Recurrent Pericardial Constriction
Vibrations of the Knock, the Calcific Shield, and the Evoked Constrictive Physiology
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.
Dr Sharif is an external consultant of Deep Breeze Co. N. Radzievsky is an employee of Deep Breeze Co. Dr Rosenschein reports no conflicts.
The online-only Data Supplement can be found with this article at http://circ.ahajournals.org/cgi/content/full/118/16/1685/DC1.