Abstract
Funding Acknowledgements
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A 50-year old woman had complained about dyspnea and leg swelling despite taking furosemide 80 mgr per day.
Her past medical history had included radiation therapy for Hodgkin"s lymphoma, prosthetic heart valves (mechanical MV, AV- INR = 3,2) and permanent pacemaker. Also her coronary vessels were normal.
On clinical examination she was non-febrile, the arterial pressure was 120/80mmHg,there was atrial fibrillation at 70 pulses/min at rest and oxygen saturation was 96%.
The chest x-ray finding was left pleural effusion. The patient also had ascites.
Kidney function was normal without proteinuria. The diagnostic paracentesis and biochemical analysis of ascitic fluid was indicative of transudative fluid.Cytologic analysis was negative for malignancy. Moreover,needle biopsy specimen was subjected to histopathology,which was negative for malignancy.
Echocardiography had revealed normal size and function of left ventricle ( LV = 46mm-EF = 60%). The mechanical valves had normal function, without paravalvular leak or masses. Also right ventricle was normal. The pulmonary artery pressure measured by echocardiography was in the normal range (RVSP = 35mmHg), but the inferior vena cava was dilated.There were also dilated hepatic veins and hepatic vein flow reversal.There was variation> 25% in triscupid inflow with respiration. TEE had confirmed the findings of transthoracic echo with regard of prosthetic valves.
CT of chest and abdomen findings were no pathologic lymphadenopathy,no pulmonary embolism and absence of tumor compressing inferior vena cava. Chest CT scan had demonstrated pericardium thickening,indicative of constrictive pericarditis. CMR was not performed because of permanent pacemaker.
The final step in diagnostic algorithm was cardiac catheterization:
a)the pulmonary artery systolic pressure measured during right heart catheterization was 35mmHg.
b)dip & plateau’ pattern or ‘square root sign of right ventricle, i.e. pattern of accentuated early dip in diastolic pressure, followed by plateauing in mid-late diastole.
c)prominent y wave of right atrium- absent x wave because of AF.
d)left ventriculography was not performed because of mechanical aortic valve.
At the end constrictive pericarditis was confirmed by the surgical report.
According to ESC guidelines a diagnosis of constrictive pericarditis is based on the association of signs and symptoms of right heart failure and impaired diastolic filling due to pericardial constriction by one or more imaging methods, including echocardiography, CT, CMR, and cardiac catheterization.
However,the most important step is the suspicion of constrictive pericarditis, especially in patients with history of radiation therapy and heart surgery.
Abstract 1099 Figure.
1099 Constrictive pericarditis:a challenge in Cardiology