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Angiocardiography in Constrictive Pericarditis
Victor Deutsch, Hylton Miller, Joseph H. Yahini, Abraham Shem-Tov and Henry
N. Neufeld
Chest 1974;65;379-387
DOI 10.1378/chest.65.4.379
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Angiocardiography in Constrictive
Pericard itis*
Victor Deutsch, M.D.; Hylton Miller, M.D.; Joseph H. Yahini, M.D.;
Abraham Shem-Tov, M.D.; and Henry N. Neufeld, M.D., F.C.C.P.
The conventional x-ray film examinations and the angio- signs, not widely appreciated, should prove helpful for
cardiographic features 13
of cases of constrictive pen- the diagnosis of constrictive penicarditis: (a) not only
carditis are analyzed andcompared with those In five straightening but concavity of the night atrial lateral
cases of cardial effusion and four cases of congestive border pelulsftng throughout the cardiac cycle (b) not
cardiomyopathy. The conventional x-ray film examina- only straightening but concavity of the septal border of
tion can contribute to the constrictive
diagnosis of pen- a small right ventricular cavity; left
(c) a small ventricular
carditis if the following of features
combination is pres- cavity displaying forceful contractions; and (d) a concav-
ent absent tomoderate cardiomegaly with poorly pulsat- Ity of the panietal of the
border left ventricular cavity.
lug straightened heart borders, together with left atnial It is noted that patients,
In our left atnial enlargement and
enlargement and signs of pulmonary venous hypertension. pulmonary venous hypertension werethe rule rather than
The angiocardiographic features described in
the liters- the exception. In our opinion, the mentioned
above fea-
tune for the diagnosis ofconstrictive penicarditis are con- hires may be particularly helpful in the differeutation of
firmed, namely: reflux of contrast material into the dilated constrictive penicarditis from penicardial effusion in
inferior vena cava straightening of the opacified right which the cardiac cavities are of normal size, shapeand
atrial lateral border increased thickness of the right atrial display normal contractility; on from constrictive cardlo-
exfraluminal shadow; straightening the opacified
of night myopathy in which there is dilatation of these cavities with
ventricular cavity’s septal border and increased pulmo- diminished contractions.
nary circulation time. It is stressed that the following
confirmation, were studied for comparison. The main clinical
A ecording to various reports, constrictive pericar-
-L-’ ditis may be suspected on clinical and radiolog- findings of the patients studied appear Table 1. in
The patients’ plain chest x-ray films, fluoroscopic findings
ic grounds in a large number of
cases15 but by
and results of angiocardiographic investigations were re-
no means in all. Indeed, it is common experience viewed. The plain chest x-ray films were examined in the
that the differentiation between constrictive pen- posteroanterior and lateral views for the following: heart
carditis, congestive cardiomyopathy, on penicardial size, superior vena cava! dilatation, of
shape the right and left
effusion may be difficult in agiven case, even with heart borders, degree of cardiophrenic angle, presence of
pleura! effusion, pulmonary venous congestion and left atnial
the help of cardiac catheterization or angiocandiog-
enlargement. The results of fluoroscopy were reviewed for
raphy. It is therefore remarkable that a review of the the quality of cardiac pulsations and the presenoo of
English literature reveals relatively few reports calcification.
dealing with this important subject,#{176}12 especially All patients underwent selective right heart angiocardio-
graphic studies, with contrast material injected into the
when one considers the fact that an accurate diag-
superior vena cava or right atrium in 11 patients and into the
nosis is imperative for the appropriate treatment
right ventricle in 2. The contrast medium used was
of these conditions. meglumine diatrizoate (75 percent Urografin), 1 ml per kg
It is the purpose of this article to report the plain x- body weight. The angiocardiograms were performed with an
ray film and angiocardiognaphic findings in 13 cases Elema roll film changer, a 70mm camera or a 35mm cine
of constrictive pericarditis. Special emphasis iscamera in the frontal view in all cases, and in the lateral view
in four. The angiocardiograms were analyzed for the follow-
placed on some hitherto undescribed angiocardio-
ing points: refiux of contrast material into and dilatation of
graphic features which were found helpful in the the inferior vena cava; maximal diameter of the right extra-
diagnosis of this condition and its differentiation luminal shadow in atrial diastole; straightening or deformity
from congestive cardiomyopathy or pericardial effu- of the opacified right atrial lateral border; refiux of contrast
sion; five cases of the former and four of the latter material into the coronary sinus; distance between the ink-
rior border of the opacified right ventricular cavity and the
were also studied to clarify the differentiating signs.
