[Early constrictive pericarditis after coronary revascularization. Apropos of a case]

The authors report a case of severe constrictive pericarditis occurring 6 weeks after coronary bypass surgery and in the absence of any other predisposing factor. The diagnosis was confirmed by CT scan and cardiac catheterisation which showed signs of a diastole. The patient died despite early surgical reoperation because of the severity of the pericardial fibrosis.

Constrictive pericarditis associated with trauma and pectus excavatum

A case of constrictive pericarditis is reported in a 31 year old man with pectus excavatum. The constriction was secondary to an organized traumatic pericardial haematoma immediately behind the pectus deformity.

Transient cardiac constriction following purulent pericarditis

Transient cardiac constriction is an unusual complication of purulent pericarditis. It should be suspected in the presence of clinical and haemodynamic deterioration when signs of activity have abated. Features of cardiac constriction were observed in a 4-year-old boy 2 weeks after surgical drainage. The patient was managed conservatively without surgery and the outcome was good. Follow up 2 years later showed a healthy boy with a normal cardiological examination.

Pregnancy complicating irradiation-induced constrictive pericarditis

A case is reported of a 24-year-old primigravida who had severe effusive constrictive pericarditis secondary to mediastinal irradiation following chemotherapy for Hodgkin's disease. Pregnancy was threatened by serious maternal cardiovascular complications, and a non-viable fetus was born spontaneously and prematurely. Patient was completely asymptomatic before pregnancy.

Pericarditis constrictiva after aortic valve replacement simulating tricuspid stenosis

Pericarditis constrictiva after cardiac surgery is rare and may occasionally lead to congestive heart failure. The case of a 29-year-old patient is described who presented with pericarditis constrictiva after aortic valve replacement with localized tamponade, causing functional tricuspid stenosis. Pericardiectomy as the treatment of choice was curative.

[Constrictive pericarditis in severe seronegative rheumatoid polyarthritis]

Constrictive pericarditis is a rare complication of rheumatoid arthritis, with 78 published cases. We report a new typical case where the pericardial disease was associated with a severe seronegative rheumatoid arthritis of 17 years duration. Constrictive pericarditis generally occurs in men (62.8% of all cases) aged 52.4 +/- 11.5 years. Its clinical features are identical with those of constrictive pericarditis due to other causes. Diagnosis rests on echocardiography and, chiefly, on right heart catheterization. The arthritis is seropositive in 85.7% of the cases, frequently nodular (75%) and advanced. There is no relation between its duration (mean: 9.6 +/- 7.4 years) and the occurrence of the pericardial pathology. The pericardial fluid has no specific abnormality. Histology shows fibrosis and a non-specific inflammatory cell infiltrate. Immunoglobulin and complement deposits in the walls of the pericardial vessels are detected by immunofluorescence. The only treatment is pericardiectomy; without it the disease is constantly lethal.

[A rare cause of right cardiac insufficiency after pneumonectomy]

The authors report the case of a 55-year old patient, hospitalized for assessment of progressive right heart failure after left pneumonectomy due to bronchial epidermoid cancer. Right catheterization showed a dip-shaped right ventricular plateau and equal diastolic pressures (DOP 21 mmHg, diastolic pressure of the right ventricle 25 mmHg, capillary pressure 25 mmHg). A chest scan ruled out the possibility of pericardial invasion. Pericardial decortication was carried out on October 3, 1989. Six months later, the clinical signs of right heart failure had regressed. Chronic constrictive pericarditis (CCP) has been reported after cardiac surgery, but not cases have been reported after pulmonary surgery. In the absence of radiotherapy or metastatic invasion, this case leads to a discussion of the possibility of either pericardial trauma during surgery or, more probably, a fortuitous association with tubercular CCP.

