Circulation. 2008;118:1685-1688
doi: 10.1161/CIRCULATIONAHA.108.770131
(Circulation. 2008;118:1685-1688.)
© 2008 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Recurrent Pericardial Constriction
Vibrations of the Knock, the Calcific Shield, and the Evoked Constrictive Physiology
Dawod Sharif, MD;
Naira Radzievsky, MSc;
Uri Rosenschein, MD
From the Department of Cardiology, Bnai Zion Medical Center, Haifa (D.S., U.R.), and Deep Breeze Co, Or Akiva (N.R.), Israel
Correspondence to Dawod Sharif, MD, Department of Cardiology, Bnai Zion Medical Center, 47 Golomb St, Haifa, Israel. E-mail dawod.sharif{at}b-zion.org.il
A 50-year-old man with a history of pericardiectomy 20 years previously was referred for investigation because of fatigue and abdominal discomfort. On physical examination, he was well nourished and without distress at rest, with a heart rate of 64 bpm and blood pressure 120/70 mm Hg. Marked distension of the neck veins was noticed, and the liver was sensitive and enlarged. Precordial auscultation revealed a pericardial knock in diastole. Recording of chest vibrations (vibration resonance imaging machine, Deep Breeze Co, Or Akiva, Israel) demonstrated a diastolic pericardial knock 108 ms after aortic closure sound (Figure 1A, arrow). Dynamic presentation of the chest vibration events are seen with the pericardial knock (Figure 1B). Echocardiography revealed constrictive physiology with abnormal septal motion, thick pericardium, inspiratory septal bounce, restrictive left ventricular filling with preserved mitral annular (Ea) velocities, and exaggerated expiratory increase of mitral and pulmonary venous velocities, whereas the inferior vena cava was dilated without respiratory change in diameter and increased hepatic vein velocities on inspirium (Figure 2). Left ventriculography revealed normal systolic function with heavy pericardial calcification (Figure 3). Simultaneous recording of left and right ventricular pressures at baseline showed higher left ventricular diastolic pressure (Figure 4, top); however, a square root shape was evident after 500 mL rapid intravenous fluid loading with equalization of diastolic left and right ventricular pressure (Figure 4, bottom). Repeat pericardiectomy was considered dangerous and the patient is still maintained on diuretics.
View larger version (48K):
[in this window]
[in a new window]
|
Figure 1. Pericardial knock demonstrated by phonocardigram. Arrows indicate an example of the knock 0.108 seconds after aortic closure (A), and dynamic mapping of chest vibrations with mobile red point on the ECG indicate timing in the cardiac cycle (B). See online-only Data Supplement Movie I to see motion.
|
|
View larger version (63K):
[in this window]
[in a new window]
|
Figure 2. Echocardiographic findings. A, M-mode with abnormal-flat septal motion and thick hyperechogenic pericardium. B, M-mode with septal bounce with inspiratory displacement of the septum toward the left ventricle. C, Apical 4-chamber view during inspirium with the ventricular septum displaced to the left. D, Restrictive left ventricular filling profile with large E-wave and short deceleration time. E, Preserved mitral annular tissue Doppler early diastolic velocity (Ea). F, Exaggerated increase of left ventricular filling velocities on experium. G, Dilated inferior vena cava without respiratory change of diameter. H, Inspiratory increase of velocities through the hepatic veins. I, Exaggerated increase in pulmonary venous velocities.
|
|
View larger version (131K):
[in this window]
[in a new window]
|
Figure 3. Left ventriculogram with heavily calcific pericardium. For motion, see online-only Data Supplement Movie II.
|
|
View larger version (51K):
[in this window]
[in a new window]
|
Figure 4. Pressure curves showing increased left and right ventricular diastolic pressures (top) with dip and plateau (square root sign) consistent with constriction physiology and equalization of diastolic pressures after volume loading (bottom).
|
|
 |
Acknowledgments
|
|---|
Disclosures
Dr Sharif is an external consultant of Deep Breeze Co. N. Radzievsky is an employee of Deep Breeze Co. Dr Rosenschein reports no conflicts.
|
Footnotes
|
|---|
The online-only Data Supplement can be found with this article at http://circ.ahajournals.org/cgi/content/full/118/16/1685/DC1.