diaphragm; concavity of the opacified right ventricular septal
MATERIAL AND Mmcos border; right ventricular cavity size; pulmonary opacification
time; presence of pulmonary venouscongestion; left atrial
The diagnosis of constrictive pericarditis was confirmedat
size and contractility; and left ventricular cavity size and
operation in 12 cases and at postmortem examination in one. contractility as well as thickness of the left ventricular extra-
Five cases of pericardial effusion, verified by pericardial tap,
luminal shadow. Right sided pressure measurements pre-
and four cases of congestive cardiomyopathy with postmortem
ceded angiocardiography in 11 patients.
5Fmm the Department of Diagnostic Radiologyand Heart
Institute, The Chaim Sheba Medical Center, Tel-Hashomer, RESULTs
and The Tel-Aviv University Medical School
Manuscript received October 21; accepted October 30. Plain Chest X-Ray Films (Table 2)
Reprint requests: Dr. Deutsch, Department of Diagnostic
Radiology, Sheba Medical Center, Tel Hashomer, Israel Constrictive PericarditLi (13 Cases): The heart
CHEST, 65: 4, APRIL, 1974 ANGIOCARDIOGRAPHY IN CONSTRICTIVE PERICARDITIS 379
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Table 1-Clinical Findings in Constrictive Pericarditis, Pericardial Effusion and Congestive Cardiomyopathy
Case Age
No. Yr. Sex Symptoms Signs ECG Clinical Diagnosis
A. Constrictive Pericarditis
1 58 F chest pain, tiredness, V.P.1, hepatomegaly S.R., low voltage, C.P. vs H.C.V.D.
palpitations B.P. 190/100 mm Hg inverted T
2 18 F tiredness, abdominal V.P.1, hepatomegaly, S.R., inverted T C.P. vs amyloidosis
swelling pericardial “knock,”
peripheral edema
3 48 F tiredness, abdominal V.P.1, hepatomegaly S.R., inverted T C.P.
swelling
4 51 F tiredness, dyspnea V.P.1, hepatomegaly S.R., inverted T C.P. vs cardiomyopathy
5 67 M tiredness, weight loss V.P.1, hepatomegaly, S.R., old MI C.P.
peripheral edema
6 21 M fever, tiredness, V.P.1, pulsus paradoxus, S.R., inverted T C.P. vs myocarditis
abdominal swelling hepatomegaly, ascites,
peripheral edema
7 72 M dyspnea, tiredness V.P.1, hematomegaly, S.R., low voltage, C.P. vs cardiomyopathy
peripheral edema inverted T
8 11 M dyspnea hepatomegaly, ascites, S.R., low voltage, C.P.
peripheral edema inverted T
9 52 F abdominal swelling V.P.1, hepatomegaly, S.R., low voltage, C.P.
peripheral edema inverted T
10 56 M abdominal swelling, V.P.1, ascites, atrial fibrillation, C.P. vs cirrhosis
dyspnea peripheral edema low voltage,
inverted T
11 38 M chest pain, fever, V.P.1, pulsus paradoxus, S.R., low voltage, C.P. vs myocarditis
dyspnea hepatomegaly inverted T
12 55 M weakness, chest pain V.P.1, peripheral S.R., low voltage, C.P. vs cardiomyopathy
edema, hepatomegaly inverted T
13 42 M weakness, dyspnea V.P.1, hepatomegaly, S.R., low voltage, C.P. vs cardiomyopathy
peripheral edema inverted T
B. Pericardial Effusion
14 68 F dyspnea, tiredness V.P.1, hepatomegaly, RBBB, clockwise “carcinoid” heart,
pansystolic murmur rotation congestive heart failure
15 12 M weakness, dyspnea V.P.1, hepatomegaly low voltage, T wave pericardial effusion
flattening and ST
depression in all leads
16 39 F dyspnea, cough V.P.1, hepatomegaly RBBB cardiomyopathy vs myocarditis
17 45 M chest pain, cough, V.P.1, pericardial low voltage, pulmonary emboli vs
fever friction, rub minor T wave changes pericardial effusion
18 48 F cough, anasarca V.P., hepatomegaly, low voltage, pericardial effusion vs C.P.
