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Coronary constriction in constrictive pericarditis
International Journal of Cardiology 106 (2006) 135 – 136 www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary constriction in constrictive pericarditis Saibal MukhopadhyayT, Jamal Yusuf, M.P. Girish, Mohit Dayal Gupta, Vijay Trehan First floor, Room no: 126, Academic block, Department of Cardiology, G B Pant Hospital, New Delhi, India Received 28 October 2004; accepted 31 December 2004 Available online 14 March 2005
Keywords: Coronary constriction; Constrictive pericarditis; Coronary angiography
A 24-year-old male patient with no risk factors of coronary atherosclerosis, diagnosed as a case of chronic constrictive pericarditis (CCP) on the basis of clinical and echocardiographic evaluation was taken up for preoperative coronary angiography in view of his additional symptom of angina on exertion. Hemodynamic study prior to coronary angiogram confirmed the diagnosis of CCP. Coronary angiogram revealed normal left system but angiogram of the right coronary artery (RCA) showed multiple eccentric filling defects in mid-RCA which were more prominent in systole than in diastole (Fig. 1). The patient was taken up for surgical pericardiectomy. At surgery, apart from a thickened pericardium, multiple dense and tight adhesions between the pericardium and the epicardium were found in the right atrioventricular groove which was responsible for the obstruction of RCA. As the surgeons failed to remove all the bands of the fibrous tissue compressing the RCA, a saphenous venous graft was placed between the aorta and the posterior descending branch of the RCA. The patient had an uneventful recovery and is completely asymptomatic on follow up of 6 months. Chest pain is rarely associated with constrictive pericarditis with few case reports in literature [1–3]. Most patients present with dyspnea on exertion, cough and abdominal swelling secondary to systemic and pulmonary venous congestion along with severe fatigue, weight loss
T Corresponding author. Tel.: +91 9810704655. E-mail address: [email protected] (S. Mukhopadhyay). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.12.053
and muscle wasting due to presence of a fixed or reduced cardiac output [4]. In our patient, the pathophysiology of chest pain can be attributed to the constraint of the right coronary artery by the fibrotic bands of pericardial adhesions as has been described in detail by Harold Levine [5]. So, patients of constrictive pericarditis complaining of angina should undergo preprocedural coronary angiogram to rule out the throttling of the coronary arteries by the scar tissue secondary to extension of the pericardial inflammation into the epicardium.
Fig. 1. Multiple filling defects in right coronary artery due to constriction by fibrotic bands.
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S. Mukhopadhyay et al. / International Journal of Cardiology 106 (2006) 135–136
References [1] Navetta F, Barber MJ, Gurbel PA, Moreadith RW, Hlatky MA, et al. Myocardial ischemia in constrictive pericarditis. Am Heart J 1988;116:1107 – 11. [2] Topaz O, Nair R, Mackall JA. Observations of angina and myocardial infarction in constrictive pericarditis. Int J Cardiol 1993;39:121 – 9.
[3] Mahe I, Braunberger E, Bergmann JF. Angina caused by calcific constrictive pericarditis. Ann Intern Med 2002;137(12):1012 – 3. [4] Cimino JJ, Kogan AD. Constrictive pericarditis after cardiac surgery: report of three cases and review of literature. Am Heart J 1989;118:1292 – 301. [5] Levine Harold D. Myocardial fibrosis in constrictive pericarditis. Circulation 1973:1268 – 80.
Letter to the Editor
Coronary constriction in constrictive pericarditis Saibal MukhopadhyayT, Jamal Yusuf, M.P. Girish, Mohit Dayal Gupta, Vijay Trehan First floor, Room no: 126, Academic block, Department of Cardiology, G B Pant Hospital, New Delhi, India Received 28 October 2004; accepted 31 December 2004 Available online 14 March 2005
Keywords: Coronary constriction; Constrictive pericarditis; Coronary angiography
A 24-year-old male patient with no risk factors of coronary atherosclerosis, diagnosed as a case of chronic constrictive pericarditis (CCP) on the basis of clinical and echocardiographic evaluation was taken up for preoperative coronary angiography in view of his additional symptom of angina on exertion. Hemodynamic study prior to coronary angiogram confirmed the diagnosis of CCP. Coronary angiogram revealed normal left system but angiogram of the right coronary artery (RCA) showed multiple eccentric filling defects in mid-RCA which were more prominent in systole than in diastole (Fig. 1). The patient was taken up for surgical pericardiectomy. At surgery, apart from a thickened pericardium, multiple dense and tight adhesions between the pericardium and the epicardium were found in the right atrioventricular groove which was responsible for the obstruction of RCA. As the surgeons failed to remove all the bands of the fibrous tissue compressing the RCA, a saphenous venous graft was placed between the aorta and the posterior descending branch of the RCA. The patient had an uneventful recovery and is completely asymptomatic on follow up of 6 months. Chest pain is rarely associated with constrictive pericarditis with few case reports in literature [1–3]. Most patients present with dyspnea on exertion, cough and abdominal swelling secondary to systemic and pulmonary venous congestion along with severe fatigue, weight loss
T Corresponding author. Tel.: +91 9810704655. E-mail address: [email protected] (S. Mukhopadhyay). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.12.053
and muscle wasting due to presence of a fixed or reduced cardiac output [4]. In our patient, the pathophysiology of chest pain can be attributed to the constraint of the right coronary artery by the fibrotic bands of pericardial adhesions as has been described in detail by Harold Levine [5]. So, patients of constrictive pericarditis complaining of angina should undergo preprocedural coronary angiogram to rule out the throttling of the coronary arteries by the scar tissue secondary to extension of the pericardial inflammation into the epicardium.
Fig. 1. Multiple filling defects in right coronary artery due to constriction by fibrotic bands.
136
S. Mukhopadhyay et al. / International Journal of Cardiology 106 (2006) 135–136
References [1] Navetta F, Barber MJ, Gurbel PA, Moreadith RW, Hlatky MA, et al. Myocardial ischemia in constrictive pericarditis. Am Heart J 1988;116:1107 – 11. [2] Topaz O, Nair R, Mackall JA. Observations of angina and myocardial infarction in constrictive pericarditis. Int J Cardiol 1993;39:121 – 9.
[3] Mahe I, Braunberger E, Bergmann JF. Angina caused by calcific constrictive pericarditis. Ann Intern Med 2002;137(12):1012 – 3. [4] Cimino JJ, Kogan AD. Constrictive pericarditis after cardiac surgery: report of three cases and review of literature. Am Heart J 1989;118:1292 – 301. [5] Levine Harold D. Myocardial fibrosis in constrictive pericarditis. Circulation 1973:1268 – 80.