Asian Cardiovasc Thorac Ann 2001;9:56-58
© 2001 Asia Publishing EXchange Pte Ltd
Right Mid-Ventricular Constriction Due to Constrictive Pericarditis
Serdar Çimen, MD,
Mehmet Kaplan, MD,
Murat Demirta
, MD,
Onur Türek, MD,
zzet Erdinler, MD,1,
Mehmet Eren, MD,1,
Kadir Gürkan, MD,1,
Tuna Tezel, MD,1,
Azmi Özler, MD
Cardiovascular Surgery Clinic
1 Cardiology Clinic Siyami Ersek Thoracic and Cardiovascular Surgery Center Istanbul, Turkey
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For reprint information contact: Mehmet Kaplan, MD Tel: 90 216 455 7452 Fax: 90 216 337 9719 email: mehmetkaplan{at}superonline.com 67 Ada Kardelen 4-4, D:11 Ataehir, Istanbul 81120, Turkey.
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Abstract
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A 16-year-old girl with atrial arrhythmia underwent excision of thickened pericardium with localized annular calcification over the proximal right ventricle. Sinus rhythm was restored postoperatively. Constrictive pericarditis and localized cardiac compression should be considered in the differential diagnosis of arrhythmias in young patients.
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Introduction
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Constrictive pericarditis is a pathology in which thickened pericardium prevents diastolic filling of the heart. In some cases, it may create external compression on the heart chambers, especially in calcified areas.1,2 Annular constriction creates a pressure gradient and proximal chamber dilatation, with all the classical findings of constrictive pericarditis.1,2
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Case Report
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A 16-year-old girl was admitted with palpitations and fatigue. She had a history of posttraumatic leg infection at 7 years old, which had become systemic and infected fluid had been removed from the left hemithorax. On admission, her heart rate was 110 beats•min–1 and arrhythmic, and her blood pressure was 110/80 mm Hg. Her liver was l-cm enlarged and palpable. Electrocardio-graphy showed atrial flutter and fibrillation. Pericardial calcification was detected by anteroposterior and lateral teleradiography (Figure 1
). Echocardiography showed pericardial thickening and a calcified ring over the right ventricular inflow tract. The calcification, approximately 10 cm in length, extended to the left ventricle from the anterior surface of the right ventricle. The right atrium was dilated. In the right ventricle, there was a secondary orifice due to external constriction, and a pressure gradient of 5 mm Hg (Figure 2). Both transesophageal echocardio-graphy and magnetic resonance imaging disclosed a calcified structure over the right ventricle, extending towards the left ventricle in a circular form 1.5 to 2 cm in width and 7.5 to 8 cm in length (Figure 3). At cathe-terization, a 9-mm Hg systolic pressure gradient was present in the right ventricle. The right ventricular pressure trace showed the characteristic square-root sign that is almost specific for constrictive pericarditis. Because of the severity of the tachycardia, it was thought that the extracardiac constriction was compressing the atrio-ventricular node. Pericardiectomy was planned, with a diagnosis of chronic constrictive pericarditis.
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Figure 2. Secondary orifice and right ventricular constriction found on the preoperative echocardiogram. LA = left atrium, LV = left ventricle, MV = mitral valve, RA = right atrium, TV = tricuspid valve.
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Figure 3. Preoperative magnetic resonance image showing the calcified structure over the right ventricle, extending towards the left ventricle in a circular form.
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A median sternotomy was carried out under general anesthesia with careful monitoring. Central venous pressure was 16 mm Hg, and the cardiac rhythm was atrial fibrillation. Because of the possibility of rupture, an oxygenator was held ready for cardiopulmonary bypass. Pericardial stripping was started from the aorta towards the left ventricle and advanced over the right ventricle, right atrium, and venae cavae. During dissection, a calcified pericardial area of 2 cm in width was found to extend from the proximal right ventricle over the left ventricular lateral surface. The right atrium was severely dilated. After resection, the right ventricle was seen to be an hourglass shape due to circular compression by a calcified annular lesion. Pericardial resection was con-tinued anterior to the phrenic nerves bilaterally, without complication. Drainage tubes were placed in the media-stinum and in both thoracic cavities. Following peri-cardiectomy, central venous pressure decreased to 5 mm Hg, there was no gradient in the right ventricle, and sinus rhythm was restored. The patient was extubated on the 4th postoperative hour and discharged on the 7th day. On the 15th postoperative day, she was found to be still in sinus rhythm and echocardiography demonstrated loss of the constriction and secondary orifice (Figure 4). Pathology of the resected calcified pericardial specimen revealed nonspecific pericardial fibrosis, dense collagen bunches, and a thick membranous structure formed by new vessels.
