Accompanying text
A 53 year old male with a history of surgical pulmonary commissurotomy
at the age of 12 presented with progressive shortness of breath, right
sided pleural effusion and peripheral edema. He was in atrial
fibrillation with adequate rate control. Echocardiogram showed normal
systolic biventricular function and severe pulmonary regurgitation.
Patient responded well to diuretics and underwent a successful
cardioversion, after which rhythm control strategy was pursued. He was
considered to be a suitable candidate for pulmonary valve replacement
and underwent a diagnostic cardiac catheterization in the work up. How
should the findings shown in Figure 1 be interpreted?
The diagnostic catheterization revealed constrictive pericarditis
physiology. Extensive pericardial calcifications were evident during
X-ray exposure at angiography. Mean right atrial pressure was
significantly elevated at 12mmHg. Simultaneous right and left
ventricular pressure tracings revealed diastolic pressure equilibration
(23-26mmHg) in the two chambers and the pathognomonic ‘dip and plateau
pattern’, also known as the ‘square root sign’ (1). Left ventricular
rapid filling (LVRFW) wave was accentuated and measured +/- 10mmHg.
LVRFW > 7mmHg is representative of the increased early
diastolic ventricular filling and is a sensitive marker for constrictive
physiology (2). Patient had no obstructive coronary artery disease. He
underwent an successful resection of the heavily thickened and calcified
pericardium and a pulmonary valve replacement (25 mm pulmonary
homograft). The post-operative recovery period was uneventful and
patient is currently symptom free 6 months after the operation.