Images in Clinical Medicine

Constrictive Pericarditis

J. Edwin Atwood, M.D., and Lars Osterberg, M.D.

N Engl J Med 2000; 343:106July 13, 2000

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Article

Figure 1 A 64-year-old man was evaluated for progressively worsening edema of the legs. He had jugular venous distention, an enlarged liver, pitting edema, no history of tuberculosis, and a negative skin test for tuberculosis. An electrocardiogram showed low-voltage and ectopic atrial tachycardia (Panel A). Catheterization of the right side of the heart showed diastolic equalization of the right atrial (RA) pressure, right ventricular (RV) pressure, pulmonary-artery (PA) pressure, and pulmonary-capillary wedge pressure (PCWP), indicated by the red line in Panel B. A chest film showed a thickened pericardium (arrows in Panel C). Computed tomographic scans of the heart showed a dilated superior vena cava (SVC), a normal aortic arch (AA) and descending aorta (DA) (Panel D), and a thickened pericardium (arrows in Panel E). There was also an increase in right atrial pressure on inspiration (Kussmaul's sign) (Panel F). Simultaneous catheterization of the right and left sides of the heart (Panel G) showed diastolic equalization of the left ventricular (LV) and right ventricular (RV) pressures. Constrictive pericarditis was diagnosed, and marked pericardial thickening (P) (arrows in Panel H) was evident during pericardial stripping. Histologic analysis of the thickened pericardium showed a dense collagenous matrix, but no cause was identified. The patient's edema decreased markedly after pericardial stripping.

J. Edwin Atwood, M.D.
Lars Osterberg, M.D.
Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304