constrictive pericarditis: a challenging diagnosis in ... · casereport constrictive pericarditis:...
TRANSCRIPT
Case ReportConstrictive Pericarditis A Challenging Diagnosis in Paediatrics
Mariana Faustino1 Inecircs Carmo Mendes2 and Rui Anjos2
1Cardiology Department Hospital Fernando Fonseca IC 19 Amadora 2720-276 Lisbon Portugal2Pediatric Cardiology Department Hospital de Santa Cruz Avenida Professor Reinaldo dos Santos Carnaxide2790-134 Lisbon Portugal
Correspondence should be addressed to Mariana Faustino marianafaustino85gmailcom
Received 17 July 2015 Revised 26 August 2015 Accepted 26 August 2015
Academic Editor Ramazan Akdemir
Copyright copy 2015 Mariana Faustino et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited
Constrictive pericarditis is an uncommon disease in children usually difficult to diagnose We present the case of a 14-year-old boywith a previous history of tuberculosis and right heart failure in whom constrictive pericarditis was diagnosedThe case highlightsthe need to integrate all information including clinical data noninvasive cardiac imaging and even invasive hemodynamicevaluation when required in order to establish the correct diagnosis and proceed to surgical treatment
1 Introduction
Constrictive pericarditis is characterized by the appearanceof signs and symptoms of right heart failure due to loss ofpericardial compliance and restricting diastolic filling [1]It results from a chronic inflammatory process involvingthe parietal and visceral pericardial layers [2] Idiopathicpericarditis cardiac surgery and radiotherapy are the mostcommon causes in developed countries Incomplete drainageof purulent pericarditis is a rare entity that should also beconsidered but tuberculosis is still the most prevalent causein developing countries particularly in paediatric population[3 4]
Constrictive pericarditis is not common in children andtherefore not readily recalled and the clinical picture oftenseems unrelated to the heart so it sometimes may representa diagnosis challenge [5]
2 Case Presentation
We present the case of a 14-year-old boy born and resident inAngola At 7 years of age he had fatigue cough fever and noweight progression
At 11 years of age pulmonary tuberculosis was diagnosedconfirmed in sputum cultures He received quadruple antitu-berculosis therapy for 6 months As heart failure symptoms
and signs arose with systemic and pulmonary congestionthe child was started on diuretics and evacuated to a PediatricCardiologyDepartment in PortugalThe clinical examinationrevealed weight and height below the 3rd percentile bloodpressure and heart rate within normal limits mild tachypneapulmonary auscultation with decreased sounds at the rightinferior third and left basal crackles and nonpulsatile hep-atomegaly and ascites jugular venous pulse was congestiveuntil mandible angle however theM-shaped pattern (promi-nent x and y descendants) was not evident No kussmaulsign was present No heart murmurs pericardial rub orpericardial knock was documented
A chest radiography showed mild cardiac dilation andbilateral pulmonary effusion predominantly in the righthemithorax (Figure 1) Electrocardiogram showed low volt-ageQRS in frontal leads compatible with effusion andor con-striction process (Figure 2) Laboratory tests revealed mildhypoalbuminemia (29mgdL) with normal liver enzymesserum inflammatory markers were negative Viral andautoimmune investigation was also negative
Echocardiography showed significant enlargement of theright atria inferior vena cava and suprahepatic veins (Figures3(a) and 3(b) clip 1 in Supplementary Material availableonline at httpdxdoiorg1011552015402740) right ven-tricular systolic pressure and function were normal Leftventricle function and volumes were normal There was no
Hindawi Publishing CorporationCase Reports in CardiologyVolume 2015 Article ID 402740 4 pageshttpdxdoiorg1011552015402740
2 Case Reports in Cardiology
Figure 1 Posteroanterior chest radiography mild cardiac dila-tion and bilateral pulmonary effusion predominantly in the righthemithorax
V4R
V1
V2
V4
V5
V6
I
II
III
aVR
aVL
aVF
Figure 2Twelve-lead electrocardiogram heart rate of 90 beatsminlow voltage QRS in frontal leads nonspecific alterations of ventric-ular repolarization
pericardial effusion but signs of ventricular interaction werefound septal bounce and significant respiratory variationin transvalvular flow (transmitral flow increasing by 50during expiration) (Figure 3(c)) Unfortunately hepatic veinrespiratory variation was not possible to adequately assessDilatation of the right chambers and the flow pattern throughthe atrio-ventricular valves in the absence of pulmonaryhypertension nor systolic left ventricle dysfunction sug-gested pericardial constriction Protodiastolic mitral annulusvelocity was preserved (1198641015840 = 14 cms) and the ratio 1198641198641015840was low (annulus paradoxus) Septal 1198641015840 velocity was higherthan medial 1198641015840 velocity (annulus reversus) This findingswere also suggestive of pericardial disease and not restrictivecardiomyopathy (Figure 3(d))
