Examine this patient s cardiovascular system.

SALIENT FEATURES

History

· Dyspnoea.

· Fatigue.

· Ankle or abdominal swelling.

· Nausea, vomiting, dizziness and cough.

Examination

· The patient may appear cachectic.

· Pulse may be regular or irregularly irregular (one third have atrial fibrillation).

· Prominent x and y descents in the jugular venous pulse, and the level of the JVP
may rise with inspiration (Kussmaul s sign).

· Apex beat is not palpable.

· Early diastolic pericardial knock along the left sternal border, which may be accentuated by inspiration.

· Lungs are clear but there may be pleural effusion.

· Markedly distended abdomen with hepatomegaly and ascites.

· Pitting leg oedema.

DIAGNOSIS

This patient has constrictive pericarditis (lesion) caused by radiation therapy for previous Hodgkin s disease (aetiology) and is now limited by dyspnoea and marked ascites (functional status).

QUESTIONS

Mention some causes of constrictive pericarditis.

· Tuberculosis (<15% of patients).

· Connective tissue disorder.

· Neoplastic infiltration.

· Radiation therapy (often years earlier).

· Postpurulent pericariditis.

· Haemopericardium after surgery (rare).

· Chronic renal failure.

ADVANCED-LEVEL QUESTIONS

What is the mechanism for pericardial knock?

It is caused by the abrupt halting of rapid ventricular filling. Mention the differential diagnosis of the early diastolic sound.

· Loud P2 (see p. 103).

· S3 gallop (see p. 39).

· Opening snap (mitral stenosis).

· Pericardial sound.

· Tumour plop (atrial myxoma).

What is Beck s triad?

The presence of low arterial blood pressure, high venous pressure and absent apex
in cardiac tamponade is known as Beck s triad.

How would you investigate a patient with constrictive pericarditis?

· Chest radiograph typically shows normal heart size and pericardial calcification (note: the combination of pulsus paradoxus, pericardial knock and pericardial calcification favours the diagnosis of constrictive pericarditis).

· ECG shows low voltage complexes, non-specific T wave flattening or atrial fibrillation.

· Echocardiogram shows myocardial thickness is normal and may reveal thickened pericardium;normal ventricular dimensions with enlarged atria and good systolic and poor diastolic dysfunction. Doppler shows increased right ventricular systolic and decreased left ventricular systolic velocity with inspiration, expiratory aug-mentation of hepatic vein diastolic flow reversal.

· CT scan or MRI: shows normal myocardial thickness usually, and pericardial thickening and calcification.

· Cardiac catheterization typically shows identical left and right ventricular filling pressures and pulmonary artery systolic pressure usually <45 mmHg, with normal myocardial biopsy.

Haemodynamic tracings show rapid y descent in atrial pressure and early dip in diastolic pressure, with pressure rise to plateau in mid or late diastole.
How would you treat a patient with constrictive pericarditis?

· Surgery is the only satisfactory treatment: Complete surgical resection of the pericardium (myocardial inflammation or fibrosis may delay symptomatic response).
Patients with tuberculous pericarditis should be pre-treated with antituberculosis therapy; if the diagnosis is confirmed after pericardial resection, full anti-tuberculous therapy should be continued for 6-12 months after resection.

C.S. Beck (1894-1971), surgeon, Peter Bent Brigham Hospital in Boston.
W. Broadbent(1868-1951), English physician who qualified from St Mary s Hospital Medical School, London. He described the Broadbent sign in constrictive pericarditis, which is an indrawing of the 11th and 12th left ribs with a narrowing and retraction of the intercostal space posteriorly; this occurs as a result of pericardial adhesions to the diaphragm.