A 65-year-old male with a history of mitral valve replacement in 1975 presents with decreased exercise tolerance over the past two months. He has a history of paroxysmal atrial fibrillation for 10 years. Cardiac catheterization was ordered to assess his coronary arteries and measure the gradient across his mitral valve. Tracings from the catheterization show early rapid filling of the ventricles followed by abrupt stopping of ventricular filling in mid diastole, consistent with constrictive pericarditis.

1. DC Fellows Forum Raj Khandwalla M.D. Georgetown/Washington Hospital Center

2. History of Present Illness 65 yo M with PMH of MV replacement in 1975 s/p Bjork Shiley mitral valve who presents to the cath lab with a two month history of decreased exercise tolerance. Patient has a history of paroxysmal AF for the past ten years with multiple cardioversions. Last cardioversion was in May, but his AF recurred and has persisted for the past two months. Previously, the patient was able to run 2.5 miles, but now he cannot run. Patient underwent an exercise stress test in which he was only able complete stage II Bruce Protocol and had an echo which showed a normal EF, but the mitral valve was not able to be evaluated.

3. History of Present Illness As such, the patient was referred for cardiac cath in order to assess his coronary arteries and measure the gradient across the mitral valve.

4. History of Present Illness PMHX: as above, GERD MEDS: Propafenone, Warfarin ALL: NKDA SOCHX: social drinker, quit smoking 40 years ago FH: denies

5. Physical Exam Gen: no apparent distress, appears younger than stated age VS: T 98.0 BP129/77 HR 60 RR 16 98% RA Neck: JVD elevated to angle of jaw Chest: Well healed sternotomy scar Heart: irreg, irreg, +valve clicks appreciated Lungs: clear to auscultation Abdomen: soft, NT, ND, + hepatojugular reflex Ext: 2+ pitting edema to the shins

6. Laboratory Assessment: 1.6 11.3 – 13.3 INR 33.6 22.1 – 35.1 Partial-thromboplastin time (sec) 118 150,000 – 300,000 Platelet Count (per mm 3 ) 4.5 0 – 8 Eosinophils 17.6 4 – 11 Monocytes 37.5 22 – 44 Lymphocytes 40 40 – 70 Neutrophils Differential Count (%) 4.0 4,500 – 11,000 White-cell count (per mm 3 ) 36.2 41.0 – 53.0 Hematocrit (%) 12.3 13.5 – 17.5 Hemoglobin (g/dl) HEMATOLOGY ON ADMISSION REFERENCE RANGE TEST

7. Laboratory Assessment: 218 0.0-99 Brain Naturitic Peptide (pg/ml) 1.3 0.6 – 1.5 Creatinine (mg/dl) 22 8 – 25 Urea nitrogen (mg/dl) 24 23.0 – 31.9 Carbon dioxide (mmol/liter) 107 100 – 108 Chloride (mmol/liter) 4.3 3.4 – 4.8 Potassium (mmol/liter) 140 135 – 145 Sodium (mmol/liter) CHEMISTRY ON ADMISSION REFERENCE RANGE TEST

9. Tracings

10. Tracings

11. Tracings

12. Tracings

13. Tracings

14. Tracings

15. What is the differential diagnosis for these tracings? How do we make the diagnosis?

16. Tracings

17. Tracings

18. Ventricular Interdependence Restrictive Constrictive

23. Normal pericardial thickness Multiple adhesions between the pericardium and the heart RV directly below the sternum

28. Constrictive Pericarditis Represents the end stage of an inflammatory process Can occur in months, but usually takes years to develop Etiologies Idiopathic Irradiation Postsurgical Infectious Neoplastic Autoimmune disorder Uremia Posttraumatic Sarcoid Methysergide therapy Implantable defibrillator patches

29. Pathophysiology Pericardial scarring restricts filling of all chambers which symmetrically results in the elevation of filling chambers Early diastole Rapid filling of the ventricles due to high atrial pressures and increased diastolic suction (due to small end-systolic volumes) Mid diastole Ventricular filling is abruptly stopped when the intracardiac volume can no longer expand due to the noncompliant pericardium

30. Hemodynamics Constrictive pericarditis RV infarct Tamponade Restrictive cardiac disease Pulses paradoxus < 1/3 Occasional Frequent Rare RA waveforms Prominent y descent Prominent y descent Prominent x descent Insp.  Variable y descent Equalization of diastolic pressures Frequent Frequent Frequent Rare “ Square root” sign Frequent Frequent Absent Variable