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A man in his mid-50s with no significant medical history was referred with 2 years of insidious exertional dyspnea and neck fullness. Examination of the jugular venous contour with the patient sitting upright at 90° is shown in Video 1. Auscultatory findings at the left lower sternal border showed normal S1 and S2 heart sounds with a diastolic sound and no murmurs (Figure 1; Video 2). Abdominal examination revealed an enlarged, pulsatile liver with smooth edges palpable 4 cm below the costal margin. Electrocardiography showed resting abnormalities (rightward axis and inferolateral T-wave inversions). Posteroanterior chest radiography showed normal heart size and clear lungs (Figure 1). Transthoracic echocardiography was performed, which showed normal left ventricular size and function without valvular abnormalities.
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B. Right and left heart catheterization
This patient has classic clinical findings of calcific constrictive pericarditis on physical examination. The jugular venous pressure is elevated to 20 cm H2O with prominent x and y descents. The jugular venous pressure contour distinguishes constriction from other clinical entities, which can present with subacute dyspnea on exertion (prominent a wave in pulmonary hypertension, giant c to v wave in severe tricuspid regurgitation, and blunted x descent in restrictive cardiomyopathy). The high-pitched early diastolic sound on auscultation is a prominent pericardial knock (Figure 2). The high-pitch frequency distinguishes it from the low-pitch middiastolic rumble of an S3 heart sound. The pericardial knock results from sudden cessation of rapid ventricular filling due to pericardial constraint1 and coincides with the y descent on jugular venous contour and the rapid diastolic filling wave in the ventricular tracing (Figure 2).
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Corresponding Author: D. Brian Newman, MD, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (firstname.lastname@example.org).
Published Online: September 4, 2019. doi:10.1001/jamacardio.2019.1677
Conflict of Interest Disclosures: Dr Vogt reports receiving advisory board fees from Bioplus Specialty Pharmacy Services. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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