involving the interventricular septum. The unusual ... constrictive pericarditis, this infiltration into the septum raised .... Septal bounce, vena cava plethora, and.
Abstract: Constrictive pericarditis causes impaired diastolic function of the heart and is an uncommon antecedent of heart failure. But it is difficult to diagnose it through imaging modalities. The presence of pericardial calcification is the key to
Oct 13, 2012 - ventricular septal shift to the left with inspiration, as well as marked diastolic ventricular septal bounce. An ECG- gated computerized ...
T2W STIR. LGE. âRip-Roaringâ Transient Constrictive Pericarditis ... Pericardial effusion/tamponade. â¢ Constrictive ... treated with colchicine, especially if treated ...
ting resolution of the congestive state and disappearance of the "typical" hemodynamic findings of constrictive pericarditis. T HE HEMODYNAMIC abnormalities.
An unusual case of constrictive pericarditis, caused by lodging of a needle in the heart wall,is presented and discussed. Attention is focused on the rapid ...
Jun 12, 2013 - OBJECTIVES: Constrictive pericarditis is the result of a spectrum of primary cardiac and non-cardiac conditions. Few data exist on the preoperative risk specific to survival after pericardiectomy. This study was designed to compare the
view this cause has never been proven unequivocally. It is the purpose of this paper to describe another case of this condition. Of special interest is the fact that constrictive pericarditis developed very rapidly in this patient, a point which rais
of constrictive pericarditis. T HE HEMODYNAMIC abnormalities of constrictive pericarditis were firstde- scribed in1946 byBloomfield and asso- ciates' who stressed "the virtually normal. (right) ventricular systolic pressure, a low ven- tricular pulse
Echo Evaluation of Pericardial Diseases. â¢ Constriction ... Pericardial effusion on Echo. â¢ Treated with Ibuprofen 2400 mg/d,. Colchicine 0.6 mg BID. â¢ Not feeling ...
Oct 4, 2010 - In both typical constrictive pericarditis and effusive-constrictive pericarditis, cardiac filling is impeded by an external force. The normal pericardium can stretch to accommodate physiologic changes in cardiac volume, and only after t
May 18, 2015 - He was found to have pericardial and bilateral pleural effusions which grew P. acnes. ... colchicine 0.6mg twice daily were initiated for treatment.
A study has been made of 62 patients with constrictive pericarditis. ... because both diagnosis and treatment can sometimes cause perplexity. .... In a few patients the diastolic sound was accompanied by a thrust felt over the praecordium.
540 Constrictive Pericarditis Accompanied by H1N1 Influenza cave ST segment .... definitive treatment for constrictive pericarditis is pericardi- ectomy,15) but ...
has had catheterization studies. A case of amyloid of the heart is presented with catheterization studies and the reasons for the clinical and physiologic similarity to constrictive pericarlditis are discussed. T HE essential pathology of constrictiv
Nov 16, 1988 - Background. The pathogenesis of sodium and water accumulation in chronic constrictive pericarditis is not well understood and may differ from that in patients with chronic congestive heart failure due to myocardial disease. This study
Constrictive pericarditis (CP) is an uncommon postin- flammatory disorder characterized by pericardial thick- ening, myocardial constriction, and impaired ...
JOURNAL OF THE ASSOCIATION OF PHYSICIANS OF INDIA â¢ MARCH 2014 â¢ VOL. 62. 67. Occult Constrictive Pericarditis. SR Mittal*. *Department of Cardiology,. St. Francis Hospital, Ajmer. Received: 01.09.2010;. Accepted: 07.10.2013. Case 1. A 45 years m
predominantly at thisannulus, the effect on the heart was similar to that resulting from more generalized constriction. In the fifth, signs of functional pulmonary, mitral, and aortic stenosis developed seven years after the original operation for co
Treatment of this disease is problematic because pericardio- centesis does not .... superimposed features of accompanying pericardial effusion or tamponade.
picture of constrictive pericarditis so fully described by Evans and Jackson (1952). There are certain aspects on the surgical management of constrictive.