[Chronic constrictive pericarditis. 27 cases]

Twenty-seven cases of chronic constrictive pericarditis seen between 1975 and 1990 in an internal medicine department were analyzed retrospectively. The chronic pericarditis was consecutive to one (n = 5) or several (n = 7) episodes of acute pericarditis. Echography demonstrated the presence of pericardial effusion in 74 percent of the cases, pericardial thickening in 41 percent and/or compression of right heart cavities in 55 percent. Computerized tomography of the chest, performed in 16 cases, showed pericardial effusion in 63 percent of the cases, pericardial thickening in 37 percent and lymph node enlargement in 19 percent. Magnetic resonance imaging of the chest was carried out in 2 patients but showed no abnormality. All 11 patients who underwent cardiac catheterization were found to be adiastolic. The cause of constrictive pericarditis, elicited in 13 patients was neoplasia in 4, sequelae of radiotherapy in 2, injuries in 2, mediastinal and retroperitoneal fibrosis in 2, myocardial infarction in 1, purulent pericarditis in 1 and bacteriologically proven tuberculosis in 1. Medical treatment with corticosteroids (n = 16) and/or antituberculous therapy (n = 15) was successful in 2 patients; 25 patients had to undergo surgery 7 +/- 11 months after constriction was diagnosed. Pericardial drainage (through a pericardiopleural window in 4 cases) proved to be sufficient in 10/15 patients but failed in 5. Pericardectomy was performed initially in 3 cases and after failure of medical treatment and/or drainage in 11 cases. The 4 patients with neoplastic constrictive pericarditis died 10 months on average after the diagnosis, but the remaining 23 patients were alive after à 9 to 48 months (mean: 19 +/- 15) follow-up. These results suggest that the data provided by echocardiography and computerized tomography of the chest usually point to the relevant therapeutic measures without a need for invasive haemodynamic exploration. Idiopathic constrictive pericarditis now accounts for 50 percent of the cases; tuberculosis has become exceptional, but the other, previously exceptional causes (neoplasia, heart surgery, radiotherapy, connective tissue diseases) are more frequent. Corticosteroids should be used in chronic constrictive pericarditis occurring after cardiac surgery or in the course of a connective tissue disease, but they are effective only in highly inflammatory forms of the disease. Modern treatment relies on early surgery, since functional results and patient's survival are closely related to the date of pericardectomy which must be carried out before very important myocardial repercussions develop.

Pulmonary actinomycosis complicated by effusive constrictive pericarditis

A case of pulmonary actinomycosis presenting with a right calf abscess and complicated by effusive constrictive pericarditis is discussed. Clinical improvement occurred with antibiotic therapy and pericardiectomy. There was no evidence of recurrence after 18 months.

[Constrictive pericarditis as differential diagnosis of hepatic disease]

Constrictive chronic pericarditis in a 13-year-old male patient was previously treated as chronic hepatitis for seven years, with the use of furosemide and spironolactone. Investigation for diagnosis included chest radiography, echo-doppler-cardiography, thoracocentesis with pleural biopsy and computerized tomography of chest, and showed ventricular diastolic restriction due to constrictive chronic pericarditis. After eight weeks of tuberculostatic treatment, the patient was submitted to hemodynamic study that confirmed the diagnosis and a pericardiectomy was performed. Long-term follow-up showed regression of diastolic restriction and decrease of hepatosplenomegaly and of jugular stasis. Tuberculostatic drugs were given for 12 months postoperatively, associated to corticosteroids.

[Heart failure in patients with valve prostheses]