In the presence of this clinical history and physical exam-ination authors suspected constrictive pericarditis Echocar-diography parameters were also suggestive of constrictivephysiology but however considered not enough to establishthe diagnosis For confirmation magnetic resonance wasperformed As the patient was uncooperative only anatomicimaging was performed and constrictive physiology was notdemonstrated
In spite of a high clinical and echocardiographic suspi-cion in order to confirm the diagnosis before proposing asurgery with no negligible risks cardiac catheterization wasperformed (Figure 4) Several parameters were suggestive ofconstriction elevated and equalized telediastolic pressuresin both ventricles telediastolic pressure in right ventricle(20mmHg) higher than one-third of its systolic pressure(42mmHg) increasedmean right atrial pressure (17mmHg)systolic area index of 129 suggesting ventricular interdepen-dence The ventricular filling pattern was suggestive of theclassic square root sign (dip and plateau)
Patient was referred for pericardiectomy Pericardiumwas thickened and adherent not calcified and it wasexcised from phrenic to phrenic nerve (Figure 5) Therewas an immediate decrease in right atria mean pressure(25 to 12mmHg) Pathologic study of the surgical speci-men revealed extensive fibrosis without active inflammationcompatible with chronic fibrous constrictive pericarditis Weassume that Tuberculosis was the cause of the constrictivepericarditis The postoperative period was uneventful withfast and complete regression of all signs of heart failure
3 Discussion
The long lasting symptoms of this patient were very likelyrelated to tuberculosis which progressed with pericardialinvolvement and constriction not reversible with antituber-culosis therapy
Although constrictive pericarditis is rare in children itshould be considered in the differential diagnosis of rightheart failure It is possible that this low incidence in childrenis due in part to subdiagnosis and also to the insidiouscharacter of this disease and its complications [5]
A high index of suspicion is necessary to establish thediagnosis of constrictive pericarditis [5] It is necessaryto integrate clinical evaluation with data from the severalavailable methods and to have a critical approach positionwhen eventual discrepancy arises
Transthoracic echocardiography is usually the first diag-nostic investigation performed for suspected constrictivepericarditis and can be very useful in the presence of thetypical findings septal bounce dynamic respiratory variationin flow (transtricuspid transmitral and hepatic vein) andenhanced ventricular interaction [3] In this way echocar-diography has an important role in the differential diagnosisof constrictive pericarditis with other causes of heart failurenamely restrictive cardiomyopathy the most challengingentity to differentiate from constrictive pericarditis [1 6]However echocardiography might not be confirmatory in allcases since some of these typical findings may not be present[5]
Cardiac magnetic resonance despite being the imagingmethod of choice to evaluate the pericardium was notuseful and potentially confounding in this patient Contrastenhanced CT angiography being also a noninvasive investi-gation is more tolerable and easier to perform in childrenthan cardiacmagnetic resonance and could have been a better
Case Reports in Cardiology 3
RA
(a)
RAIVC
SHV
(b)
+
25 cms50 cmslowast
(c)
14 cms
(d)
Figure 3 (a) Apical 4-chamber view with dilated right atria (RA) left deviated atrial septum (b) subcostal view of dilated inferior vena cava(IVC) and suprahepatic veins (SHV) (c) significant (50) transmitral flow variation with breathing increasing during expiration (lowast) anddecreasing during inspiration (+) (d) high protodiastolic mitral annulus velocity (septal 14 cms higher than lateral)
InspirationExpiration
114mm2107mm2
473mm2572mm2
Figure 4 Elevated and equalized telediastolic pressure in ventricles(20mmHg arrow head) systolic area index calculated as theratio between right ventricleleft ventricle systolic area in inspi-ration and right ventricleleft ventricle systolic area in expiration(114473)(107572) = 129
option for this patient It is useful to identify pericardial thick-ness and effusion to detect enlargement of the mediastinallymph nodes and to evaluate lung parenchyma which maybe important in patients suspected to have tuberculosis [3]
Cardiovascular catheterization although an invasivemethod and not always necessary is the gold standard forthe diagnosis of constriction and was crucial to confirmthe diagnosis A recent described criteria is the systolic area
