Pericardial Constriction

The tracings at top and bottom were taken from a mid-aged woman who presented with a several month history of worsening shortness of breath. Constrictive pericarditis was diagnosed after obtaining the tracings shown above and below. The hemodynamic findings shown here demonstrate several key features needed to confirm the diagnosis. At top, the Right Atrial waveform shows the classic 'M' or 'W' pattern which is characteristic of elevated right atrial pressure, rapid atrial emptying in early diastole (pronounced 'y' descent), and then rapid diastolic increase in atrial pressure as blood flow into the ventricles is greatly reduced after the first third of diastole because of the constricted pericardium. The corresponding Right Ventricular tracing shows the classic 'Dip and 'Plateau' which reflects rapid (dip) ventricular filling in the first third of diastole and then a relative plateau for the remainder of diastole. Diastolic pressures become equalized in constrictive pericarditis. The tracing below shows equalization of the Right Ventricular and Left Ventricular waveforms.

Constrictive pericarditis is often difficult to diagnose because the clinical symptoms mimic other diseases, particularly right heart failure and malignancy. Patients with advanced constriction often have significant body edema and even ascites and pleural effusions. The physical exam may demonstrate apical retraction and a pericardial 'knock' in early diastole. In contrast to Tamponade , pulsus paradoxus is usually absent although the neck veins may display a Kusmaul response where the JVP rises (instead of falling) with inspiration. The etiology of pericardial disease may include prior clinical pericarditis, post-thoracotomy syndrome, malignancy, viral infection, collagen-vascular disease, Tuberculosis, bacterial infection, radiation exposure, and idiopathic and other causes.

Treatment is often difficult and involves a surgical procedure to remove the pericardium and sometimes strip the visceral pericardium from the myocardium. This procedure is generally associated with moderate risk but when successful often results in significant symptomatic improvement.