Diastolic Coronary Artery Compression in Constrictive Pericarditis

Abstract

Phasic coronary artery compression during diastole is a rare phenomenon. We describe a case of diastolic coronary artery compression which was caused by constrictive pericarditis. (Level of Difficulty: Beginner.)

Graphical abstract

Phasic coronary artery compression during diastole is a rare phenomenon. We describe a case of diastolic coronary artery compression which was caused…

A 54-year-old male was referred to the authors’ institution with a 1-year history of worsening shortness of breath and lower limb swelling. His medical history was significant for recurrent episodes of idiopathic pericarditis that began 4 years previously and were treated with non steroidal anti-inflammatory agents, colchicine, and prednisone. He showed no evidence of metastatic malignancy, uremia, tuberculosis, or chronic bacterial infection. On examination, the jugular venous pressure was elevated with a rapid “Y” descent, a pericardial knock, peripheral edema, and ascites. Chest radiography demonstrated cardiomegaly with prominence of the left cardiac border but no calcifications (Figure 1A). Transthoracic echocardiography showed ventricular interdependence, respiratory variation of the mitral inflow, annulus reversus, and expiratory end-diastolic hepatic venous flow reversals, which was diagnostic for constrictive pericarditis (Supplemental Figure 1). Cardiac magnetic resonance imaging demonstrated mild (3-mm) pericardial thickening anterior to the right ventricle (Figure 1B, arrows) and no regional wall motion abnormalities. The patient was referred for pericardiectomy. Preoperative coronary angiography showed no atherosclerotic lesions, but there were discrete regions of diastolic compression of the mid left anterior descending artery; and diagonal, ramus, and distal left circumflex arteries (Figures 1C and 1D, arrows, Video 1). During surgery, it was noted that the pericardium was thick, with transverse cylindrical cords of scar which compressed the underlying epicardium (Figures 1E and 1F). Surgical pathology revealed non-calcific fibrous thickening and minimal non-granulomatous lymphoplasmacytic infiltrate, consistent with constrictive pericarditis. The patient had an uneventful postoperative course. On 6-month follow-up, his symptoms of shortness of breath and edema had completely resolved, and repeated echocardiography showed no evidence of constrictive physiology. Diastolic coronary artery compression is a rare phenomenon (1, 2, 3, 4, 5, 6, 7), unlike systolic myocardial bridging of arteries with an intramural course. Diastolic external compression usually occurs from localized pericardial thickening during cardiac relaxation and enlargement. It has also been reported in association with left atrial enlargement and following coronary artery bypass grafting and heart transplantation (4, 5, 6, 7). Myocardial ischemia is a theoretical concern which likely resolves after correction of the structural cause of the compression (such as pericardiectomy). In the present patient, ischemia prior to surgery was not investigated because the clinical presentation was that of heart failure without anginal symptoms, and definitive therapy with pericardiectomy was planned.

Figure 1.

Chest Radiography Shows Cardiomegaly but no Calcifications

(A) Chest radiography shows cardiomegaly but no calcifications. (B, white arrows) Cardiac magnetic resonance demonstrates increased pericardial thickening. (C) Coronary angiography shows normal coronary anatomy in systole but phasic compression of multiple coronary arteries during diastole (D, yellow arrowheads). During pericardiectomy, thick cylindrical cords of pericardium were visualized (E and F, white arrows).

Online Video 1.

Download video file ^{(3.5MB, mp4)}

Coronary angiography showing diastolic coronary artery compression.