Figure 5 Thickened and adherent pericardium during and imme-diately after pericardiectomy
index ratio of right ventricle to left ventricle systolic areaduring inspiration and expiration that predicts ventricularinterdependence with 97 sensitivity and 100 positivepredictive power when higher than 11 [7]
The case highlights the need to integrate all informationincluding clinical data electrocardiography chest radiogra-phy cardiac imaging data and even invasive hemodynamic
4 Case Reports in Cardiology
evaluation Cardiac catheterization is usually reserved forpatients in whom there is significant diagnostic doubt afternoninvasive evaluation since the confirmation of the diagno-sis is decisive for the therapeutic approach in order to ensurethat the expected benefit outweighs the potential risk
A correct and early diagnosis of constrictive pericarditisis extremely important since successful pericardiectomy canbe curative [3] In advanced disease surgery results are sub-optimal and mortality is higher which is also related to poorpreoperative general condition and advanced preoperativeNYHA class [3]
Ethical Approval
The identity of the patient was absolutely preserved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] L Marta M Alves M Peres et al ldquoEffusive-constrictivepericarditis as the manifestation of an unexpected diagnosisrdquoRevista Portuguesa de Cardiologia vol 34 no 1 pp 69e1ndash69e62015
[2] SM A G Ferreira A G Ferreira Jr A doNascimentoMoraisW S Paz and FAA Silveira ldquoConstrictive chronic pericarditisin childrenrdquo Cardiology in the Young vol 11 no 2 pp 210ndash2132001
[3] S Talwar V V Nair S K Choudhary et al ldquoPericardiectomy inchildren lt15 years of agerdquo Cardiology in the Young vol 24 no4 pp 616ndash622 2014
[4] P P Sengupta M F Eleid and B K Khandheria ldquoConstrictivepericarditisrdquo Circulation Journal vol 72 no 10 pp 1555ndash15622008
[5] J Guitti ldquoConstrictive pericarditis in a 19-month-old childrdquoArquivos Brasileiros de Cardiologia vol 74 no 1 pp 47ndash542000
[6] D Silva L Sargento M Gato Varela M Lopes D Brito and HMadeira ldquoPericardite constritivamdashconstrictive pericarditismdashnew methods in the diagnosis of an old disease a case reportrdquoRevista Portuguesa de Cardiologia vol 31 pp 677ndash682 2012
[7] D R Talreja R A Nishimura J K Oh and D R HolmesldquoConstrictive pericarditis in the modern era Novel criteria fordiagnosis in the cardiac catheterization laboratoryrdquo Journal ofthe American College of Cardiology vol 51 no 3 pp 315ndash3192008
2 Case Reports in Cardiology
Figure 1 Posteroanterior chest radiography mild cardiac dila-tion and bilateral pulmonary effusion predominantly in the righthemithorax
V4R
V1
V2
V4
V5
V6
I
II
III
aVR
aVL
aVF
Figure 2Twelve-lead electrocardiogram heart rate of 90 beatsminlow voltage QRS in frontal leads nonspecific alterations of ventric-ular repolarization
pericardial effusion but signs of ventricular interaction werefound septal bounce and significant respiratory variationin transvalvular flow (transmitral flow increasing by 50during expiration) (Figure 3(c)) Unfortunately hepatic veinrespiratory variation was not possible to adequately assessDilatation of the right chambers and the flow pattern throughthe atrio-ventricular valves in the absence of pulmonaryhypertension nor systolic left ventricle dysfunction sug-gested pericardial constriction Protodiastolic mitral annulusvelocity was preserved (1198641015840 = 14 cms) and the ratio 1198641198641015840was low (annulus paradoxus) Septal 1198641015840 velocity was higherthan medial 1198641015840 velocity (annulus reversus) This findingswere also suggestive of pericardial disease and not restrictivecardiomyopathy (Figure 3(d))
In the presence of this clinical history and physical exam-ination authors suspected constrictive pericarditis Echocar-diography parameters were also suggestive of constrictivephysiology but however considered not enough to establishthe diagnosis For confirmation magnetic resonance wasperformed As the patient was uncooperative only anatomicimaging was performed and constrictive physiology was notdemonstrated
In spite of a high clinical and echocardiographic suspi-cion in order to confirm the diagnosis before proposing asurgery with no negligible risks cardiac catheterization wasperformed (Figure 4) Several parameters were suggestive ofconstriction elevated and equalized telediastolic pressuresin both ventricles telediastolic pressure in right ventricle(20mmHg) higher than one-third of its systolic pressure(42mmHg) increasedmean right atrial pressure (17mmHg)systolic area index of 129 suggesting ventricular interdepen-dence The ventricular filling pattern was suggestive of theclassic square root sign (dip and plateau)
