Correspondence to Ezra A. Amsterdam, MD, Division of Cardiovascular Medicine, University of California, Davis, 4150 V St, Suite 3500, Sacramento, CA 95817.
A 51-year-old man was admitted to an outside hospital for
weight gain, dyspnea on exertion, and orthopnea. He was found to have
bilateral pleural effusions, ascites, and marked peripheral
edema. An echocardiogram revealed normal right and left
ventricular systolic function. As a result of the
echocardiographic findings, congestive heart failure
(CHF) was given a low priority in the differential. Subsequently, an
extensive and comprehensive workup was undertaken, including
consultations by specialists in infectious disease, rheumatology,
oncology, surgical oncology, and pathology. With the goal of
discovering an occult malignancy, multiple tissues and fluids were
obtained and sent for pathological evaluation. These included pleural
and peritoneal fluid, cervical lymph nodes, pleural biopsy, biopsy of a
pelvic mass, and bladder biopsy. All biopsies, cultures, and serologies
were negative for neoplasia, infection, or vasculitis. The patient was
then referred to our institution for further evaluation.
History and physical examination were consistent with the
diagnosis of CHF. A Swan-Ganz catheter was placed for bedside
hemodynamic monitoring while aggressive
diuretic therapy was administered. Simultaneous
right and left heart catheterization demonstrated
equalization of elevated ventricular diastolic
pressures and normal systolic function. The right
ventricular pressure tracing was consistent with a
constrictive or restrictive process (Fig 1a
On day 7 after surgery, the right ventricular pressure
tracing showed resolution of the dip-and-plateau waveform and
normalization of the right ventricular
diastolic pressure (Fig 1b
Footnotes
From the Division of Cardiovascular Medicine, University of California, Davis.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine
Constrictive Pericarditis
). Computerized tomography of the chest
demonstrated a thickened pericardium, which confirmed the diagnosis of
constrictive pericarditis (Fig 2). The
patient was referred to cardiothoracic surgery for pericardiectomy.
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Figure 1. a, Initial bedside right
ventricular (RV) pressure tracing with
simultaneous electrocardiogram (EKG). Note
elevated RV diastolic pressure with characteristic
dip-and-plateau waveform ("square root sign"). Also note abnormally
large P waves (arrow) consistent with right atrial enlargement
as a result of elevated filling pressure. b, Postoperative bedside RV
waveform showing decreased RV diastolic pressure,
normalization of the dip-and-plateau waveform, and decrease in P-wave
size.
View larger version (99K):
[in a new window]
Figure 2. Computerized tomogram of chest demonstrating
abnormally thickened pericardium (arrows). This pericardial membrane is
5 mm thick and does not appear to be calcified. Also note large
bilateral pleural effusions. 
). The patient was discharged and
continued to improve. When he was seen in the clinic at a 2-week
postdischarge follow-up visit, all signs and symptoms of CHF were
absent.
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  R. B. McCully, S. T. Higano, J. K. Oh, E. A. Amsterdam, and S. D. Correa Diagnosis of Constrictive Pericarditis • Response Circulation, May 11, 1999; 99(18): 2476 - 2479. [Full Text] [PDF]
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