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Journal of Postgraduate Medicine, Vol. 48, Issue 2, 2002 pp. 126, 130 Spot the Diagnosis Krishnamoorthy KM, DM. Sri Sathya Sai Institute of Higher Medical Sciences, Puttaparthi, Andhra Pradesh, India. E-mail: saikm@sctimst.ker.nic.in Code Number: jp02057 A 40-year-old man had systemic venous hypertension and restrictive right heart filling. During cardiac catheterisation, pressures (in mm Hg) were recorded as follows: right atrial mean = 20; right ventricular end-diastolic = 23; pulmonary artery diastolic = 22; pulmonary artery wedge mean = 24; left ventricular end-diastolic = 21. Pressures showed equalization with each other within a rage of 5 mm Hg. Right ventricular and pulmonary artery systolic pressures were 44 mm Hg each. Right atrial and both ventricular waveforms showed early diastolic dip-and-plateau or "square-root" patterns. This indicated early rapid filling, which was quickly arrested by the restriction.Right atrial waveform showed a rapid "y" descent followed by a steep "a" wave and "x" descent producing an "M" pattern.Inspiration did not produce phasic augmentation of right heart filling . Cardiac output was normal. Restrictive physiology was confirmed. Figure shows the fluroscopic image. What is the diagnosis? Diagnosis is calcific pericarditis. Fluoroscopy shows calcification around the atrioventricular groove arranged like a bangle all around the heart. Restrictive physiology is present in constrictive pericarditis as well as restrictive cardiomyopathy. Diagnosis of constrictive pericarditis in a patient with restrictive heart disease can be made solely on the basis of the site of calcium deposition. Location of calcification helps in differentiating constrictive pericarditis from enodmyocardial fibrosis, a restrictive cardiomyopathy where calcification is very common. It is another endemic restrictive heart disease. In constrictive pericarditis, calcification is seen in the anterior and diaphragmatic aspects of the heart with frequent involvement of the atrioventricular groove and over the right atrium. It tends to involve the less pulsatile right sided chambers. In endomyocardial fibrosis, one finds calcification of the ventricular endocardium, which is not seen in constrictive pericarditis. Calcification is seen in 50% of patients with constrictive pericarditis and suggests tuberculous aetiology. Although calcification raises the possibility of constrictive pericarditis, it is not specific for this, and pericarditis need not always be constrictive.
Krishnamoorthy KM, DM. Sri Sathya Sai Institute of Higher Medical Sciences, This article is also available in full-text from http://www.jpgmonline.com/ © Copyright 2002 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp02057f1.jpg] |
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