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Answer: B, Effusive constrictive
Educational Objective: Diagnose effusive
Critique: The most likely diagnosis in this
patient is effusive constrictive pericarditis. Effusive
constrictive pericarditis is a clinical entity in which patients
who have a pericardial effusion, with or without cardiac tamponade,
experience persistent symptoms and hemodynamic derangements after
treatment and relief of the pericardial effusion. In some patients
with constrictive pericarditis, pericardial inflammation results in
an effusion, which is placed under pressure by the inelastic
pericardium. Symptoms of low cardiac output, systemic congestion,
and an elevated jugular venous pulse are seen, as in constrictive
pericarditis; however, in patients with effusive constrictive
pericarditis, a pericardial knock is absent and the y descent of
the jugular venous pulse may be less prominent. Additionally,
pulsus paradoxus may be present, which is not a typical finding of
constrictive pericarditis. This disorder is caused by pericarditis
involving the visceral layer of the pericardium. Thickening of the
visceral layer of the pericardium can be difficult to detect with
CT and other noninvasive imaging, and a high index of clinical
suspicion is necessary to establish the diagnosis. In this patient,
effusive constrictive pericarditis is suggested by the persistently
elevated right atrial pressure following pericardiocentesis.
Similar findings in the jugular venous pulse can occur in
patients with cor pulmonale or heart failure. With cor pulmonale,
however, evidence of right ventricular dysfunction or chamber
enlargement is usually seen on imaging. The clear lungs on
auscultation do not support the presence of heart failure.
The presence of a normal electrocardiogram and the absence of
the typical symptom of chest pain argue against recurrent acute
pericarditis as a diagnosis. Additionally, acute pericarditis
cannot explain this patient's pulsus paradoxus and elevated jugular
Key Point: Effusive constrictive pericarditis
is a clinical entity in which patients who have a pericardial
effusion experience persistent symptoms and hemodynamic
derangements after relief of the pericardial effusion.
Syed FF, Ntsekhe M, Mayosi BM, Oh JK. Effusive-constrictive
pericarditis. Heart Fail Rev. 2013 May;18(3):277-87. [PMID:
November International Newsletter