We describe sum of two units cases of worsening tricuspid regurgitation following surgical pericardiectomy for constrictive pericarditis.

We describe sum of two units cases of worsening tricuspid regurgitation following surgical pericardiectomy for constrictive pericarditis. the two patients demonstrated hemodynamic profiles characteristic of constrictive pericarditis in succession cardiac catheterization. They also had moderate tricuspid regurgitation as judg by the agency of Doppler echocardiography. The worsening tricuspid regurgitation observ was a outcome of postoperative right ventricular dilatation. These cases demonstrate the importance of determining tricuspid valvular function in patients with constrictive pericarditis prior to pericardiectomy; however, the hemodynamic changes that inference in worsening tricuspid regurgitation may not be not absent for weeks.

Evaluation of tricuspid regurgitation in the nearness of constrictive pericarditis may be difficult since the pair conditions may present with similar hemodynamic profiles. We describe sum of two units cases of clinically significant worsening of tricuspid regurgitation following surgical pericardiectomy for constrictive pericarditis. Guidelines for evaluation and management are discussed.

CASE REPORTS

CASE 1

A 78-year-old woman with a history of hypertension, coronary artery bypass grafting 5 years ago, breast cancer, and thoracic radiation therapy 7 years ago readyed with increasing dyspnea on exertion and chest influence Physical examination revealed jugular venous distention, pitting edema of the lower extremities, and a pericardial knock. No rales, indistinct utterance or rub were noted. Pulsus paradoxus was not current In view of her history, the diagnosis of dyspnea equivalent angina was considered. Cardiac catherization demonstrated normal left ventricular systolic function (ejection fraction [EF]=69 percent) with a well-vascularized myocardium via five patent grafts. There was no visible calcification of the pericardium. The mean right atrial crushing was 17 mm Hg, with a prominent A wave, a V wave of 20 mm Hg and a true prominent Y descent. Simultaneous left and right ventricular hurrys demonstrated diastolic equalization with a prominent early diastolic dip and a late plateau, characteristic of constrictive pericarditis (Fig 1) A diagnosis of constrictive pericarditis was made. Hemodynamic variables are instanted in Table 1.

Transthoracic echocardiography demonstrated symmetric left ventricular hypertrophy a dilated right atrium and ventricle, dilated hepatic veins, and moderate tricuspid regurgitation (Fig 2 top). She was discharged from the hospital forward a regimen of the following: L-thyroxine, 005 mg orally each day; furosemide, 40 mg orally each day; enalapril, 2.5 mg orally each day; diltiazem SR, 90 mg orally each day; and aspirin, 325 mg orally each day. Despite medical treatment, the patient replyed with dyspnea and lower extremity edema. Physical examination revealed jugular venous distension, ascites, and pitting edema of the lower extremities. No rales, grumble rub, or knock were lay opened The patient subsequently underwent visceral pericardiectomy 4 weeks after the initial presentation. A left anterolateral thoracotomy incision was utilized in view of her previous coronary artery bypass grafting. The pericardium was noted to appear thin intraoperatively. [TABULAR DATA OMITTED]

During the step the right ventricle was noted to expand and the cardiac output improved from 33 to 40 L/min. Excision was believed to be consummate with dissection from phrenic self-command to phrenic nerve. Pathologic evaluation of the pericardium revealed fibromembranous tissue with fibrosis and mild nonspecific chronic inflammation. Immediately postoperatively, the patient's right atrial squeezing tracing was noted to suffer ventricularization. The patient was discharged from the hospital 10 days later forward a regimen of the following: L-thyroxine, 010 mg orally each day; diltiazem, 60 mg orally each day; enalapril, 2.5 mg orally each day; furosemide, 40 mg orally each day; and aspirin, 325 mg orally each day. The patient was readmitted to the hospital 4 weeks later with increasing dyspnea and fatigue. Physical examination revealed massive edema of the lower extremities and lower back, moderate jugular venous distention, bibasilar rales, and no gallop further a grade 2/6 systolic plaint heard best at the upper left sternal border. A chest radiograph revealed slight cardiomegaly and one accentuation of the perihilar and upper lobe vascularity. A transthoracic echocardiogram revealed inexorable tricuspid regurgitation, with reversal of spring in the hepatic veins (Fig 2 bottom). Tricuspid annuloplasty was subsequently performed. An intraoperative transesophageal echocardiogram demonstrated austere tricuspid regurgitation due to a dilated tricuspid annulus. The right ventricle demonstrated normal wall motion. All of the tricuspid leaflets were intact with no ruptur or elongated chordae noted intraoperatively. Annuloplasty with a No. 34 Carpentier ring was prosperous In follow-up, the patient felt well and was walking up stairs without difficulty. forward examination there was no peripheral edema, the neck veins were flat, and the lung were clear to auscultation.

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