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.