Occult constrictive pericardial disease. Diagnosis by rapid volume expansion and correction by pericardiectomy.

TLDR

Occult constrictive pericardial disease can present with normal baseline hemodynamics yet cause fatigue, dyspnea, and chest pain, and is identified by a characteristic response to rapid volume infusion. This study outlines a diagnostic method for OCPD and recommends pericardiectomy to relieve disabling symptoms. Diagnosis is achieved by infusing 1000 mL of saline over 6–8 minutes, observing marked filling‑pressure rises, characteristic constrictive pressure‑pulse morphology, loss or reversal of right‑atrial respiratory variation, and diastolic equilibration of intracardiac pressures. In a five‑year series of 19 patients, 11 underwent pericardiectomy with dramatic symptom relief, histologic confirmation of pericardial disease, and post‑operative hemodynamics returning to normal or near‑normal.

Abstract

Significant pericardial disease can exist without overt manifestations. Occult constrictive pericardial disease (OCPD) is identified by normal baseline hemodynamics and normal left ventricular systolic function with a characteristic response to rapid volume infusion. Following the intravenous administration of 1000 ml of normal saline over six to eight minutes, striking elevations of filling pressures are seen; however, diagnosis depends specifically upon a) the development of typical pressure pulse morphology of constriction, b) loss or reversal or respiratory variation of right atrial pressure, and c) precise diastolic equilibration of intracardiac pressures. Nineteen patients with OCPD have been identified in a five year period. Unexplained fatigue, dyspnea and chest pain was the uniform pattern of presentation. Eleven have undergone pericardiectomy resulting in a dramatic symptomatic improvement in all. Each demonstrated gross and/or microscopic evidence of pericardial disease. Recatheterization with volume infusion in five patients following pericardiectomy has revealed return to normal or near normal hemodynamics. This study describes the method for diagnosis of OCPD and recommends pericardiectomy for the management of disabling symptoms.