Constrictive pericarditis (CP) is considered to be a process of inflammation of the pericardium, which often leads to thickened, scarred, and calcified tissues that lim- its diastolic ventricular filling. Generally, a pericardiec- tomy is the only ef
A total of 1184 patients with pericarditis were evaluated, 218 of whom had tamponade. Of these 218, 190 underwent combined pericardiocentesis and catheterization. Fifteen of these patients had effusiveâconstrictive pericarditis and were included in
Twelve of the 14 had preoperative cardiac catheterization. All demonstrated the findings considered diagnostic of constrictive pericarditis: (1) an elevated right atrial pressure, usually with an M- or W-shaped contour; (2) an abnormally high right v
Circ J 2002; 66: 610 – 612
Constrictive Pericarditis Caused by Calcification and Organized Hematoma 30 Years After Cardiac Surgery Yoshiyuki Takami, MD; Hiroshi Ina, MD; Yukiaki Tanaka, MD*; Akihiro Terasawa, MD* A 54-year-old man, who had undergone atrial septal defect (ASD) closure 30 years previously, was admitted for exertional dyspnea and chest oppression. He presented with right pleural effusion and hepatomegaly. Hemodynamic characteristics were consistent with constrictive pericarditis caused by multiple cystic lesions anterior to the main pulmonary artery and right ventricle, and severe calcification over the posterior and diaphragmatic sides of the heart. Magnetic resonance imaging was useful for differential diagnosis of the cystic mass and at surgery, it was revealed that the cystic lesions were old hematoma without cells. Pericardiectomy and removal of the calcification were performed safely using an ultrasonic scalpel, without cardiopulmonary bypass, resulting in hemodynamic improvement and relief of his symptoms. (Circ J 2002; 66: 610 – 612) Key Words: Calcification; Constrictive pericarditis; Magnetic resonance imaging; Hematoma; Ultrasonic scalpel
ostoperative constrictive pericarditis may not be as uncommon as we think. The incidence has been reported from 0.2% to 0.3% after open heart surgery1–3 and should be suspected when the postoperative course deviates from expected. Although the actual cause is unknown, several factors after cardiac operations are suspected, including surgical trauma, hemopericardium, infection, postpericardiotomy inflammation, cold injury, and air desiccation. The onset has been reported from 2 weeks to 21 years after surgery1,2 and we present an unusual case of a patient who developed symptoms of constrictive pericarditis 30 years after cardiac surgery.
Case Report A 54-year-old man was admitted for evaluation of exertional dyspnea and chest oppression. He had undergone closure of ASD via a median sternotomy 30 years previously and had not had any health problems since then. On admission, his blood pressure 94/66 mmHg and heart rate was 90 beats/min. The jugular vein was markedly distended and the liver was palpable below the right costal margin. Auscultation revealed no pathological sounds or arrhythmia. Laboratory data showed mild liver dysfunction (total billirubin of 1.9 mg/dl and lactate dehydrogenase of 567 IU/L). An electrocardiogram demonstrated normal sinus rhythm with inverted T waves in the precordal leads. The chest radiograph revealed mild cardiac enlargement with a cardiothoracic ratio of 0.6, right pleural effusion, calcification on the posterior and inferior parts of the cardiac silhouette, and 2 wires fixing the sternum. An echocardiography showed dilated right atrium (RA), ventricle (RV) and inferior vena cava (IVC), prominent diastolic flow reversals in (Received June 22, 2001; revised manuscript received July 18, 2001; accepted July 27, 2001) Divisions of Cardiovascular Surgery and *Cardiology, Kasugai Municipal Hospital, Kasugai, Japan Mailing address: Yoshiyuki Takami, MD, Division of Cardiovascular Surgery, Kasugai Municipal Hospital, 1-1-1 Takagi-cho, Kasugai 486-8510, Japan. E-mail: [email protected]
the dilated hepatic vein (Fig 1), and an echolucent mass anterior to the main pulmonary artery (PA) and RV. On a computed tomography (CT) chest scan, the mass was revealed to be multiple cystic lesions compressing the PA and RV outflow (Fig 2). CT also showed right pleural effusion and a heavily calcified mass over the posterior and diaphragmatic sides of the heart. From the T2-weighted magnetic resonance imaging (MRI) scans, the cystic mass anterior to the PA seemed to contain blood, protein and viscous components (Fig 3). A gallium scintigram did not show accumulation of the agent around the heart. Cardiac catheterization revealed elevated end-diastolic pressures in the right atrium and both ventricles (22, 20, and 27 mmHg, respectively). The pressures were: RA 25/22 mmHg; RV 40/16 mmHg with an early diastolic dip; PA 41/23 mmHg; mean pulmonary wedge, 24 mmHg; and left ventricle, 119/14 mmHg. The thermodilution cardiac index was 2.8 L·min–1 ·m–2.
Fig 1. Transthoracic echocardiograms before (I) and after (II) the surgery. Note that the inferior vena cava (IVC) was dilated up to 22 mm and there were prominent diastolic flow reversals in the dilated hepatic vein before surgery (I). After surgery (II), the diameter of the IVC decreased to 15 mm and the diastolic flow reversals in the hepatic vein became less prominent.
Circulation Journal Vol.66, June 2002
Postoperative Constrictive Pericarditis
Fig 2. Computed tomography scans of the chest before (I) and after (II) the surgery. Note the multiple cystic lesions compressing the pulmonary artery and right ventricle before surgery (I). Also note the heavily calcified posterior and diaphragmatic sides of the heart. After surgery (II), the cystic mass had gone and the calcified mass was reduced.
