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Grand Rounds Vol 11 pages 111–114
Specialities: Cardiology
Article Type: Case Report
DOI: 10.1102/1470-5206.2011.0025
ß 2011 e-MED Ltd
Constrictive pericarditis after tuberculosis
in adolescence
Irina Kozarez, Gerhard Schuler and Steffen Desch
Department of Cardiology, Heart Center Leipzig/University of Leipzig, Leipzig, Germany
Corresponding address: I. Kozarez, Herzzentrum Leipzig, Strümpellstrasse 39,
04289 Leipzig, Germany.
Email: [email protected]
Date accepted for publication 21 October 2011
Abstract
Constrictive pericarditis is a difficult diagnosis that requires a high degree of clinical suspicion
due to unspecific signs and symptoms. We present a 73-year-old patient with symptoms of
chronic heart failure. Cardiac catheterization revealed the diagnosis of constrictive pericarditis,
likely as a late consequence after tuberculosis in adolescence. The patient underwent complete
pericardectomy and had marked clinical improvement at follow-up. We describe the investigation
and treatment options of this condition.
Keywords
Constricitive pericarditis; pressure tracing; pericardectomy.
Case report
The patient is a 73-year-old man with a known history of atrial fibrillation, pacemaker
implantation due to total arteriovenous block, chronic renal failure (with an estimated glomerular
filtration rate of 58.2 ml/min per 1.73 m2 according to the ‘‘modification of diet in renal disease’’
formula) and pulmonary tuberculosis several decades ago (1953). In the 3 months prior to
admission the patient developed progressive exertional dyspnea accompanied by cyanosis of the
lips. Physical examination revealed a right-sided pleural effusion and ascites. Echocardiography
showed a left ventricular ejection fraction of 69% without any valve disorders, marked diastolic
dysfunction, pericardial calcification and a small pericardial effusion. The patient underwent right
and left heart catheterization under the working diagnosis of diastolic heart failure. Coronary
angiography showed slight calcification of vessels without significant stenosis. Cardiac
catheterization displayed several hemodynamic signs of constrictive pericarditis: Simultaneous
right ventricular and left ventricular pressure curves were recorded. Dip and plateau (or square
root) configuration of ventricular pressures reflects a rapid early diastolic filling of the ventricles,
followed by lack of additional filling during late diastole (Fig. 1a). Near equalization of ventricular
pressures during diastole and elevation of end diastolic right ventricular pressure (41/3 of right
ventricular systolic pressure) are also evident in Fig. 1a.
Fig. 1b displays the discordance of ventricular systolic pressures during the respiratory cycle
(as left ventricular pressure increases during expiration, right ventricular pressure decreases (and
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Fig. 1. (a) Dip and plateau (or square root) configuration (circle) of ventricular pressures (rapid early diastolic filling of the
ventricles, followed by lack of additional filling due to compression in mid and late diastole). The black arrows point to the
left ventricular pressure tracing, the yellow arrows to the right ventricular pressure tracing. (b) Discordance of ventricular
systolic pressures during the respiratory cycle (as left ventricular pressure increases during expiration, right ventricular
pressure decreases (and vice versa on inspiration). (c) Kussmaul sign (increase in right atrial pressure during inspiration). LV,
left ventricle; RV, right ventricle; RA, right atrium.
vice versa on inspiration), known as ventricular interdependence. An increase in right atrial
pressure during inspiration (Kussmaul sign) is shown in Fig. 1c. Fluoroscopy showed marked
calcification of the pericardium (Fig. 2). In the patient presented, the cause can likely be attributed
to a history of pulmonary tuberculosis during adolescence.
The patient underwent successful excision of the pericardium 8 weeks after the diagnosis was
established and experienced a major improvement in symptoms in the weeks after surgery, which
was maintained at the time of the latest follow-up (9 months after surgery).
Constrictive pericarditis after tuberculosis in adolescence
113
Fig. 2. Pericardial thickening (red arrows). 758 left anterior oblique view without caudal or cranial angulation. The blue
arrow points to a right atrial pacemaker lead, the yellow arrow to a right ventricular lead and the green arrow to a pigtail
catheter in the left ventricle.
Discussion
The diagnosis of constrictive pericarditis is difficult because of its common clinical signs with
many other possible diagnoses and the rarity of this condition.
Constrictive pericarditis should be considered in patients with signs of right heart failure[1].
Tuberculosis is one of the known causes of the disease, although the incidence of tuberculosisrelated cases is declining. Other causes include scarring after open heart surgery, radiation
therapy, direct trauma and viral infection[2].
Traditionally, increased pericardial thickness has been considered a specific diagnostic feature
of constrictive pericarditis, but these days there is also a subset of patients with hemodynamic
signs of constrictive pericarditis and normal thickness of the pericardium[3].
Several criteria on invasive pressure tracings have been examined for the diagnosis of
constrictive pericarditis. Among these, the change in the ventricular pressure curves during the
respiratory cycle (reflecting ventricular interdependence) is unique to patients with constrictive
pericarditis[4].
According to guidelines, there are two therapeutic options for the treatment of constrictive
pericarditis[5]: (i) pericardectomy which is considered the only definitive treatment and potential
cure (although perioperative mortality is high); (ii) medical management, which is generally
ineffective in most patients unless a prominent inflammatory component is present. A recent
study has demonstrated a potential beneficial role of colchicine and also the use of
corticosteroids in acute and recurrent pericarditis[6].
Survival after pericardectomy differs among the various causes and is best for idiopathic or
miscellaneous forms of constrictive pericarditis[2].
There are no randomized trials that compare medical with surgical therapy.
Teaching points
Constricitive pericarditis is a difficult diagnosis that should be suspected in patients with
symptoms and signs of right heart failure and a medical history compatible with the condition.
The diagnosis can be established on the basis of clinical symptoms and several hemodynamic
signs in catheter pressure curve tracings.
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