Constrictive Pericarditis

Question 1

Constrictive pericarditis presentation

Answer 1

This man has had previous mantle radiotherapy for lymphoma and has a chronic history of leg oedema, bloating and weight gain.

Question 2

Clinical signs of Constrictive pericarditis

Answer 2

I. Predominantly right‐side heart failure

1. Raised JVP
   ⚬⚬ Dominant, brief y‐descent due to rapid early ventricular filling and rise in diastolic pressure
   ⚬⚬ Kussmaul’s sign: paradoxical increase in JVP on inspiration (may need to sit the patient at 90° rather than 45° to observe the JVP meniscus)
2. Pulsus paradoxus:
   ⚬⚬ >10 mm Hg drop in systolic pressure in inspiration (not a true paradox as it normally decreases by 2–3 mmHg!)
3. Auscultation:
   ⚬⚬ Pericardial knock – it’s not a knock but a high‐pitched snap (audible, early S3 due to rapid ventricular filling into a stiff pericardial sac)
4. Ascites, hepatomegaly (congestion) and bilateral peripheral oedema

Question 3

Causes of Constrictive pericarditis

Answer 3

1. TB: cervical lymphadenopathy
2. Trauma (or surgery): sternotomy scar, post‐MI
3. Tumour, Therapy (radio): radiotherapy tattoos, thoracotomy scar
4. Connective Tissue disease: rheumatoid hands, SLE signs.

Question 4

Investigation for Constrictive pericarditis

Answer 4

1. CXR: pericardial calcification, old TB, sternotomy wires
2. Echo: high acoustic signal from pericardium, septal bounce, reduced mitral flow velocity during inspiration
3. Catheter laboratory:
   ⚬⚬ Dip and plateau of the diastolic wave form: square‐root sign
   ⚬⚬ Equalization of LV and RV diastolic pressures
4. CT: thickened pericardium.

Question 5

Pathophysiology of Constrictive pericarditis

Answer 5

⚬⚬ Thickened, fibrous capsule
» Reduces ventricular filling and
» ‘insulates’ the heart from intrathoracic pressure changes during respiration
»> leading to ventricular interdependence – filling of one ventricle reduces the size and filling of the other.

Question 6

Treatment of Constrictive pericarditis

Answer 6

1. Medical: diuretics and fluid restriction

2. Surgical: pericardial stripping

Question 7

Differentiating pericardial constriction from restrictive cardiomyopathy

Answer 7

It is difficult to differentiate pericardial constriction from restrictive cardiomyopathy but observing ventricular interdependence (fluctuating LV/RV pressure or MV/TV flow velocities during respiration) is highly diagnostic for constriction!

Question 8

Jugular venous pressure waves

Answer 8

a: atrial systole
c: closure of tricuspid valve
x: movement of atrioventricular ring during ventricular systole
v: filling of the atrium
y: opening of the tricuspid valve