Congestive heart failure in patients with prosthetic valves is a complex syndrome which poses difficult clinical and therapeutical problems. In order to identify etiologic factors, pathophysiologic substrates, clinical pictures and natural history we retrospectively evaluated 124 consecutive patients (mean age 61 +/- 11 years) with prosthetic valves, hospitalized during the 1984-1990 period because of congestive heart failure. The following main etiologies were identified: acute prosthetic valve failure (19%), chronic prosthetic failure (15%), preexisting left ventricular dysfunction (9%), newly acquired left ventricular dysfunction (8%), associated valve diseases (15%), chronic constrictive pericarditis (2%), multiple causes (31%). At a mean follow-up of 8.9 +/- 4.5 years, mortality was 8.8%/patients/year in the whole group, 3% in the subgroup with chronic prosthetic failure and 19% among the cases with preexisting left ventricular dysfunction. Among the patients who underwent reoperation because of prosthetic failure, the following were incremental risk factors: mechanical (vs biological) failing prosthetic valve, mitral prosthesis, emergency operations, mitral and or aortic insufficiency as the initial diagnosis. The preliminary knowledge of the possible etiologies and of the pathophysiologic substrates can help the physician while treating the single patient with heart failure after valve replacement. Many implications derived from this kind of patients are also useful in order to select surgical candidates among patients with valve disease.

Echocardiographic diagnosis of effusive-constrictive pericarditis due to staphylococcal pericarditis after cardiac surgery

Two weeks after coronary artery bypass surgery, a 43-year-old man was readmitted with fever, pneumonia, left pleural effusion, and pericarditis. Echocardiography showed a localized posterior pericardial effusion, pericardial thickening, and bulging of the ventricular septum toward the left ventricle. Right-sided catheterization indicated pericardial constriction. Effusive-constrictive pericarditis was confirmed at surgery. Cardiac imaging played an important role in diagnosis of this unusual complication of cardiac surgery.

Early constrictive pericarditis and anemia after Dressler's syndrome and inferior wall myocardial infarction

Early constrictive pericarditis and anaemia developed in a 52 year old man after he had an inferior wall myocardial infarction complicated by Dressler's syndrome. Total pericardiectomy at the time of coronary artery bypass surgery resulted in complete resolution of signs and symptoms.

Asbestos induced pericardial effusion and constrictive pericarditis

The number of disorders attributable to asbestos exposure has increased gradually over the years. The latest to be recorded is pericardial effusion and constrictive pericarditis, and three cases are reported here. A man with bilateral pleural thickening and plaques developed acute pericarditis and an effusion and was treated by pericardiectomy. Two men died from constrictive pericarditis associated with bilateral pleural effusions and diffusion pleural thickening. The pericardium showed nonspecific fibrous thickening. All had been occupationally exposed to asbestos. In the fatal cases the lungs contained amphibole fibres, in keeping with a modest degree of occupational exposure. Asbestos produces progressive fibrosis of the pericardium that is similar to diffuse pleural thickening and may be fatal. Both conditions may develop after relatively short or light exposure.

[Post-traumatic constrictive pericarditis with fast course]

A case is reported of a 46-year-old male patient who sustained a blunt thoracic injury with an anterior flail chest, and right haemopneumothorax. He was intubated and ventilated because of acute respiratory failure. There were initially no signs suggesting any myocardial injury. It was not before day 20 that the electrocardiogram showed a QS wave in leads V2 and V3. The hypothesis of an antero-septal myocardial infarct was not confirmed by echocardiography, which only revealed slight thickening of the posterior pericardium. From day 50 on, the patient had tachycardia, raised jugular venous pressure, and effort dyspnoea. Echocardiography (day 59) showed an anterior and posterior pericardial effusion (about 500 ml), marked pericardial thickening, and inferior vena caval collapse during inspiration, with normal myocardial wall movements. Drainage pericardiocentesis was therefore carried out, followed by, four days later, a pericardiectomy. A small ecchymosis was found on the anterior aspect of the right ventricle. The pericardium was thickened, fibrous, hyperhaemic, Case is y stuck to the epicardium. Eight months later, echocardiography showed that the posterior pericardium remained thickened, and there was a very small residual effusion. Movements of the septum had returned to normal.

