[Electron microscopic study of the small intestine in intestinal lymphangiectasia and constrictive pericarditis (author's transl)]

Electron microscopic study of the small intestine in cases of intestinal lymphangiectasia and in cases of constrictive pericarditis was performed. This study revealed that numerous chylomicron-like particles are present in the lymphatic lumina, in the extracellular spaces of the lamina propria, and within the interepithelial spaces between the absorptive cells. Presence of chylomicron-like particles in the intestinal lumen suggested possibility of passage of these substances into the intestinal tract through the interepithelial spaces. Similar findings to those as seen in intestinal lymphangiectasia were observed in constrictive pericarditis. A few pseudopode-like cytoplasmic projections of the undifferentiated crypt cells were noted. Other mechanisms of enteric protein loss are postulated.

Echocardiographic findings in constrictive pericarditis. A case report

The echocardiographic findings in a 73-year-old woman with constrictive calcified pericarditis are presented. The diagnosis was confirmed by physical examination, chest X-rays and cardiac catheterization. The echocardiogram demonstrated abnormal motion of the interventricular septum and of the left ventricular posterior wall, multiple thickened echoes of the posterior pericardium, and a localized dense band of anterior pericardial echoes, which corresponded to the calcification seen on the chest X-ray.

Radiation pericarditis and myocardial fibrosis

The case of a 45-yr-old man with constrictive pericarditis due to radiation for Hodgkin's disease is described. After pericardiectomy and clinical condition did not improve. At necropsy an extensive fibrosis of the myocardium especially located in the anterior part of the heart was found. The clinical consequences of this finding with respect to surgical treatment are briefly discussed.

Constrictive pericarditis

A patient with constrictive pericarditis following an open-heart operation without sepsis is discussed. In the absence of sepsis, it has been widely held that this complication does not develop following an open-heart procedure. The fatal outcome in this patient could have been avoided had such an association been known.

Surgery in acute and chronic pericarditis. Pathophysiology and management

Forty-two cases of surgically treated pericarditis are presented, with comments on the management and pathophysiology of the acute, recurrent, and chronic stages of the disease. The spectrum of aetiological factors has changed within the last few decades in that tuberculosis is now rare, whereas uraemic pericarditis is referred to surgery with increasing frequency. With the advent of haemodialysis and renal transplantation, these cases should be treated vigorously, since they are amenable to surgical cure. Rapid surgical intervention is advocated in impending tamponade, and in all other acute cases which do not respond promptly to conservative management. In recurrent and chronic pericarditis, surgery is also preferable to long-term medical treatment with steroids and diuretics. Chronic pericarditis should not be allowed to progress to an advanced stage of disease with myocardial involvement and impairment of liver function. Early operation carries little hazard and gives lasting relief in the majority of cases. Microscopical examinations and laboratory analyses point towards an abnormal permeability of capillaries and visceral pericardium as an early and major event in the development of pericardial effusions. Destruction or preservation of the mesothelial cell lining is probably an important factor in determining the progression of acute disease towards adhesions and constriction.

Rheumatic valvulitis and constrictive pericarditis. Report of case

A 13-year-old girl was admitted with congestive heart failure, edema, ascites, and jaundice. There was an apical pansystolic murmur of mitral insufficiency and marked cardiomegaly. Her venous pressure was elevated. Despite medical treatment her condition deteriorated, hepatic and renal failure as well as disseminated intravascular coagulation ensued, leading to her death. At post mortem she was found to have rheumatic mitral valvulitis and constrictive pericarditis. The pathologic picture of pericarditis was nonspecific, but in presence of a positive skin test for tuberculosis the latter is considered to be the most likely cause of the pericarditis, nevertheless, rheumatic etiology of pericarditis in this case cannot be excluded. The presence of rheumatic heart disease and cardiomegaly may have led to the exacerbation of symptoms and signs of constrictive pericarditis and severe right heart failure.