Based on a diagnosis of chronic constrictive pericarditis, surgery was performed to remove both the multiple cystic mass and the heavily calcified lesions. After a median sternotomy along the previous skin incision, the closed pericardium was opened. The cystic mass over the main PA ruptured, overflowing thick, semifluid, chocolate-like material, presumably old coagulated blood. Other cystic lesions with separating capsules over the anterior surface of the heart were also removed. Pathological evaluation of the mass was consistent with an organized hematoma without cells. Subsequently, the adhered pericardium was dissected from the surface of the RA, superior vena cava, and RV with the aid of an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, CVG, Cincinnati, OH, USA). We removed as much of the calcified lesions on the diaphragmatic surface, which were cement-like, as was possible without using cardiopulmonary bypass. The postoperative course was uneventful. The chest CT scan revealed that the cystic mass had gone and less calcification around the heart (Fig 2). The echocardiographic examination showed that the diameter of the IVC had decreased (from 22 mm to 15 mm) and there were less prominent diastolic flow reversals in the hepatic vein (Fig1). The mean RA pressure decreased to 18 mmHg and the early diastolic ‘dip’ of the RV pressure disappeared. Laboratory data before discharge showed a decrease in total billirubin to 0.5 mg/dl and lactate dehydrogenase to 290 IU/L.
Discussion The most recent report from the Mayo Clinic revealed that the 3 most common identifiable causes of constrictive pericarditis are cardiac surgery (18%), pericarditis (16%), and mediastinal irradiation (13%), although 33% of cases were idiopathic.3 There was a trend toward open heart surgery and irradiation as important causes because of the declining incidence of tuberculous pericarditis. The first interesting point about the present case of constrictive pericarditis is that the patient presented 30 years after cardiac surgery, and the second interesting point is that it was induced by the mixed pathology of hemopericardium and calcification. There have been other case reports of conCirculation Journal Vol.66, June 2002
Fig 3. Preoperative magnetic resonance images (T2-weighted). The multiple cystic lesions compressing the pulmonary artery and right ventricle show higher intensity than the chest wall muscles, which indicates the likelihood of blood, protein and viscous components in the cyst The images also show right pleural effusion, dilated inferior vena cava, and the heavily calcified mass over the diaphragmatic side of the heart.
strictive pericarditis caused by hemopericardium triggered by blunt trauma or pericardiocentesis,4–9 but the present patient did not have a history of chest trauma, and the hematoma was considered to be secondary to the previous surgery. Although the diagnosing the calcification was easy, it was difficult to qualitatively identify the multiple cystic lesions over the PA before surgery. MRI was the most useful among the several diagnostic modalities we tried, including CT and echocardiography. Others have also stressed the utility of MRI for assessing intrapericardial hematoma causing hemodynamically significant cardiac compression.6,8 As a diagnostic modality, Doppler echocardiography is quite easy and useful for defining the hemodynamic condition of the patient with constrictive pericarditis, compared with catheterization, which is invasive and influenced by examination conditions. In particular, the expiratory flow reversals in the dilated hepatic vein (Fig 2) are considered to be of equal importance to catheterization in evaluating the hemodynamic effect of constrictive pericarditis. At surgery, we used the Harmonic Scalpel to dissect the adhered pericardium. It was so safe and effective for pericardiectomy that we could remove the calcified lesions without the need for cardiopulmonary bypass, resulting in hemodynamic improvement. The Harmonic Scalpel has 2 cutting mechanisms: longitudinal vibration enabling the scalpel to incise tissues, and cavitational fragmentation disrupting low-density tissues and causing tissue planes to separate.10 The latter mechanism facilitates the dissection planes of adhered pericardium and avoids damage to adjacent vital structures such as the RA. References 1. Kutcher MA, King SB, Alimurung BN, Craver JM, Logue RB.
TAKAMI Y et al.
Constrictive pericarditis as a complication of cardiac surgery: Recognition of an entity. Am J Cardiol 1982; 50: 742 – 748. Cimino JJ, Kogan AD. Constrictive pericarditis after cardiac surgery: Report of three cases and review of the literature. Am Heart J 1989; 118: 1292 – 1301. Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB, et al. Constrictive pericarditis in the modern era: Evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999; 100: 1380 – 1386. Adachi T, Kitamura N, Ohtaki M, Miki T, Hukushima Y, Yamaguchi A, et al. A case of constrictive pericarditis due to traumatic pericardial hematoma. Kyobu Geka 1990; 43: 393 – 396. Hartl WH, Kreuzer E, Janetschek ER, Schmidt D, Reichart B. Pericardial mass mimicking constrictive pericarditis. Ann Thorac Surg 1991; 52: 557 – 559.
6. Isobe M, Yamaoki K, Sugiyama T, Seko Y, Yoshizumi M, Nagai R, et al. Right ventricular inflow obstruction due to giant hematoma formed by chronic constrictive pericarditis. Intern Med 1993; 32: 346 – 349. 7. Shah A, Melarkey D, Ness VT. Extrinsic nonvalvular mitral obstruction due to large epicardial hematoma. Chest 1993; 104: 285 – 286. 8. Meleca M, Hoit B. Previously unrecognized intrapericadial hematoma leading to refractory abdominal ascites. Chest 1995; 108: 1747 – 1748. 9. Sugita T, Ueda Y, Ogino H, Morioka K, Sakakibara Y, Matsubayashi K, et al. Constrictive pericarditis caused by an old hematoma. Thorac Cardiovasc Surg 1997; 45: 250 – 252. 10. Higami T, Maruo A, Yamashita T, Shida T, Ogawa K. Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel. J Thorac Cardiovasc Surg 2000; 120: 1142 – 1147.