Station 3.9: Pericardial disease

Question 1

Clinical signs

What are the clinical signs of Pericardial disease - Constrictive pericarditis?

Pericardial disease - Constrictive pericarditis

This man has had previous mantle radiotherapy for lymphoma and has a chronic history of leg oedema, bloating and weight gain.

Answer 1

• Predominantly right‐side heart failure
  ⚬ Raised JVP
  ⚬⚬ Dominant, brief y‐descent due to rapid early ventricular filling and rise in diastolic
  pressure
  ⚬⚬ Kussmaul’s sign: paradoxical increase in JVP on inspiration (may need to sit the
  patient at 90° rather than 45° to observe the JVP meniscus)
  ⚬ Pulsus paradoxus:
  ⚬⚬ >10mm Hg drop in systolic pressure in inspiration (not a true paradox as it
  normally decreases by 2–3mm Hg!)
  ⚬ Ausculatation:
  ⚬⚬ Pericardial knock – it’s not a knock but a high‐pitched snap (audible, early S3 due
  to rapid ventricular filling into a stiff pericardial sac)
  ⚬ Ascites, hepatomegaly (congestion) and bilateral peripheral oedema
• Cause:
  ⚬ TB: cervical lymphadenopathy
  ⚬ Trauma (or surgery): sternotomy scar, post‐MI
  ⚬ Tumour, Therapy (radio): radiotherapy tattoos, thoracotomy scar
  ⚬ Connective Tissue disease: rheumatoid hands, SLE signs

https://1drv.ms/i/s!AofDuV8g6bhQge8oDVTmHYZ-3hjrfA?e=8JLYKd

Question 2

Discussion - investigation

What investigations do you recommend of Pericardial disease - Constrictive pericarditis?

Pericardial disease - Constrictive pericarditis

This man has had previous mantle radiotherapy for lymphoma and has a chronic history of leg oedema, bloating and weight gain.

Answer 2

• Investigation:
  ⚬ CXR: pericardial calcification, old TB, sternotomy wires
  ⚬ Echo: high acoustic signal from pericardium, septal bounce, reduced mitral flow velocity during inspiration
  ⚬ Catheter laboratory:
  ⚬⚬ Dip and plateau of the diastolic wave form: square‐root sign
  ⚬⚬ Equalization of LV and RV diastolic pressures
  ⚬ CT: thickened pericardium

Question 3

Discussion - investigation

What Pathophysiology do you recommend of Pericardial disease - Constrictive pericarditis?

Pericardial disease - Constrictive pericarditis

This man has had previous mantle radiotherapy for lymphoma and has a chronic history of leg oedema, bloating and weight gain.

Answer 3

• Pathophysiology:
  ⚬ Thickened, fibrous capsule reduces ventricular filling and ‘insulates’ the heart from intrathoracic pressure changes during respiration leading to ventricular interdependence – filling of one ventricle reduces the size and filling of the other

Question 4

Discussion - Treatment

What treatment do you recommend of Pericardial disease - Constrictive pericarditis?

Pericardial disease - Constrictive pericarditis

This man has had previous mantle radiotherapy for lymphoma and has a chronic history of leg oedema, bloating and weight gain.

Answer 4

⚬ Medical: diuretics and fluid restriction
⚬ Surgical: pericardial stripping

Differentiating pericardial constriction from restrictive cardiomyopathy is difficult but observing ventricular interdependence (fluctuating LV/RV pressure or MV/TV flow velocities during respiration) is highly diagnostic for constriction!