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Figure 4. Postoperative echocardiography demonstrating loss of the constriction and secondary orifice. MV = mitral valve, TV = tricuspid valve.
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Discussion
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Constrictive pericarditis is an uncommon pathology. In the past, tuberculosis was the most frequent etiology, especially in developing countries. Nowadays, idiopathic cases are more common. Other causes are open heart surgery, radiotherapy, connective tissue disorders, trauma, and viral, bacterial, purulent, fungal, parasitic, uremic, and neoplastic diseases.3 Chronic constrictive pericarditis is an inflammatory process affecting fibrous and serous layers of the pericardium. In most cases, cardiac muscle atrophy occurs in the early period and myocardial fibrosis starts in the late phase.4 Calcification can be detected in 40% of cases, especially on lateral teleradiography, and it is very specific but not very sensitive. Atrial fibrillation is seen in 25% of cases and it has a detrimental effect on the clinical condition.4
There are very few reports of annular constriction due to constrictive pericarditis. Yanase and colleagues1 described bilateral atrioventricular annular constriction in a case of pericarditis with effusion. Localized pericardial effusion was noted in the area adjacent to the right ventricular wall and behind the left ventricular posterior wall, with fixed bilateral atrioventricular constriction in 2-dimensional echocardiography. There was also an 8-mm Hg gradient at the tricuspid valve at cardiac catheterization. Tanaka and colleagues2 reported a calcified constrictive bundle 2 to 3 cm in width coursing along the anterior face of the great arteries towards the posterolateral face of the left ventricle and behind the great arteries, in a case of constrictive pericarditis. Iseki and colleagues5 found a calcified mass on teleradiography in a 62-year-old man with palpitations. Magnetic resonance imaging showed that the right ventricle was compressed by a mass resembling a tumor. Exploration of the mass at surgery revealed locally calcified and thickened pericardium.
In our patient, the 2-cm wide constrictive bundle formed a circular mass beginning 3 cm below the right atrio-ventricular sulcus, coursing over the outflow tract on the right ventricular anterior surface and the left ventricular lateral and posterior surface. The right atrium was severely dilated due to constriction of the right ventricle. From this experience, it was concluded that constrictive pericarditis with localized cardiac compression should be considered in the differential diagnosis of arrhythmias in young patients. As early diagnosis and surgical treatment de-creases the morbidity and mortality considerably, resection of the pericardium should be performed without delay.
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References
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Yanase O, Motomiya T, Watanabe K, Tokuyasu Y, Sakurada H, Tejima T, et al. Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction: a case report. J Cardiol 1989;19: 1147–56.[Medline]
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Tanaka H, Kadoba K, Mitsuno M, Chang JC, Nakano S, Matsuda H. An unusual case of annular constrictive pericarditis: a "framed heart" [Japanese]. Nippon Kyobu Geka Gakkai Zasshi 1992;40:996–1000.[Medline]
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Cameron J, Costerlo SN, Baldwin JC, Hancock EW. The etiologic spectrum of constrictive pericarditis. Am Heart J 1987;113:354–60.[Medline]
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Levine HD. Myocardial fibrosis in constrictive pericarditis. Electrocardiographic and pathologic observations. Circulation 1973;48:1268–81.[Abstract/Free Full Text]
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Iseki H, Kayaba Y, Tamura T, Uzawa H, Suko Y, Miyamoto K. Localized pericarditis with calcifications mimicking a pericardial tumor. Intern Med 1999;38:355–8.[Medline]
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Abstract
Introduction