peripheral edema inverted T
C. Congestive Cardiomyopathy
19 65 M dyspnea pansystolic murmur, low voltage, C.C. vs C.P.
v.P.1, hepatomegaly, inverted T
peripheral edema
20 40 M dyspnea V.P., systolic murmur RBBB C.C.
21 57 M dyspnea aortic systolic murmur LVII, RBBB C.C.
22 43 F dyspnea V.P.1, hepatomegaly, atrial fibrillation, C.C. vs pulmonary emboli
ascites, pansystolic extreme clockwise
murmur rotation, RAD,
ILBBB
380 DEUTSCH El AL CHEST, 65: 4, APRIL, 1974
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Table 2-Plain Chest X-ray Film Findings in Constrictive Table 3-Hemodynamic Findings in Constrictive
Pericarditis, Pericardial Effusion and Congestive Pericarditis, Pericardial Effusion and Congestive
Cardiomyopathy Cardiomyopathy
Congestive Congestive
Constrictive Pericardial Cardio-
Constrictive Pericardial Cardio-
Pericarditis Effusion myopathy Pericarditist Effusion myopathy II
5 4
Mean right atrial pressure* 21 (8-15) 10 (8-15) 9 (7-11)
Patients, No. 13
Right ventricular
[Normal 2
end diastolic pressure** (J (1 1-25) 8 (4-25) 15 (5-25)
Heart size Moderately enlarged 10 2 3
1
Pulmonary artery systolic
LMarkedly enlarged 1 3
0 0 pressure 34 (25-43) 29 (23-42) 63 (50-76)
Superior vena caval enlargement 5
0
Pulmonary artery diastolic
Straightening of right heart border 9 0
Straightening of left heart border 5 0 0
pressure 22 (15-27) 12 (5-26) 31 (25-37)
Mean pulmonary capillary
Cardiopbrenic angle 10#{176}
70#{176}-i 6
60#{176}-110#{176} 0#{176}-90#{176}
(wedge) pressure 22 (13-30) 1 (5-20)
1 28 (25-31)
Pleural effusion 6 4 0
Pulmonary venous congestion 12 2 4 *J$3jfl.5 in mm of mercury; numbers in brackets indicate range of
Left atrial enlargement 12 2? 4 pressure values.
Decreased pulsations on fluoroscopy 12 5 2 **Dip and plateau configuration present in eight patients with constrictive
Pericardial calcification 3 0 0 pericarditis, in one with pericardial effusion and in one with congestive
cardiomyopathy.
was of normal size in two patients, moderately en-
tNine patients.
larged in ten and markedly enlarged in one. Superior JFour patients.
vena cava enlargement was observed in five pa- II Two patients.
tients. The border of the left side of the heart was
angle was acute in all. Prominent pulmonary venous
normally convex in four and straightened in five; the
congestion and left atrial enlargement were found in
border of the right side of the heart was straightened
in nine patients ( Fig 1) The. cardiophrenic angle
all four
Fluoroscopy
patients.
varied from to
70#{176} 11O . Pericardial calcification
Decreased cardiac pulsations a
werepparent in 12
was present inonly three patients. Mild to moderate
patients with constrictive pericarditis, in 4 of them to
pulmonary venous congestion and left atrial en-
largement were present in all cases except one. Aa greater degree on the border of the right side of
pleural effusion was observed in just haff
under the the heart than on the left. In a single case pulsations
were described as good. In all five patients with
patients.