[Radiation-induced pericarditis. Long-term outcome. 45 cases with thoracotomy and biopsy]

Between 1970 and 1989, 45 cases of pericarditis consecutive to thoracic irradiation for cancer were studied to determine their long-term outcome and the course of their pericardial lesions. All patients were symptomatic and required surgery on account of cardiac dysfunction or, more rarely, for diagnostic purposes, i.e. to distinguish between pure autonomous pericardial complications and recurrent mediastinal neoplasias, the latter being excluded from the study. All patients were explored by thoracotomy which permitted histopathological examination of the pericardium and the pericardial fluid, at the same time as therapeutic surgery (pericardial decortication for constriction in 22 cases, creation of pleuro-pericardial windows to ensure drainage of major effusions in 23 cases). The outcome was often poor owing to associated post-radiotherapy myocardial and pulmonary lesions: there were 20 deaths, 5 of which were directly due to the neoplasia and 13 to the radiotherapeutic complications; 5 patients remained with impaired cardiorespiratory function.

Constrictive epicarditis after open heart surgery: the turtle cage operation

A 60-year-old man developed constrictive epicarditis within 1 year after isolated mitral valve replacement (MVR). At reoperation, decortication of the thick epicardial layer resulted, impossible without a high risk of injury of the myocardium and major coronary arteries. Therefore, multiple longitudinal and transverse incisions were performed on the epicardial peel, which at the end acquired a turtle cage appearance allowing myocardial reexpansion, relief of constriction, and restoration of adequate hemodynamics.

Constrictive pericarditis

Constrictive pericarditis is a complex disorder characterized by abnormal thickening of the pericardium that leads to pathologic changes in cardiac hemodynamic data. The disorder can be suspected by history and physical findings. Data from echocardiography, CT, and MRI offer diagnostic information. The diagnosis cannot generally be established with certainty by noninvasive methods. Additional information from cardiac catheterization may help confirm the diagnosis. Together, these diagnostic modalities aid in the assessment of disease and help to differentiate it from related conditions such as restriction, cardiac tamponade, and right ventricular infarction. Treatment is largely surgical, and new techniques and approaches have made it relatively safe. Early diagnosis and pericardiectomy may lead to cure in most patients.

Constrictive pericarditis in Saudi Arabia

Twenty four patients underwent pericardectomy for constrictive pericarditis. There were 2 operative deaths. Tuberculosis was the aetiological factor in 20 patients and a post surgical aetiology was found in 2 patients. The aetiology remained unclear in 2 patients.

Constrictive pericarditis caused by primary liposarcoma

A 30 year old man presented with symptoms of constrictive pericarditis. Echocardiography and computed tomography showed a mass extending from the pericardium to surround the heart and penetrating the left ventricular apex. An unresectable pleomorphic liposarcoma arising from the pericardium was found at thoracotomy.

Futility of pericardiectomy for postirradiation constrictive pericarditis?

Two patients underwent pericardiectomy for postirradiation constrictive pericarditis. Both had received radiotherapy (more than 6,000 rads) for treatment of Hodgkin's disease 17 (patient 2) and 20 years (patient 1) earlier. At the time of operation, the patients were in New York Heart Association functional class III-IV or IV. Preoperative catheterization showed the following pressures for patients 1 and 2, respectively: right atrial, 30 and 14 mm Hg; right ventricular end-diastolic, 28 and 14 mm Hg; wedge, 29 and 13 mm Hg; and left ventricular end-diastolic, 27 and 14 mm Hg. Complete epicardiectomy and pericardiectomy was attempted in both patients. However, hospital mortality was 100%; patient 1 died of multiorgan failure after six days, and patient 2 died of biventricular failure after 3 months. A review of the literature revealed 44 cases of pericardiectomy for postirradiation constrictive pericarditis and a late survival rate of less than 50%. The poor results in these patients compared with patients having pericardiectomy for other reasons seem to be due mainly to the various kinds of radiation-induced damage to the heart as a whole, including untimely coronary artery disease, myocardial fibrosis, atrioventricular conduction disturbances, and valve dysfunction, with the result that complete relief by epicardiectomy and pericardiectomy may not be technically feasible.