[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.

Calcific constrictive pericarditis due to rheumatoid arthritis

A patient with calcific constrictive pericarditis due to rheumatoid arthritis is presented: the literature reveals only one previous case which was attributed to the long duration of the rheumatoid arthritis.

Constrictive pericarditis after cardiac surgery: report of three cases and review of the literature

Constrictive pericarditis after cardiac surgery is a rare phenomenon occurring with an incidence of 0.2% to 0.3%. To date only 158 cases have been reported in the world literature. Symptoms include dyspnea (81%), chest pain (34%), and fatigue (29%). Peripheral edema (90%) and an elevated jugular venous pressure (86%) were the most common abnormal signs found during physical examination. Chest x-ray and ECG abnormalities were not helpful in making the diagnosis, and abnormal echocardiographic findings were reported in less than half of the cases. Computerized tomography and magnetic resonance imaging scans of the heart were usually of great diagnostic benefit. Diastolic equalization of cardiac pressures remains the sine que non for diagnosis. Oral steroids have been reported to favorably alter the course early in the disease, but pericardial stripping remains the definitive form of therapy. Operative mortality rates vary from 5.5% to 14.5%.

[Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction: a case report]

A case of Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction was reported. A 49-year-old man, who had been diagnosed by indirect fluorescent antibody test as the first case of Lassa fever in Japan, was referred to the Hiroo Hospital because of syncope, progressive hepatomegaly, ascites and pericardial effusion in spite of pericardiocentesis and corticosteroid therapy. On admission, his blood pressure was 92/60 mmHg and he had a paradoxical pulse. Two-dimensional echocardiography revealed a localized pericardial effusion adjacent to the right ventricular wall and behind the left ventricular posterior wall. Bilateral atrioventricular annular constriction was also present. On pulsed Doppler echocardiography, the peak inflow velocities of the right and left ventricles increased during atrial systole. Right heart catheterization revealed a mean diastolic pressure gradient of 8 mmHg across the tricuspid valve. After pericardiectomy, a diastolic dip and plateau pattern became evident in the right ventricular pressure tracing, suggesting the presence of residual constriction. However, the atrioventricular annular constriction was no longer evident on two-dimensional echocardiography. This is considered the first reported case of subacute effusive constrictive pericarditis caused by Lassa fever.

Constrictive pericarditis after cardiac surgery

Forty-five patients were identified as having constrictive pericarditis after cardiac surgery. The mean patient age was 61 years (range, 40 to 77 years). Twenty-three of 37 patients with adequate clinical information were reported to have had a diagnosis of postpericardiotomy syndrome after the original surgery. The mean interval from original surgery to presentation with constriction was 23.4 months (range, 1 to 204 months). Computerized tomography was helpful in establishing a diagnosis of constriction in 23 of 29 patients (79%). Bypass graft patency was 93% (85 of 91 grafts). Severe pulmonary hypertension (pulmonary artery systolic pressure greater than or equal to 60 mm Hg) was present in nine patients; 8 had coexistent valvular disease (seven cases of mitral valve disease, and aortic valve disease in one). Thirty-seven of the 45 patients underwent pericardial stripping, 28 of whom experienced marked symptomatic improvement. One patient had persistent right heart failure, which was not documented to be secondary to constriction. Four patients had persistent constrictive physiologic conditions. Three of these patients had more extensive pericardial stripping and showed clinical improvement. Four patients (11%) died within 30 days of stripping. Eight patients received medical therapy alone. The decision to treat patients medically was based either on favorable response to medical therapy (five patients), or poor general clinical status.

[Postoperative constrictive pericarditis]

Seven cases of postoperative constrictive pericarditis (PCP) were discovered in a retrospective study of patients given heart surgery in a hospital receiving patients from all over Italy in 1970-85. Five of those patients had received surgery for chronic rheumatic heart disease, 2 for congenital heart defects. Four had received a second heart operation before the pericardial condition was recognised. All were females and all presented systemic venous hypertension (one of them only after acute doses of physiological solution) with thickening of the pericardial layers revealed by sonography. In six cases the electrocardiographic ventricular complexes were normal or increased in amplitude and the heart/chest ratio was greater than 0.55. Pericardial knock was masked by natural or artificial atrioventricular valve opening noises in 6 cases. In one case only there were pericardial calcifications or signs of an earlier postpericardiotomy syndrome. The haemodynamic investigation revealed signs of ventricular diastolic constriction in 6 patients. Three patients died from complications of cardiac cirrhosis: 2 of them had previously received partial pericardiectomy. Another two, given the same operation, preserved a reasonable functional capacity 5 and 10 years after the pericardiectomy. One patient in NYHA functional class III has so far refused haemodynamic assessment (and surgical treatment) of the pericardial disease. Finally, the last patient complains only of attacks of heart palpitation caused by atrial flutter and controlled by antiarrhythmic treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic constrictive pericarditis. A case report and review of the literature

Actinomycosis is typically a chronic infection of the cervicofascial, thoracic, or abdominal region. Involvement of the heart occurs but is unusual. We present a case of chronic constrictive pericarditis caused by actinomycetes. The actinomycosis infection was present for 20 years, thereby representing the longest duration reported in the literature, to our knowledge.