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Middle-aged Man With Exertional Dyspnea and Neck Fullness

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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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Constrictive pericarditis

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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Article Information

Corresponding Author: D. Brian Newman, MD, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (newman.darrell@mayo.edu).

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.

References
1.
Tyberg  TI, Goodyer  AV, Langou  RA.  Genesis of pericardial knock in constrictive pericarditis.  Am J Cardiol. 1980;46(4):570-575. doi:10.1016/0002-9149(80)90505-6PubMedGoogle ScholarCrossref
2.
Abraldes  JG, Sarlieve  P, Tandon  P.  Measurement of portal pressure.  Clin Liver Dis. 2014;18(4):779-792. doi:10.1016/j.cld.2014.07.002PubMedGoogle ScholarCrossref
3.
Gillaspie  EA, Stulak  JM, Daly  RC,  et al.  A 20-year experience with isolated pericardiectomy.  J Thorac Cardiovasc Surg. 2016;152(2):448-458. doi:10.1016/j.jtcvs.2016.03.098PubMedGoogle ScholarCrossref
4.
Welch  TD, Oh  JK.  Constrictive pericarditis.  Cardiol Clin. 2017;35(4):539-549. doi:10.1016/j.ccl.2017.07.007PubMedGoogle ScholarCrossref
5.
Welch  TD, Ling  LH, Espinosa  RE,  et al.  Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria.  Circ Cardiovasc Imaging. 2014;7(3):526-534. doi:10.1161/CIRCIMAGING.113.001613PubMedGoogle ScholarCrossref
6.
Nozohoor  S, Johansson  M, Koul  B, Cunha-Goncalves  D.  Radical pericardiectomy for chronic constrictive pericarditis.  J Card Surg. 2018;33(6):301-307. doi:10.1111/jocs.13715PubMedGoogle ScholarCrossref
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