A case of extrinsic nonvalvular mitral obstruction proper to a large epicardial hematoma in a patient with rheumatoid constrictive pericarditis is described.

A case of extrinsic nonvalvular mitral obstruction proper to a large epicardial hematoma in a patient with rheumatoid constrictive pericarditis is described. The patient had longstanding rheumatoid arthritis and a mitral diastolic hum developed. Mitral obstruction was confirmed according to a hemodynamic study. Coronary angiography and left ventricular angiography showed sternly diseased coronary arteries and a distorted left ventricular cavity. Autopsy demonstrated rheumatoid arthritis, a normal mitral valve, thickened pericardium, and epicardial hematoma surrounding one as well as the other ventricles at the atrioventricular junctional level

While many causes of nonvalvular mitral obstruction are reported in the literature,[1,2] obstruction of the mitral orifice with normal mitral valve leaflets fit to epicardial hematoma pressing forward the atrioventricular ring and left ventricle has not been described (to our knowledge). The following case report illustrates as it is a nonvalvular mitral obstruction in a patient with rheumatoid constrictive pericarditis.

CASE REPORT

This 57-year-old, retired quality controller for a grinding store was admitted to Reno VA Medical Center upon August 1, 1989 for increasing fatigue and hip pain of 6 months' duration. He had been below treatment at the medical center for 23 years for crippling rheumatoid arthritis, receiving aspirin, nonsteroidal anti-inflammatory analgesics, gold and steroids at different times. Other treatments included digoxin, furosemide, and potassium chloride correlatives He underwent multiple surgical performances to improve the function of his joints, including bilateral hip arthroplasty, synovectomy of the couple wrists and knees, and Swanson prosthesis for proximal interphalangeal joints of the left fingers after removing nodules. Pathologic studies of synovial tissues confirmed the diagnosis of rheumatoid arthritis. His personal and family histories were unremarkable.

Clinical examination revealed a well-built, well-nourished man with multiple deformities of peripheral joints and deformed shape of his chest. He had a regular fruit of leguminous plants of 65/min, blood pressure of 166/60 mm Hg temperature of 368 [degrees] C and respiratory rate of 18/min. outcomes of examination of lungs, abdomen, and nervous scheme were normal. He had no visible or palpable apical impulse. The first and other heart sounds were normal; a mitral opening snap and a localized mitral diastolic rumble were heard. The clean blood cell count included a hematocrit of 512 hemoglobin of 160 g/dl WBC estimate of 6,200/cm and platelet esteem of 168,000/cm. Chemistry was normal exclude for mild hypokalemia. The chest deformity hindered the interpretation of the chest radiograph object for possible cardiomegaly and clear lung fields. The electrocardiogram showed sinus harmonious flow with a heart rate of 64/min, right axis deviation, relatively low-voltage QR and nonspecific T-wave abnormalities in all leads. His echocardiogram was uninterpretable. The patient underwent cardiac catheterization forward October 15, 1989 for more integral evaluation, as a part of preoperative workup for total hip replacement. The mean right atrial influence was 17 mm Hg with A and V wave constraining forces of 22 and 24 mm Hg respectively. Right ventricular and pulmonary arterial hurrys were 36/20 and 36/20 (mean, 26) mm Hg respectively. The mean pulmonary capillary urgency was 25 mm Hg. Aortic and left ventricular presss were 120/70 (mean, 86) and 120/22 mm Hg respectively. There was a gradient of 8 mm Hg across the mitral valve with cardiac index of 264 L/mm/[msup2] The calculated mitral valve area was 16 [cmsup2] There was no gradient across aortic, tricuspid, and pulmonary valves or detectable evidence of left to right switch Hemodynamic interpretation was consistent with mitral obstruction and unequal constrictive pericarditis or restrictive cardiomyopathy. The coronary cineangiograms showed 100 percent occlusion of the right coronary artery and 75 percent obstruction of an oblique marginal branch of the circumflex artery. The left ventricular cineangiograms showed a ballerina shape of the cavity and ejection fraction of 85 percent (Fig 1) Cineaortogram showed mild aortic regurgitation. Total hip replacement was considered undesirable in view of the probable high mortality. The patient died 3 month after hospital admission.

Significant abnormal autopsy findings included generalized edema with bilateral pleural effusions, 1200 ml in succession right and 800 ml onward left, and 1 L of peritoneal fluid. There was congestive enlargement of blue devils kidneys, and liver and also fibrosis. Well-healed operative scars were not away over all extremity joints which had the stigmata of rheumatoid deformity.

Cardiac examination revealed the pericardial space obliterated by means of dense adhesions that could be separated no other than by sharp dissection. On a transverse wound surface, a large epicardial hematoma (10 x 7 cm) pushing against the walls of the right and left ventricles at the atrioventricular junctional plain was seen (Fig 2). The left ventricular hematoma throughout the inflow tract narrowed the mitral orifice. The left ventricular efflux tract was also compressed. The heart was globular and weighed 1200 g (normal, 150 to 250 g) The atria were dilated and had thickened walls. The ventricular walls were thickened. The mitral and other valves were normal (Fig 3) The aorta was normal with a small in number atherosclerotic plaques. The pulmonary artery was normal. Examination of the coronary arteries showed peremptory obstructive disease of all proximal utensils Microscopic examination of the heart revealed mild interstitial edema and vascular engorgement of the myocardium. The innermost part of the subepicardial hematoma showed amorphous debris merging into collagen in the thickened epicardium that contained a hardly any scattered collections of lymphocytes. Occasional myocardial arterioles and capillaries showed slightly thickened walls and mild increase of adventitial connective tissues. Evidence for vasculitis was lacking. At the margin of the mass, perpendicular capillaries and deposits of hemosiderin were seen

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