A case of medical management of tricuspid regurgitation related to atrial fibrillation with constrictive pericarditis-like hemodynamics

A surgical case of solitary severe tricuspid regurgitation mimicking constrictive pericarditis

BACKGROUND

It has been reported that severe tricuspid regurgitation may demonstrate constrictive pericarditis-like hemodynamics. In this article, we report a surgical case of solitary severe tricuspid regurgitation in which the hemodynamic features are consistent with constrictive pericarditis.

CASE PRESENTATION

The patient was a 78-year-old man with chronic atrial fibrillation and tricuspid regurgitation. He was admitted to our hospital with complaints of edema and dyspnea, and transthoracic echocardiography showed severe tricuspid regurgitation and enlargement of the bilateral atrium. A right heart catheterization revealed "dip and plateau" patterns in the biventricular pressure waveforms, and both right and left ventricle endo-diastolic pressure had increased to 30 mmHg. Although there were no signs of calcification or thickening of the pericardium in computed tomography, we diagnosed the patient with constrictive pericarditis with severe tricuspid regurgitation and underwent surgical intervention since his heart failure symptoms were resistant to medication. The surgical findings did not show any pericardial thickening or adhesions either; therefore, we diagnosed the patient with solitary severe tricuspid regurgitation showing constrictive pericarditis-like hemodynamics. We performed tricuspid valve replacement with a bioprosthetic valve and his heart failure symptoms improved postoperatively.

CONCLUSIONS

To determine the best timing for surgery, it is essential to recognize the existence of severe tricuspid regurgitation mimicking constrictive pericarditis.

Severe pulmonary regurgitation mimicking constrictive pericarditis: a case report—the sac or the content? That is the question

Background

Constrictive pericarditis (CP) is a pathological condition of the pericardium, resulting from fibrosis, scarring, and calcification of the pericardium. Other conditions have been reported to mimic ‘constrictive physiology’ despite the presence of an intact pericardium. However, there has been no report of pulmonary regurgitation (PR) mimicking the haemodynamic characteristics of CP.

Case summary

A 51-year-old woman was admitted to our institute because of severe right-sided heart failure. Transthoracic echocardiography revealed severe PR concomitant with significant dilatation of the right-sided heart. Septal bounce and the respiratory reciprocation of the transmitral and transtricuspid inflow velocities were also observed, indicating exacerbated ventricular interdependence. Cardiac catheter examination demonstrated elevated right atrial pressure with a prominent y descent, dip, and plateau waveform in the right ventricular pressure, and equalization of the diastolic pressure of all cardiac chambers, which are quite consistent with CP. On surgical inspection, however, there was no pericardial thickening or adhesion, indicating no obvious signs of CP.

Discussion

Pericardial constriction results from the relative relationship between intrapericardial volume and pericardial reserve. When the intrapericardial volume exceeds the physiological limit, the cardiac chambers compete with each other in a fixed pericardial space. In this case, prominent dilation of the right-sided chambers caused by severe PR resulted in overstretching of the pericardium above the pericardial reserve, which led to a characteristic haemodynamic picture that resembled CP. Thus, it is important to recognize the diagnostic pitfall in the preoperative evaluation of a ‘CP mimic physiology’.