Pericardial Effusion (Five Cases): The heart size pericardial effusion and in
two with cardiomy-
was moderately enlarged in two patients and mark-
opathy, pulsations were decreased.
edly so in three. The typical “flask-shaped” appear- Hemodynamic Findings (Table 3)
ance was observed in all five patients, and the Eleven patients with constrictive pericarditis, four
cardiophrenic angle varied from 6O 100#{176}.Peri-
to with pericardial effusion and two with congestive
cardial calcification was not seen. In
two patients cardiomyopathy underwent right heart catheteriza-
mild left atrial enlargement and mild pulmonary tion prior to selective angiocardiography. The oxy-
congestion were considered present. gen saturation values were normal in each case. A
Congestive Cardiomyopathy (Four Cases): summary of the pertinent pressure measurements is
Heart size was moderately increased in three pa- presented in Table 3.
tients and markedly increased in one. The heart Angiocardiography (Table 4)
borders were of normal shape. The cardiophrenic Caastrictive Pericarditis (13 Cases): Marked re-
Ficuns 1A and B. Plain x-ray films show-
ing constrictive pericarditis in two different
patients. Straightening of right and left
heart borders is marked by arrows.
CHEST, 65: 4, APRIL, 1974 ANCIOCARDIOGRAPHY IN CONSTRICTIVE PERICARDITIS 381
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FIGunx 2 A-D. Constrictive of contrast material into superior vena cava,
frontal views ( A, B ) dextrophases in atrial systole and diastole; ( C, D) levophases in ventricular
systole and diastole, respectively. Marked refiux is seen in dilated inferior vena cava, hepatic veins
and coronary sinus ( vertical arrows, B,C ) Right .
atrial lateral border is rigid and even concave
both in systole and diastole ( horizontal arrows, A, B ). Right ventricular size is diminished and
its septa! border concave. ( C ) Enlarged left atrium ( LA), dilated upper lobe pulmonary veins,
persistence of pulmonary artery opacification and of dye in inferior
stasis vena cava are obvious.
Small left ventricle ( LV) (between horizontal arrows) and prominent thickness of left ventricular
extra!uminal shadow ( white arrow )are apparent.
flux into a dilated inferior vena cava and the hepatic trunk and major pulmonary arterial branches were
veins was present inine
n ( Fig 2, 3) . The right atrial enlarged in half the cases, four of them demonstrat-
extraluminal shadow in diastole was of normal ing a prominent flow through the upper and a de-
thickness in one patient and varied from 8 to
40mm creased flow through the lower lobe arteries ( Fig 2,
( average 16mm ) in the other ten ( Fig 5, 6). In 3 ) . Mild to moderate pulmonary venous congestion
eight, the opacified right atrial lateral border was was present in nine patients ( Fig 2, 3, 5, 6. The
) left
straightened and rigid throughouut the whole car- atrium as judged in diastole was mildly to moderate-
diac cycle ( Fig 3, 4, 5 ) ; in three it was even concave ly enlarged in nine patients in sinus (
rhythm Fig 2,
( Fig 2, 6). The distance between the opacified right 3, 5, 6) and in the one with atrial fibrillation. It was
ventricular cavity and the diaphragm was normal in of normal size in the remaining three patients. In
all patients, when this sign was sought in diastole. five patients (one of them with atrial fibrillation)
The septal border of the opacified right ventricular the left atrial contractility was clearly diminished
cavity was markedly concave in 10 of 13 studies ( Fig 3 ) . It was normal in the remaining eight cases
( Fig 2-6 ) . This concave appearance was observed ( Fig 5 ). In 12 out of 13 studies the left ventricular
throughout the whole cardiac cycle but was more cavity could be assessed on the levophase; the
prominent in systole ( Fig 3-5 ). The size of the right diastolic size of this cavity was normal in one, mod-
ventricular cavity was markedly decreased in five erately decreased in four ( Fig 2-4 ) and markedly
patients ( Fig 2, 3) and moderately decreased in decreased in seven ( Fig 5, 6) . In the latter seven
another five ( Fig 4-6). Pulmonary opacification time patients contractions were vigorous in all, with al-
was prolonged all 13 patients,
in moderately in 4 and most complete disappearance of contrast material at
markedly in the others ( Fig 2, 3). The pulmonary the end of systole ( Fig 5) In two patients the small .
