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Constrictive pericarditis — ABIM Board MCQ

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HardCardiovascularConstrictive pericarditisABIM Board

A 62-year-old man has progressive exertional dyspnea, lower-extremity edema, and abdominal distention 20 years after receiving mediastinal radiation. Jugular venous pressure is elevated and rises during inspiration. Echocardiography shows normal left ventricular wall thickness and ejection fraction, an abrupt respiration-related interventricular septal shift, a medial mitral annular e' velocity of 11 cm/s, a lateral e' velocity of 6 cm/s, and prominent expiratory diastolic flow reversal in the hepatic veins. There is no pericardial effusion or chamber collapse. Cardiac CT shows no calcification and a maximal pericardial thickness of 3 mm. Which of the following is the most likely diagnosis?

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Correct answer: A — Radiation-induced constrictive pericarditis

This is **radiation-induced constrictive pericarditis**. Prior mediastinal radiation is a recognized cause, and the edema, ascites, elevated jugular venous pressure, and Kussmaul sign reflect impaired right-sided filling. Respiration-related septal shift, preserved medial e', annulus reversus (medial e' greater than lateral e'), and expiratory hepatic-vein diastolic reversal are characteristic of constrictive physiology. Normal pericardial thickness and absent calcification do not exclude constriction. Restrictive cardiomyopathy usually reduces both medial and lateral e' velocities and causes less respiratory ventricular interdependence. Severe tricuspid regurgitation causes hepatic-vein systolic, rather than expiratory diastolic, flow reversal. Tamponade would generally involve an effusion and chamber collapse and does not typically cause Kussmaul sign. Pulmonary arterial hypertension does not explain the characteristic Doppler and septal findings.

Reference: Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circulation: Cardiovascular Imaging. 2014;7:526-534. https://pubmed.ncbi.nlm.nih.gov/24633783/