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Chapter 12 Pericardial Diseases

CHAPTER 12 PERICARDIAL DISEASES

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FIGURE 12-31 A: RV inflow view ( left ) shows severe tricuspid regurgitation (TR), but hepatic vein Doppler ( right ) shows diastolic flow reversals with expi- ration ( arrow ), not systolic flow reversal expected for severe TR. This comes from a patient with severe tricuspid regurgitation and constrictive pericardi- tis. B: Annulus reversus was present in the same patient with severe TR and constriction.

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EFFUSIVE-CONSTRICTIVE PERICARDITIS Effusive-constrictive pericarditis is a unique clinical con- dition consisting of the combination of pericardial effu- sion and constrictive pericarditis (47,48). Although this entity is uncommon among pericardial syndromes, it occurs in more than 50% of patients with tuberculous pericardial effusion (49). The patient usually presents with pericardial effusion and clinical or hemodynamic evidence of cardiac tamponade. Despite drainage and resolution of the pericardial effusion and reduction in intrapericardial pressure, intracardiac pressure remains elevated due to constriction of the visceral pericardium. In some patients, this underlying constrictive pericar- ditis requires pericardiectomy, and importantly, exten- sive epicardiectomy (50). In other patients, constrictive pericarditis results from reversible inflammation of the pericardium and may resolve spontaneously or after treatment with anti-inflammatory agents. The latter con- dition has been termed transient constrictive pericarditis (see below) (51). Echocardiography identifies patients with effusive-constrictive pericarditis if the characteris- tic 2-D and Doppler features of constriction persist after resolution of the pericardial effusion. (52) This condition &RS\ULJKW ‹

is most typically diagnosed in patients who undergo peri- cardiocentesis. We reviewed 205 consecutive patients who underwent pericardiocentesis at Mayo Clinic and identified effusive-constriction in 33 patients (16%) by echocardiography. In patients with effusive constrictive pericarditis, hemopericardium was more frequent. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversals in the hepatic vein, and respirophasic ventricular septal shift were more frequent in patients with effusive constrictive pericardi- tis than those with isolated pericardial effusion. During a mean follow-up of 3.8 years, only 2 patients required pericardiectomy. The others improved spontaneously or after treatment with anti-inflammatory medications. (52). We have also observed that Doppler echocardiog- raphy at the time of pericardiocentesis may be able to identify the subset of the patients who would develop effusive-constrictive pericarditis. In patients with pure tamponade, early diastolic filling is reduced resulting in lower mitral E velocity than A velocity, and hepatic vein Doppler shows marked reduction in diastolic forward flow velocity. In patients who more likely develop effu- sive constrictive pericarditis, mitral inflow and hepatic

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