382 DEUTSCH ET AL CHEST, 65: 4, APRIL, 1974
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A B
C D
Ficuii 3 A-D. Constrictive pericarditis. Injection of contrast material into superior vena cava,
frontal views. ( A, B ) Dextrophases of ventricular systole and diastole, respectively. Right atrium
is dilated and refiux of dye into dilated inferior vena cava, hepatic veins and coronary (lower sinus
arrow ) is clearly seen. Right atria! lateral border appears straight even in atnal ( white
diastole
arrow, .
A ) Right ventricular size is diminished and its septal border is concave both in systole and
diastole ( oblique black arrows, A, B ) Pulmonary. conus and its main branches are dilated and
upper lobe pulmonary artery branches are prominent, simulating “mitral type of pulmonary
hypertension.” ( C, D) Levophase. Ventricular systole and diastole, respectively. Pulmonary
artery is still visualized suggesting increased pulmonary circulation time. Upper lobe pulmonary
veins are dilated suggesting pulmonary venous hypertension. Dilated LA)
(atrium does not
contract in atria! systole. Small left ventricle is superimposed on large left atrium.
left ventricular cavity showed a diastolic concavity mm, with an average of 20 mm. The opacified right
of its parietal wall instead its normal
of elliptical atrial lateral border was straightened in patients
two
form ( Fig 6) . The left ventricular extraluminal during atrial systole but wasormally
n convex in
shadow varied in thickness from 875 to mm, with an atrial diastole in all. In three patients there was
average of Z8 mm. elevation of the opacified right ventricular cavity
Pericardial Effusion (Five Cases): Moderate re- above the diaphragm ( Fig 7 ). The septal border of
flux into a dilated inferior vena cava and the hepatic the opacified right ventricular cavity was slightly
veins was demonstrated in one patient only. Reflux concave in one patient but right ventricular cavity
into the coronary sinus was not seen in any. The size was normal in all. In three patients pulmonary
right atrial diastolic extraluminal shadow was in- circulation time was slightly prolonged, but in none
creased in all cases, varying in thickness from 8 to 40 was pulmonary venous congestion or left atrial en-
Ficunx 4 ( A, B ) Constrictive . pericarditls.
Injection of contrast material into superior
vena cava, frontal views. ( A, B ) Dextro-
phases in ventricular diastole and systole,
respectively. Right border of opacified
right atrium is rigid and straight both in
atria! systole and diastole (white arrows).
Right ventricular septal border is concave
(RV, black arrows).
CHEST, 65: 4, APRIL, 1974 ANGIOCARDIOGRAPHY IN CONSTRICTIVE PERICARDITIS 383
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Table 4-Angiocardiographic Features in 13 Cases of the left side of the heart with obliteration of its
Constrictive Pericarditis, Five Cases of Pericardial normal concavity hasbeen noted in 28 to 90 percent
Effusion and Four Cases of Congestive Cardiomyopathy
of cases.5’7 The incidence of an enlarged cardiac
Congestive silhouette in pericardial effusion is higher and the
Constrictive Pericardial Cardio- cardiac contour described as “flask-shaped” in the
Pericarditis Effusion myopathy
majority without straightening of the heart borders.h1
Patients, No. 13 5 4 Congestive cardiomyopathy is associated with an
Injection site: superior yeas cava 11 5 3 enlarged cardiac silhouette, with no differentiating
right ventricle 2 1 1
features.
Refiux & dilatation of inferior
vena cava 9/11 1/5 3/4 Our results reveal an even higher percentage of
Coronary sinus refiux 5/11 0 0 cardiac enlargement in constrictive pericarditis
Straightening or concavity of (Table 2). Thus, it follows that cardiac size
per se is
lateral right atrial border only occasionally helpful in differentiating constric-
indiastole 8/11 0 0
tive pericarditis from pericardial effusion or conges-
increased extraluminal right
atrial shadow 10/11 5/5 0 live cardiomyopathy. On the other hand, straighten-
Increased distance between ing of the border of the left side of the heart was
diaphragm and opacified I present in five (38 percent) and of the border of the
right ventricular cavity 0 3/5 0 right side of the heart in
nine of our patients (69
Concavity of opacified right
percent) with constrictive pericarditis, while it was
ventricular cavity septal
border 10/13 1/5 0 not encountered in any patient with pericardial effu-
Right ventricular cavity, size normal 3 normal 5 normal 0 sion or congestive cardiomyopathy. Thus, it appears
decreased 10 decreased 0 increased 4 that straightening of the borders of the heart favors
Prolonged pulmonary the diagnosis of constrictive pericarditis whether
opacification time 13/13 3/5 4/4
cardiac enlargement is present or not.
