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The Echo Manual

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CHAPTER 12 PERICARDIAL DISEASES

more common diseases. Because constrictive pericardi- tis is potentially curable, it should be considered in all patients with heart failure, especially those with normal or relatively preserved ejection fraction and predispos- ing factors for the disease. In the United States, the most common identifiable causes of constriction are previous cardiac surgery, an antecedent episode of acute pericardi- tis, and radiotherapy (23,24). These causes highlight the importance of iatrogenic constrictive pericarditis, which may become more prevalent as a greater number of com- plex, catheter-based (including epicardial), electrophysi- ological, and structural cardiac procedures are attempted (25). Patients with constrictive pericarditis present with dyspnea, peripheral edema, ascites, pleural effusion, fatigue, or anasarca. The jugular venous pressure is almost always elevated, with a characteristic rapid “y” descent (Fig. 12-16). Other notable physical findings include Kussmaul sign and pericardial knock. The nadir of the “y” descent corresponds to the timing of a pericardial knock. Because ascites and elevated liver enzymes from hepatic venous congestion occur frequently with constriction, FIGURE 12-16 Simultaneous jugular venous pressure ( JVP ) tracing and pulsed wave Doppler recording of hepatic vein ( HV ) velocities. There is the characteristic y descent. D , diastolic flow; S , systolic flow; x and y , jugular venous pressure wave forms.

FIGURE 12-14 Parasternal long-axis view of a thick layer of epicardial fat ( arrows ). Ao , aorta; LA , left atrium; LV , left ventricle; RV , right ventricle.

mobility in tandem with the underlying myocardium. Two layers of fat may be identifiable—epicardial fat, which is beneath the epicardium and surrounds the epicardial coronary arteries, and paracardial fat, which is external to the parietal pericardium (22). Epicardial (rather than paracardial) fat correlates with visceral adiposity, meta- bolic syndrome, cardiovascular risk factors, and prevalent coronary artery disease (2). CONSTRICTIVE PERICARDITIS Constrictive pericarditis results from an adherent, inflamed, fibrotic, or calcified pericardium that limits dia- stolic filling of the heart (Fig. 12-15). Though not uncom- mon, constrictive pericarditis is frequently overlooked because the clinical presentation mimics that of other ar

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FIGURE 12-15 Heart specimens from two patients who died with constrictive pericarditis. A: The peri- cardium is thickened and calcified. B: The pericardial thickness is relatively normal but adherent to the epicardium. In both cases, diastolic filling of the right- and left-heart chambers was markedly reduced.

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