Fading Out Dip-and-Plateau Pattern of Right Ventricular Pressure in Constrictive Pericarditis
A 64-year-old woman presented with general fatigue and abdominal distension of several months' duration. She had no history of cardiac surgery, mediastinal irradiation, or infectious diseases. Computed tomography revealed constrictive pericarditis with massive ascites and pleural effusion. Surgical therapy was indicated. Doppler sonography of the hepatic vein demonstrated a typical W-shaped pattern with reverse flow during expiration (Figure 1). Under general anesthesia, the chest was opened via a median sternotomy while right ventricular (RV) pressure was monitored with a pulmonary artery balloon catheter (780HF75, Swan-Ganz oximetry Paceport TD catheter, Edwards Lifesciences, Irvine, Calif), which was equipped with an RV lumen. RV pressure showed a typical dip-and-plateau pattern (square root sign; Figure 2A). The calcified pericardium adhered tightly to the epicardium without effusion.
We dissected the pericardium overlying the right ventricle, right atrium, venae cavae, and anterior wall of the left ventricle using a surgical knife, scissors, and an ultrasonic scalpel (Harmonic Scalpel, Ethicon Endo-Surgery Inc, Cincinnati, Ohio; hemodynamics shown in Figure 2B). Pericardiectomy was performed on the inferior cardiac surface, which was fully exposed by elevating and rotating the left ventricle with a cardiac positioner (Tentacles, Sumitomo Bakelite Co Ltd, Tokyo, Japan). However, RV pressure still showed a dip-and-plateau pattern (Figure 2C). To expose a deep surgical field of vision and gain sufficient operative space, we adopted a partial cardiopulmonary bypass. The posterolateral pericardium was decorticated, with the exception of a band near the left phrenic nerve. The dip-and-plateau pattern of the RV pressure faded out during the procedure (Figures 2D and 2E). The patient was weaned off of cardiopulmonary bypass, and the operation was completed with no complications or problems. After the median sternotomy was closed, pressure measurements demonstrated the dip-and-plateau pattern of the RV pressure had disappeared (Figure 2F) without administration of cardiac inotropes. The patient recovered uneventfully. On follow-up, the patient was well, with no ascites or pleural effusion (Figure 3).
Hansen and colleagues1 reported the typical RV pressure pattern in patients with constrictive pericarditis and their postoperative improvements in 1951; however, there have been few studies that have well illustrated when RV hemodynamics improve after pericardiectomy. In the present case, the dip-and-plateau pattern faded out during decortication of the posterolateral pericardium.