Pulmonary venous congestion 9/13 0 4/4
Increased left atrial size 10/13 0 3/4 Superior vena cava enlargement or the presence
Decreased left atrial contractility 5/13 1/5 4/4 of an acute cardiophrenic angle did not prove to be
Left ventricular cavity, size decreased normal 5 increased 4 of help in the differentiation of the three conditions
11/12
concerned (Table 2).
Contractility, left ventricular increased normal 5 decreased 4
The incidence ofpericardial calcification in con-
7/12
Increased left ventricular strictive pericarditis varies from 33 to 70 percent
extraluminal shadow 12/12 5/5 3/4 in the literature.2L5.7.hl This most helpful diag-
Left ventricular parietal nostic sign was found in only five of our cases, a low
wail, concavity 2/12 0 0
incidence which is probably the result of selection,
since most of our patients with pericardial calcifica-
largement observed. Left atrial size was normal in
tion were referred for operation without further
all, and good atrial contractility was present in four
studies and were not included in the present series.
out of five cases. The left ventricular cavity size was
The presence of decreased cardiac pulsations on
normal in all. The extraluminal left ventricular
fluoroscopy was not helpful in the differential diag-
shadow was increased in all and
varied in thickness
nosis of the three conditions concerned (Table 2).
from 12 to 60 mm ( Fig 7).
Congestive Cardiomyopathy (Four Cases): The
A pleural effusion and/or pulmonary vascular
congestion were described in about half the cases of
positive features were inferior vena cava reflux in
three of the four patients; prolonged pulmonary constrictive pericarditis.2’5’7’1’ We found a similar
incidence of pleural effusion in our cases of constric-
opacification time and venous congestion in all; in-
tive pericarditis, while this was not a feature in any
creased left atrial size in three, with reduced con-
case of congestive cardiomyopathy.
tractility in all patients. The striking feature was an
increase in size of both ventricular cavities in all Left atrial enlargement has been described in con-
patients with markedly diminished contractions. strictive pericarditis in between 20 to 76 percent of
the cases.2’5’7 In our series, left atrial enlargement
DiscussioN
was noted in 10 of 13 patients (76 percent) with
Plain Chest X-Ray Films constrictive pericarditis and in all four with conges-
Recent reports have pointed out that cardiac size tive cardiomyopathy. Its presence was suspected in
may vary considerably in constrictive pericarditis, two of five patients with pericardial effusion but this
and that the “small heart” originally described this
in was not confirmed on angiocardiography. Therefore,
condition is rarer than first thought; thus, an en- it appears that left atrial enlargement is a frequent
larged cardiac silhouette r
hasecently been de- feature of constrictive pericarditis or congestive
scribed in 25 to 66 percent of cases of constrictive cardiomyopathy and that it is unusual in pericardial
pericarditis.7’1#{176} Straightening of the border of effusion.
384 DEUTSCH El AL CHEST, 65: 4, APRIL, 1974
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FIGuas 5. Constrictive pericarditis. (A-F)
Angiography into superior vena cava be-
fore and after operation, frontal views.
(A, B ) Dextrophase in ventricular dia-
stole and systole, respectively showing
straight and rigid right atrial lateral bor-
der. Right atrial extraluminal shadow is
thickened ( right arrow ). Rightward con-
cavity of right ventricular septal border is
present ( RV, oblique arrows). ( C, D)
Levophase, same investigation in ventricu-
lar systole and diastole, respectively. Left
atrium is enlarged and displays little van-
ation during atria! systole and diastole.
