Cardiovascular · Year 1 · from Cardiovascular
Case 3: Constrictive Pericarditis - Diastolic Filling Impairment
Clinical Image
Source: Radiopaedia - Pericardial calcification - Educational use
Patient Presentation
A 62-year-old man presents with progressive lower extremity edema, abdominal swelling, and fatigue over the past 6 months. He was treated for tuberculous pericarditis 20 years ago in his home country before immigrating. He denies chest pain or dyspnea at rest, though he becomes short of breath with exertion. He has noticed his legs swell by the end of the day, and his wife says his abdomen has been getting bigger.
Demographics
- Age: 62 years
- Sex: Male
- Past Medical History: Tuberculous pericarditis (treated 20 years ago), latent TB
- Medications: None currently
- Social History: Born in Philippines, immigrated 15 years ago
Chief Complaint
Progressive edema, abdominal distension, and exercise intolerance
Physical Examination
- Blood pressure: 124/82 mmHg
- Heart rate: 88 bpm
- Respiratory rate: 16/min
- JVP: Markedly elevated with prominent y descent
- Kussmaul sign: Positive (JVP rises with inspiration)
- Cardiovascular: High-pitched early diastolic sound (pericardial knock), no murmurs
- Abdomen: Distended with ascites (shifting dullness), hepatomegaly
- Extremities: 3+ pitting edema to thighs bilaterally
- Lungs: Clear (despite severe congestion - suggests pericardial not cardiac cause)
Workup
- ECG: Low voltage, nonspecific ST-T changes
- Chest X-ray: Pericardial calcification (ring-like), normal cardiac silhouette
- CT chest: Thickened, calcified pericardium (4-6 mm)
- Echocardiography:
- Septal bounce (respirophasic septal shift)
- Preserved LV systolic function (EF 60%)
- Mitral annular e' velocity: 12 cm/s (normal/elevated - unlike restrictive cardiomyopathy)
- Respiratory variation in mitral inflow: 30%
- Dilated IVC
- BNP: 180 pg/mL (mildly elevated - would be much higher in restrictive cardiomyopathy)
- Cardiac catheterization:
- Elevated and equalized diastolic pressures in all chambers
- "Square root sign" (rapid early filling, then plateau)
- Respiratory discordance between RV and LV pressures
Diagnosis
Constrictive Pericarditis (Post-tuberculous)
Treatment
- Diuretics for symptomatic relief of congestion (limited efficacy)
- Pericardiectomy - definitive treatment
- Surgical removal of the thickened, calcified pericardium
- Best outcomes with earlier surgery before extensive calcification and myocardial atrophy
- Preoperative optimization of nutritional status
- Risk counseling: Operative mortality 5-15% depending on etiology and severity
- Post-TB etiology has intermediate prognosis (better than radiation-induced)
Physiological Principles Demonstrated
- Constrictive physiology: The thickened, rigid pericardium limits diastolic filling. Early filling is rapid (the ventricle is not stiff), but abruptly stops when the fixed pericardial volume is reached ("square root sign").
- Kussmaul sign: In constriction, the rigid pericardium prevents the normal inspiratory increase in right heart filling. Increased venous return backs up, raising JVP paradoxically.
- Constriction vs. restriction differentiation: In constriction, the myocardium is normal so the mitral annular velocity (e') is preserved. In restrictive cardiomyopathy, the stiff myocardium causes reduced e'. Both cause elevated filling pressures, but this key distinction guides management.
- Ventricular interdependence: In constriction, the total pericardial volume is fixed. Inspiration increases RV filling at the expense of LV filling, causing the septal bounce and respiratory variation in filling velocities.