Ascites and leg edema as the first manifestations of tuberculous effusive constrictive pericarditis

Correlation of transesophageal ultrasound of the pericardium with computed tomography

OBJECTIVE

In this study, we assess the sensitivity and specificity of ultrasound and computed tomography (CT) for pericardial effusion and constrictive pericarditis.

MATERIALS AND METHODS

This was a retrospective, institutional review board-approved, and health insurance privacy accountability act compliant study performed at a single tertiary center over a 10-year period (2001-2011) for patients who had clinical symptoms of pericarditis and had undergone both cardiac CT imaging and transesophageal echocardiogram (TEE) in a span of 2 weeks.

INCLUSION CRITERIA

Inclusion criteria included patients with clinical symptoms of pericarditis, pericardial thickness measuring more than 2 mm on CT, and patients who had both cardiac CT imaging and TEE performed within 2 weeks.

EXCLUSION CRITERIA

Exclusion criteria included patients with pericardial thickness measuring 2 mm or less on CT, no TEE, TEE not done within 2 weeks of the thoracic CT, and calcified pericardium on CT.Computed tomographic images were retrospectively reviewed by 2 radiologists who were unaware of the TEE findings. Pericardial effusion on CT was deemed present if there was obliteration of the fat plane in the left pulmonic recess.

STATISTICAL ANALYSIS

Statistical analysis was performed using the R statistical environment (Rstat). Intraobserver and interobserver variability was estimated using Cohen κ- statistic (Cohen).

RESULTS

Forty-three cases constituted the study population (28 men and 15 women; mean age, 55 years; age range, 22-82 years). Twenty-one patients had pathologic confirmation of pericarditis.The findings for CT and TEE were discrepant in 10 cases. Intraobserver variability Cohen κ statistic was 0.855. Interobserver variability Cohen κ statistics were 0.54 and 0.49.

CONCLUSIONS

Computed tomography is sensitive to pericardial effusion and pericardial thickening, whereas TEE seems insensitive to isolated pericardial thickening.

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.

Effusive-constrictive pericarditis in the absence of overt pericardial disease on multiple imaging modalities

Effusive-constrictive pericarditis (ECP) is a rare condition that may prove fatal without appropriate treatment. In ECP, there is concomitant existence of a pericardial effusion and CP, that together lead to impaired cardiac filling. Therapeutic pericardiocentesis only addresses part of the problem; surgical pericardiectomy may be required to relieve the constrictive element. Imaging in ECP characteristically demonstrates calcification or thickening of the pericardium. The authors describe a case of ECP were a number of imaging modalities (including echocardiography, cardiac magnetic resonance and CT) did not identify overt pericardial disease. The patient underwent surgical pericardiectomy that led to a rapid resolution of symptoms and full recovery. Histopathological analysis of the pericardial biopsy indicated a non-specific pericardial fibrosis, in keeping with the final diagnosis of ECP.