Left ventricular diastolic size is markedly
diminished ( LV between oblique arrows,
D). This chamber empties completely in
systole ( C) Left . ventricular extraluminal
shadow is markedly enlarged ( white ar-
rows, C, D). ( E, F) Angiograms after
penicardiectomy. Right ventricular septal
border concavity is no longer present
( compare A, E ); left ventricle ( LV ) is
now of normal size (compare B, F).
Angiocardiography it was normal in congestive cardiomyopathy. The
range and degree of thickening could not differen-
As already stated, a review of the literature
tiate between pericardial constriction or effusion.
reveals relatively few reports dealing with the
However, it is interesting to note that this thickening
angiographic diagnosis of constrictive pericardi-
was even greater in constrictive pericarditis ( mean
tis.6’4 The features emphasized in this condition
28mm ) that in pericardial effusion ( mean 25mm).
are: increased thickness of the diastolic right atrial
Straightening of the opacified right atrial lateral
extraluminal shadow; straightening and rigidity
border in diastole was present only in constrictive
of the right atrial lateral border; increased distance
pericarditis ( 72 percent) as opposed to pericardial
between the opacified right ventricular cavity and
effusion in which such a straightening was occa-
the diaphragm; rigidity of the right ventricular sep-
sionally present and only in systole, or to congestive
tal border; prolongation of the pulmonary opaci-
cardiomyopathy in which this feature was not ob-
fication time; signs of pulmonary venous conges-
served in any phase of the cardiac cycle. Further-
tion; normal left atrial size with decreased systolic-
more, in three cases of constrictive pericarditis the
diastolic volume changes; and decreased left yen-
opacified right atrial lateral border was not only
tricular cavity size.
straight but even concave throughout the cardiac
In our series, the thickness of the right atrial
cycle, indicating an even further degree of constric-
extraluminal shadow was clearly increased both in tion. It follows that diastolic straightening of the
pericardial effusion and constrictive pericarditis, but right atrial lateral border, or its
concavity, consti-
CHEST, 65: 4, APRIL, 1974 ANGIOCARDIOGRAPHY IN CONSTRICTIVE PERICARDITIS 385
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1974, by the American College of Chest Physicians
Ficuns 6 (A, B) Constrictive pericarditis.
Injection of contrast material into superior
vena cava, frontal views, dextro- and levo-
phases, respectively, in ventricular diastole.
(A) Right atrial lateral border is concave
( black arrow). Bight atrial extraluminal
shadow is markedly enlarged (right sided
white arrow). Refiux into inferior vena cava
and hepatic veins is visible. Right ventri-
cle’s septal border is concave ( left sided
white arrow). Right ventricular cavity size
is decreased. ( B ) Marked engorgement of
upper lobe pulmonary veins. Left ventric-
ular cavity size is markedly decreased
( LV), and its parietal border is concave
( oblique arrow ). Left ventricular extra-
luminal shadow is markedly increased
( white horizontal arrow ). Stasis of re-
gurgitant contrast material into inferior
vena cava persists until later levophase
(black arrow).
Ficuiu 7. Injection of contrast material
into superior vena cava in patient with
penicardial effusion. (A, B ) Frontal views
of right atrium and ventricle in ventricular
diastole and systole, respectively. (C) Lat-
eral view in ventricular diastole. (D) Levo-
phase, frontal view in diastole. In atrial
systole (A ) right atrial lateral border is
straightened (horizontal arrow) while it is
convex in atrial diastole (horizontal arrow,
B ). Right atrial extraluminal shadow is
markedly ( compare
increased A, B with
horizontal arrow, D). Right ventricular
floor is elevated (bottom arrow A, C).(D)
left atrium and ventricle are of normal size.