Constrictive pericarditis in childhood due to mediastinal irradiation

Between 1955 and 1972, eight children receiving mediastinal irradiation for intrathoracic malignancy developed constrictive pericarditis. Six of these followed irradiation for Hodgkin's disease and represent 7% of 86 children receiving irradiation for that disease. In patients with Hodgkin's disease, the development of constrictive pericarditis was related to the dose of radiation and the use of orthovoltage technique. Constrictive pericarditis has not yet developed among the 44 children radiated by supravoltage technique. Symptoms of constrictive pericarditis occurred an average of 15 months (4/12 to 3 2/12 years) after irradiation and were preceded in five of the eight patients by acute pericarditis. Prominent clinical findings included dyspnea, Kussmaul sign, pulsus paradoxicus, hepatomegaly, cardiomegaly and electrocardiographic evidence of low QRS voltages with ST-T wave changes. Pericardiectomy was performed in six patients and resulted in immediate but only transient symptomatic relief. There was no operative mortality. Death occurred in six of the eight patients (1 5/12 to 6 6/12 years following irradiation) due to cardiac disease in three, progression of the malignancy in two and infection in one. In addition to constrictive pericarditis, extensive myocardial fibrosis and involvement of the antero-lateral papillary muscle and chordae tendineae of the mitral valve were demonstrated at postmortem examination. These factors may explain the progression of cardiac disease despite an initial symptomatic improvement following pericardiectomy.

Clinical features of non-tuberculous constrictive pericarditis

Ikram, H., Banim, S. O., and Makey, A. R. (1974).Thorax, 29, 204-208. Clinical features of non-tuberculous constrictive pericarditis. This paper describes the clinical features of five cases of constrictive pericarditis of non-tuberculous aetiology. The findings in this syndrome are compared with those in tuberculous constrictive pericarditis. The non-tuberculous variety had a short history, and absence of ascites and third heart sounds. Pericardial calcification, paradoxical arterial pulse, and the marked `y' descent in the venous pulse were absent in contrast to tuberculous constriction. An atrial sound was usual and the chief venous wave was the `a' wave.

The difficulty in diagnosing this type of pericardial constriction and its differentiation from `restrictive' cardiomyopathy is discussed. It is suggested that all currently available diagnostic techniques are liable to failure and, if in doubt, a diagnostic thoracotomy is mandatory.

Myocardial fibrosis in constrictive pericarditis. Electrocardiographic and pathologic observations

It has been suggested that a tentative preoperative decision favoring a pericardial lesion, on the one hand, or a myocardial lesion, on the other, may be made from certain noninvasive procedures, including the electrocardiogram. An attempt was therefore made to detect associated myocardial fibrosis by electrocardiogram in 67 patients with constrictive pericarditis as proven at catheterization (63 patients), surgery (64 patients) or postmortem examination (12 patients). Seven of the 67 had electrocardiograms characteristic of, and 16 compatible with, old myocardial infarct. The electrocardiographic experience was otherwise typical of the literature with non-specific changes in the T waves or RS-T segments and/or low voltage in the remaining 44. All three autopsied patients whose electrocardiograms were interpreted as diagnostic of an old myocardial infarct and both autopsied patients with electrocardiograms compatible with that diagnosis showed myocardial fibrosis. In seven autopsied cases with non-specific T waves or low voltage, the myocardium was normal in three while four showed myocardial fibrosis. It appears that in a few cases right ventricular hypertrophy might have simulated infarct by inducing tall R waves over the right precordium, or R waves which decreased in amplitude as the electrode was passed from the right to the left precordium.

Pathologic evidence related myocardial fibrosis to: (1) direct subepicardial penetration by the inflammatory process or deposit of fat in the subepicardial myocardium; (2) compromise of coronary blood flow, as by (a) direct throttling of coronary arteries by scar tissue or (b) deficient irrigation of subendocardial layers due to rigidity of the pericardium; or (3) a concomitant myocardial and pericardial process (lupus, radiation fibrosis, rheumatoid). Independent pericarditis and coronary disease was surprisingly rare. This limited experience (1) suggests that, though myocardial fibrosis may be predicted in constrictive pericarditis if the electrocardiogram shows characteristic changes of myocardial infarction, non-specific T wave changes or low voltage may likewise be associated with myocardial fibrosis, and (2) emphasizes that the difficulty in determining the site of a constrictive process may be compounded by the co-existence in the same heart of both a pericardial and a myocardial process.