Pericardial constriction

Template:Pericardial constriction Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Atif Mohammad, M.D.

See also: pericarditis, pericardial effusion, cardiac tamponade

Diagnosis

Laboratory Findings

Protein losing enteropathy, nephrotic syndrome, LFT abnormalities c/w hepatic congestion and chylous ascites has also been reported.

Cardiac Catheterization

Typically, there is equalization of diastolic pressures in all four chambers. These filling pressures are typically elevated. RVSP is usually moderately elevated but rarely exceeds 60 mmHg.

If RVSP is >60 mmHg, restriction is suggested. The RVEDP is usually at least 1/3 of the RVSP. Again, if it is lower, restriction is suggested. Some say that the LVEDP may be slightly higher than the RVEDP in restriction, especially after volume load or exercise.

The RV and LV waveforms exhibit a “dip and Plateau or square root” sign, which is another manifestation of the early rapid diastolic filling, followed by abrupt cessation of flow. Discordance between the RVS and LVS pressures can also be seen during inspiration.

Diuresis can obscure the hemodynamic findings in the catheterization laboratory, and diuretics should be held and careful IVF rehydration given if the diagnosis is entertained.

Perciardial constriction should be differentiated from restriction (which involves the left ventricle more selectively). The clinical features and hemodynamic findings of the two syndromes have significant overlap. One useful test in the cardiac catheterization laboratory to distinguish the two is a volume challenge. On simultaneous LV and RV diastolic pressure tracings, constriction compromises both ventricles equally (the LV and RV diastolic pressures will rise equally). Restriction on the other hand, will affect the LV more than the RV, and the LV diastolic pressure will rise out of proportion to the RV diastolic pressure. If restriction is suspected, one should screen for hemochromatosis, sarcoid, the hypereosinophillic syndrome, amyloid and radiation induced-myopathy.

Constrictive Pericarditis can also be differentiated from Restrictive Cardiomyopathy during cardiac catheterization using "Systolic Area Index" as a reliable hemodynamic criterion .Systolic Area Index is the ratio of right ventricular to left ventricular systolic area pressure -time (mm Hg X s) area during inspiration and expiration .It is increased (>1.1) in Constrictive Pericarditis as compared to Restrictive Cardiomyopathy which confirms the "ventricular interdependence" phenomenon present in Constrictive Pericarditis. |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)03432-8}}

MRI and CT

MRI or CT may demonstrate thickening or calcification of the pericardium.

Below is a video demonstrating MR findings of constrictive pericarditis where, in mid-diastole, the thickened pericardium begins to restrict right ventricular filling, causing a rapid increase in ventricular pressure. Early changes of septal flattening and bowing of the interventricular septum toward the left ventricle (normally concave in shape toward the left ventricle during diastolic filling) are seen. This pressure change results in diastolic septal dysfunction, the septal bounce described in echocardiography. <youtube v=5srXVJdWIAM/>

Echo

Echocardiography can demonstrate thickening of the pericardium and specific flow patterns across the mitral and tricuspid valves that are evidence of the abnormal diastolic filling in constriction. Collapse of the IVC and hepatic veins can be seen.

References

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