Left ventricular extraluminal shadow is
markedly enlarged (left lateral arrow).
bates an important point in the differential diagnosis against congestive cardiomyopathy. On the other
of constrictive pericarditis from pericardial effusion hand, diastolic straightening of the opacified right
or congestive cardiomyopathy. It should also be atrial lateral border with a normal distance between
emphasized that in contrast to previous reports,13”4 the opacified right ventricular cavity and the
an increased distance between the opacified right diaphragm in diastole can differentiate constrictive
ventricular cavity and the diaphragm was not ob- pericarditis from pericardial effusion ( Table 4).
served in constrictive pericarditis and was present In constrictive pericarditis, straightening of the
only in pericardial effusion in our cases. It should be septal border of the opacified right ventricular cavi-
recalled here that this sign should be evaluated inty has been noted by others.7’8’12’14 Among the
the diastolic phase of the opacified right ventricular three conditions concerned here, this straightening
cavity since in our opinion its assessment in systole is or even bulging of the septum into the right yen-
open to pitfalls. On the other hand, reflux of contrast tricular cavity was seen in 10 of 13 patients with
material into a dilated inferior vena cava was not aconstrictive pericarditis, but in only 1 out 5
of pa-
feature of pericardial effusion and favored constric- tients with pericardial effusion, and then only to a
tive pericarditis or congestive cardiomyopathy. mild degree. It was not observed in any patient with
According to the above facts, an increased right congestive cardiomyopathy. This alteration in the
atrial extraluminal shadow thickness and an in- outline of the septum which could be recognized
creased distance between the inferior border of the both in systole and diastole is due to bulging of the
opacified right ventricular cavity and the diaphragm left ventricle into the right ventricular cavity. It may
would suggest pericardial constriction or effusion as be explained by the marked restriction of motion of
388 DEUTSCH El AL CHEST, 65: 4, APRIL, 1974
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1974, by the American College of Chest Physicians
the left ventricular parietal and diaphragmatic wall tiation from pencardial effusion or congestive
in constrictive pericarditis. For the sake of complete- cardiomyopathy.
ness we should mention that we have also observed Clearly, the angiocardiographic signs invoked in
such a septal bulging in cases diffuse
of left ventricu- the literature for the diagnosis of constrictive peri-
lar dilatation with markedly impaired left ventricu- carditis and its differentiation from pericardial effu-
lar compliance secondary to coronary disease. In sion and congestive cardiomyopathy”4 are
these instances, however, the presence of an en- not specific enough. We believe that the diagnosis of
larged left ventricular cavity differentiates them constrictive pericarditis may rest on much
firmer
from constrictive pericarditis ( see below). grounds if more attention is focused on the angio-
Pulmonary venous congestion and left atrial en- cardiographic details described above (Table 4).
largement were not seen on angiography inany of Thus, one should look for a ) diastolic
( straighten-
our cases of pericardial effusion even though left ing or even more for concavity of the opacified right
atrial enlargement was suspected in the plain chest x- atrial lateral border; (b) a small right ventricular
ray film findings of two. In contrast, these features cavity with a straight septal border or even more
were present in two-thirds of our patientswith con- for a bulging of the intraventricular septum into the
strictive pericarditis and in all with congestive car- right ventricular cavity and finally; ( c) the pres-
diomyopathy. The presence of often left
marked ence of a small left ventricular cavity with or with-
atrial enlargement in most of
our patients with con- out a concave parietal border displaying vigorous
strictive pericarditis ( all in sinus rhythm with the contraction, with complete systolic emptying. While
exception of one) contrasts with the findings of these hitherto undescribed or little emphasized fea-
Figle who described left atrial enlargement in hires may be rarer than the ones described so far,
angiocardiography in only three of eight cases (37.5 we feel that their recognition may contribute greatly
percent) and is definitely opposed to the findings of to the diagnosis of constrictive pericarditis and its
Cotsman et aP’ who found a normal atrial
left size in differentiation from congestive cardiomyopathy or
all their cases. Also, the diminished left atrial con- pericardial effusion.
tractility in only 5 of our 13 patients with constric-
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CHEST, 65: 4, APRIL, 1974 ANGIOCARDIOGRAPHY IN CONSTRICTIVE PERICARDITIS 381
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1974, by the American College of Chest Physicians
Angiocardiography in Constrictive Pericarditis
Victor Deutsch, Hylton Miller, Joseph H. Yahini, Abraham Shem-Tov and Henry N.
Neufeld
Chest 1974;65; 379-387
DOI 10.1378/chest.65.4.379
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