of patients with constrictive pericarditis.J Pak Med Assoc640 A. H. Laghari, J. M. TaiFigure-3: Cardiac CT image, showing heavily thickened pericardium.Figure-4: Cardiac CT image, showing heavily thickened pericardium.Therefore, in the absence of features like cachexia, atrialfibrillation, hepatic dysfunction, or pericardial calcificationwhich indicate that the constrictive pericarditis is chronic,newly diagnosed patients who are haemodynamicallystable may be given a trial of conservative managementfor 2 to 3 months before pericardiectomy.Pericardiectomy is the only definitive treatment, andmedical therapy such as diuretics may be used as atemporising measure, or for patients who are notcandidates for surgery. Patient outcomes are best at highvolume centres with greater experience ofpericardiectomy. In patients who underwentpericardiectomy between 1970 and 1985, the operativemortality was 12%, but significantly lower mortality ratebetween 4 to 8% was reported in patients whounderwent pericardiectomy between 1977 and 2006.10ConclusionConstrictive pericarditis is a rare condition characterisedby clinical features of right heart failure. TB is thefrequent cause of constrictive pericarditis in developingcountries whereas cardiac surgery is the most commoncause in developed countries. Cases defined asidiopathic constrictive pericarditis are still seen as wasthe case in our patient.References1. Robertson R, Arnold CR. Constrictive pericarditis with particularreference to etiology. Circulation 1962; 26: 525-9.2. Larrieu AJ, Tyers GF, Williams EH, Derrick JR.Recent experiencewith tuberculous pericarditis. Ann Thorac Surg 1980; 29: 464-8.3. Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB,et al. Constrictive pericarditis in the modern era: evolving clinicalspectrum and impact on outcome after pericardiectomy.Circulation 1999; 100: 1380-6.4. Imazio M, Brucato A, Maestroni S, Cumetti D, Belli R, Trinchoro R, etal. Risk of constrictive pericarditis after acute pericarditis.Circulation 2011; 124: 1270-5.5. Bansal R, Perez L, Razzouk A, Wang N, Bailey L. Pericardialconstriction after cardiac transplantation. J Heart Lung Transplant2010; 29: 371-7.6. Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmüller R, Adler Y, etal. Guidelines on the diagnosis and management of pericardialdiseases executive summary; The Task force on the diagnosis andmanagement of pericardial diseases of the European society ofcardiology. Eur Heart J 2004; 25: 587-610.7. Talreja DR, Edwards WD, Danielson GK, Schaff HV, Tajik AJ,Tazelaar HD, et al. Constrictive pericarditis in 26 patients withhistologically normal pericardial thickness. Circulation 2003;108: 1852-7.8. Verhaert D, Gabriel RS, Johnston D, Lytle BW, Desai MY, Klein AL.The role of multimodality imaging in the management ofpericardial disease. CircCardiovasc Imaging 2010; 3: 333-43.9. Feng D, Glockner J, Kim K, Martinez M, Syed IS, Araoz P, et al.Cardiac magnetic resonance imaging pericardial late gadoliniumenhancement and elevated inflammatory markers can predict thereversibility of constrictive pericarditis after anti-inflammatorymedical therapy: a pilot study. Circulation 2011; 124: 1830-7.10. Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R,Talwar S, et al. Pericardiectomy for constrictive pericarditis: aclinical, echocardiographic, and hemodynamic evaluation of twosurgical techniques. Ann Thorac Surg 2006; 81: 522-9.Vol. 63, No.5, May 2013Heavily thickened pericardium with constrictive pericarditis 641

Heavily thickened pericardium with constrictive pericarditis.

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1261&amp;context=pakistan_fhs_mc_med_med

Heavily thickened pericardium with constrictive pericarditis.

Abstract

Similar works

Full text

Available Versions

eCommons@AKU