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2012 Summer Image of the Issue: Uncovering Constrictive Pericarditis

Heart & Vascular Institute Physician eNewsletter - Summer 2012

After 10 minutes mowing the lawn, Kathy*, 44, felt winded and didn't have the energy to continue. Her legs showed no swelling, but shortness of breath limited her activities. Three years before seeing physicians at Cleveland Clinic, Kathy was diagnosed at another hospital with atrial fibrillation (AFib). She had undergone radiofrequency ablation of her pulmonary veins two times to relieve atrial fibrillation—and both times, the procedure failed.

"She continued to have shortness of breath and symptoms, so she came to Cleveland Clinic for the possibility of another ablation for her atrial fibrillation," says Milind Desai, MD, Staff Cardiologist in the Section of Cardiovascular Imaging at Cleveland Clinic’s Heart & Vascular Institute and Associate Professor of Medicine at the Lerner College of Medicine, Case Western Reserve University.

During her workup at Cleveland Clinic, "One thing led to another," Dr. Desai relates. The first step was an echocardiogram that revealed normal heart function. "But she had evidence to suggest that the lining of the heart, or the pericardium, was constricting her and not allowing the heart to expand," he says. "Contraction was not a problem, but expansion was a big problem."

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Image 1: This echocardiogram confirms the calcified lining of the heart (notice the white rim surrounding the heart). This calcified pericardium is not allowing the heart to contract. This is a classic image of constrictive pericarditis.
Click on the image for a larger view (image will open in a new window).

Next, a CAT Scan of Kathy's chest and heart revealed normal heart size, but the pericardium was heavily calcified. It had essentially turned into rock. "This was significantly impeding her ability to expand her heart, and that is never good," Dr. Desai says. "The normal heart is a dynamic organ and when it can't expand, you get symptoms."

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Image 2: Notice the four chambers of the heart. The right side is compressed (evidenced by the conical deformity). This image shows how the heart’s constricted state is not allowing it to expand or contract due to calcification.
Click on the image for a larger view (image will open in a new window).

The calcified pericardium helped explain Kathy's shortness of breath, but the team dug deeper to determine how Kathy's pericardium could have calcified to such a significant extent. Typical causes for constrictive pericarditis include a virus, autoimmune diseases and in some parts of the world tuberculosis. Sometimes the condition is "man-made," such as constrictive pericarditis following open-heart surgery.

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Image 3: This short Axis CT shows the heart encased in a rim of calcium.
Click on the image for a larger view (image will open in a new window).

In Kathy's case, unsuccessful ablation performed at the other hospital most likely caused constrictive pericarditis. This is a rare circumstance, Dr. Desai says.

"At the time of her ablation, a small hole was created in the atria and that was not recognized," he explains. "That lead to an inflammatory reaction of the lining of the heart, which then calcified and started to eventually give her symptoms of constriction."

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Image 4: These images measure the tissue Doppler velocity of the heart muscle. The velocity is normal, which suggest that there is no problem with the heart muscle. Rather, the heart is being constricted by its calcified lining.
Click on the image for a larger view (image will open in a new window).

"These sort of medical mishaps are not common, but in this patient’s case, it was a perfect storm: there was a small perforation [during ablation] resulting in a pericardial effusion which resulted in an exuberant inflammatory reaction," Dr. Desai says. "The whole heart lining calcified as a result."

Kathy underwent a complex surgery to strip the pericardium from the heart so that it would not be constricted and Kathy could breathe easy. A maze surgery was also performed to treat Kathy's atrial fibrillation. Today, Kathy is breathing easy and has no symptoms of constriction or atrial fibrillation.

*Not her real name

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Reviewed: 07/12

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