A 23-year-old previously healthy male presented with dyspnea. Clinical examination demonstrated elevated jugular venous pressure, lower extremity edema, abdominal distension, tachycardia (111 bpm), and a narrow pulse pressure (116/94 mmHg) without pulsus paradoxus. Bedside cardiac ultrasound (parasternal short axis) demonstrated pathologic ventricular interdependence with ventricular septal shift toward the left ventricle (LV) on deep inspiration (“D-sign”). Mitral valve inflow velocities were measured and demonstrated a 35% decrease in inflow velocity with deep inspiration. Formal echocardiogram revealed a reduced ejection fraction of 25% with paradoxical septal motion.
Ventricular interdependence is a normal phenomenon but may become pathologic/exaggerated in constrictive states.1 A rigid pericardium results in fixed cardiac volumes throughout the cardiac cycle and prevents transmission of intrathoracic pressures to the cardiac chambers.2 In this setting, increased right ventricle (RV) filling along with reduced LV filling during inspiration results in septal flattening and shift of the septum into the LV, which reverses during expiration.2 Pulsus paradoxus may be absent in up to 80% of patients with constrictive pericarditis, as in our patient.3 The patient was diagnosed with constrictive pericarditis secondary to disseminated non-pulmonary tuberculosis and treated with heart failure goal directed medical therapy and anti-tuberculosis quadruple therapy. The patient improved significantly and has recovered ejection fraction over the ensuing year.
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References
- 1.Shaver JA, Reddy PS, Curtiss EI, Ziady GM, Reddy SC (2001) Noninvasive/invasive correlates of exaggerated ventricular interdependence in cardiac tamponade. J Cardiol 37 Suppl 1:71-76. [PubMed]
- 2.Myers RB, Spodick DH (1999) Constrictive pericarditis: clinical and pathophysiologic characteristics. Am Heart J 138 (2 Pt 1):219-232. 10.1016/s0002-8703(99)70105-5. [DOI] [PubMed]
- 3.Talreja DR, Nishimura RA, Oh JK, Holmes DR (2008) Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory. J Am Coll Cardiol 51 (3):315-319. 10.1016/j.jacc.2007.09.039. [DOI] [PubMed]
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