Cite this write-up as:Ata F, Osman O, Javed S, et al. (July 06, 2020) A Conundrum of Diagnostic Analogy in between Constrictive Pericarditis and also Pericardial Tamponade. Bromheads.tv 12(7): e9036. Doi:10.7759/bromheads.tv.9036


Abstract

Constrictive pericarditis and also cardiac tamponade space two key pathologies the the pericardium. Both rise the intrapericardial pressure and cause adverse effects on the physiological distention and relaxation that the heart’s chambers. Lock share multiple overlapping functions and, therefore, can be very complicated to differentiate between the two v regards come clinical presentation and also non-invasive imaging techniques. We existing a comparable case through a diagnostic an obstacle from the laboratory investigations and non-invasive imaging. Us have discussed the pathophysiology with the common and distinguishing features of the two pathologies once there is an ambiguity.

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Constrictive pericarditis (CP) and pericardial tamponade room two different entities with different pathophysiology and treatment modalities. However, infrequently patients can existing with comparable clinical features, equivocal electrocardiogram (ECG), and analogous echocardiogram and also MRI findings. Subsequently, it might come under to invasive studies, i.e., cardiac catheterization, come differentiate between the two. We present a situation in i m sorry clinical presentation, an easy workup, and advanced non-invasive investigations remained inadequate to distinguish in between effusive CP and also pericardial tamponade.


A 23-year-old Indian gentleman presented with a three-week background of shortness the breath on exertion and also productive cough with whitish sputum for five days. He likewise complained the a low-grade fever and pleuritic chest pain for one week. His past medical background was unremarkable. He had actually a history of alcohol intake and smoking. The patient to be vitally stable, various other than tachycardia (105 beats every minute). ECG proved sinus tachycardia. A chest X-ray to be done, which was grossly unremarkable.

On examination, the patient had a mild diminished intensity of breath sounds over the right infrascapular area and also a positive pulsus paradoxus. The rest of the physics examination was unremarkable.

A opportunity of famous pericarditis with heart fail was considered, and consequently, a transthoracic echocardiogram to be ordered, which confirmed a circumferential pericardial effusion, mainly surrounding to the ideal ventricle with echo indicators of tamponade (Figure 1). The famous panel for typical respiratory viruses was negative.


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At this point, the diagnosis that pericardial tamponade was considered, and a pericardiocentesis was attempted. Approximately 100 cc that hemorrhagic liquid was aspirated and sent for analysis. The liquid was transudate and also did no grow any pathogen.

Follow-up echocardiogram revealed a septal bounce (Figure 2) and also thickened pericardium. Regardless of the patient gift admitted v pericardial tamponade, minimal fluid can be drained native the pericardium.


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(A) Pre-drainage: pericardial effusion (red arrow) and septal bounce (yellow arrow). (B) Post-drainage: persistent septal bounce (yellow arrow).


MRI that the heart showed proof of interventricular septal bounce (Figure 3), and the so late gadolinium improvement images proved pericardial enhancement suggestive of pericarditis (Figure 4). 


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Ultimately best heart catheterization to be planned to assess the right-sided pressures and confirm the constriction hemodynamics accurately. When admitted, the patient received a food of antibiotics and ibuprofen, and he was discharged in one asymptomatic condition, v a plan of outpatient cardiac catheterization yet to it is in done.


The pericardium envelopes the cardiac chambers and under physiological conditions exerts subtle functions, consisting of mechanical impacts that enhance normal ventricular interaction that add to balancing left and also right cardiac outputs <1>.

Pericardial tamponade is typically an acute or subacute condition in which liquid accumulates in between the outer fibrous layer and the within membranous great of the pericardium. Because the pericardium is non-compliant, this build-up of fluid causes a increase in the intrapericardial pressure and hence compresses the heart. The common causes include idiopathic, infectious, autoimmune, neoplasms, and trauma.

On the various other hand, CP is normally a chronic process of gradual thickening of the pericardium, bring about it to lose its elasticity over time. This results in border of the heart to expand completely during incentive to accommodate a venous return, hence causing a decline in pulmonary venous pressure and also ultimately lessened left ventricular volume. Common causes include viral, post-radiotherapy, connective tissue disorders, and idiopathic.

CP and also pericardial tamponade share many similarities in miscellaneous aspects. Both have the right to be preceded by famous infections or deserve to be an additional to malignancies or autoimmune diseases. Pulsus paradoxus may additionally be checked out in CP, though v a frequency much less than that seen in cardiac tamponade <2>. Other mutual findings may include a increased jugular venous press (JVP), sinus tachycardia, and also a pericardial rub.

Echo features can be strikingly congruent, because that example, ventricular interdependence; the distension the the best ventricle is limited to the interventricular septum, which together with relative underfilling that the left ventricle enables the septal protrusion come the left, diminish left ventricular compliance and leading to an ext reduced left ventricle loading throughout inspiration <3>.

MRI is the best suited modality because that detecting young or limit pericardial effusions, pericardial inflammation, and functional irregularities brought about by pericardial constriction and also pericardial mass characterization. The vast field that view allows assessment of neighboring structures too <4>. It allows detection the pericardial effusions with high sensitivity, demonstrating fluid collections as tiny as 30 mL <5>. The ultimate modality come categorically distinguish in between CP and cardiac tamponade is invasive, i.e. catheterization, which is also the gold traditional for the diagnosis the pericardial constriction <6>

Cardiac tamponade and also CP, while having several functions in common, execute differ in their effect on exactly how they alter ventricular filling. The distinctions stem from distinctions in the pattern of restriction to ventricular filling. After ~ the drainage of pericardial fluid, the existence of annulus inversus (Figure 5) (seen in echocardiogram) is very suggestive of CP. Furthermore, in CP restriction is minimal to so late diastole, while it is throughout the diastole in cardiac tamponade. This is noticeable by the quick "y" descent, "dip & plateau" pattern, and also pressure equalization during late diastole in instances of CP. Top top the contrary, in instances involving cardiac tamponade, pressure equalization wake up throughout the diastole. Furthermore, unrestricted thoracic press transmission in cardiac tamponade contributes to a preserved inspiratory increase in systemic venous return (absence the the Kussmaul sign) and respiratory variability in the right atrial pressure. The preferential inspirational filling of RV, therefore, is secondary to raised filling, fairly than reduced left ventricular filling checked out in CP <7>.


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(A) tissue Doppler pulsed tide over septal annulus the the mitral valve. (B) organization Doppler pulsed tide over lateral annulus of the mitral valve.

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Although CP and also cardiac tamponade room two discrete clinical conditions with respect come etiology, pathophysiology, and management, significant similarities exist amongst the two. Sometimes similar clinical features and also non-invasive investigations have the right to be poor to single out the diagnosis, and also eventually cardiac catheterization is forced for the diagnostic purpose.