Patient was referred for pericardiectomy Pericardiumwas thickened and adherent not calcified and it wasexcised from phrenic to phrenic nerve (Figure 5) Therewas an immediate decrease in right atria mean pressure(25 to 12mmHg) Pathologic study of the surgical speci-men revealed extensive fibrosis without active inflammationcompatible with chronic fibrous constrictive pericarditis Weassume that Tuberculosis was the cause of the constrictivepericarditis The postoperative period was uneventful withfast and complete regression of all signs of heart failure
3 Discussion
The long lasting symptoms of this patient were very likelyrelated to tuberculosis which progressed with pericardialinvolvement and constriction not reversible with antituber-culosis therapy
Although constrictive pericarditis is rare in children itshould be considered in the differential diagnosis of rightheart failure It is possible that this low incidence in childrenis due in part to subdiagnosis and also to the insidiouscharacter of this disease and its complications [5]
A high index of suspicion is necessary to establish thediagnosis of constrictive pericarditis [5] It is necessaryto integrate clinical evaluation with data from the severalavailable methods and to have a critical approach positionwhen eventual discrepancy arises
Transthoracic echocardiography is usually the first diag-nostic investigation performed for suspected constrictivepericarditis and can be very useful in the presence of thetypical findings septal bounce dynamic respiratory variationin flow (transtricuspid transmitral and hepatic vein) andenhanced ventricular interaction [3] In this way echocar-diography has an important role in the differential diagnosisof constrictive pericarditis with other causes of heart failurenamely restrictive cardiomyopathy the most challengingentity to differentiate from constrictive pericarditis [1 6]However echocardiography might not be confirmatory in allcases since some of these typical findings may not be present[5]
Cardiac magnetic resonance despite being the imagingmethod of choice to evaluate the pericardium was notuseful and potentially confounding in this patient Contrastenhanced CT angiography being also a noninvasive investi-gation is more tolerable and easier to perform in childrenthan cardiacmagnetic resonance and could have been a better
Case Reports in Cardiology 3
RA
(a)
RAIVC
SHV
(b)
+
25 cms50 cmslowast
(c)
14 cms
(d)
Figure 3 (a) Apical 4-chamber view with dilated right atria (RA) left deviated atrial septum (b) subcostal view of dilated inferior vena cava(IVC) and suprahepatic veins (SHV) (c) significant (50) transmitral flow variation with breathing increasing during expiration (lowast) anddecreasing during inspiration (+) (d) high protodiastolic mitral annulus velocity (septal 14 cms higher than lateral)
InspirationExpiration
114mm2107mm2
473mm2572mm2
Figure 4 Elevated and equalized telediastolic pressure in ventricles(20mmHg arrow head) systolic area index calculated as theratio between right ventricleleft ventricle systolic area in inspi-ration and right ventricleleft ventricle systolic area in expiration(114473)(107572) = 129
option for this patient It is useful to identify pericardial thick-ness and effusion to detect enlargement of the mediastinallymph nodes and to evaluate lung parenchyma which maybe important in patients suspected to have tuberculosis [3]
Cardiovascular catheterization although an invasivemethod and not always necessary is the gold standard forthe diagnosis of constriction and was crucial to confirmthe diagnosis A recent described criteria is the systolic area
Figure 5 Thickened and adherent pericardium during and imme-diately after pericardiectomy
index ratio of right ventricle to left ventricle systolic areaduring inspiration and expiration that predicts ventricularinterdependence with 97 sensitivity and 100 positivepredictive power when higher than 11 [7]
The case highlights the need to integrate all informationincluding clinical data electrocardiography chest radiogra-phy cardiac imaging data and even invasive hemodynamic
4 Case Reports in Cardiology
evaluation Cardiac catheterization is usually reserved forpatients in whom there is significant diagnostic doubt afternoninvasive evaluation since the confirmation of the diagno-sis is decisive for the therapeutic approach in order to ensurethat the expected benefit outweighs the potential risk
A correct and early diagnosis of constrictive pericarditisis extremely important since successful pericardiectomy canbe curative [3] In advanced disease surgery results are sub-optimal and mortality is higher which is also related to poorpreoperative general condition and advanced preoperativeNYHA class [3]
Ethical Approval
The identity of the patient was absolutely preserved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] L Marta M Alves M Peres et al ldquoEffusive-constrictivepericarditis as the manifestation of an unexpected diagnosisrdquoRevista Portuguesa de Cardiologia vol 34 no 1 pp 69e1ndash69e62015
[2] SM A G Ferreira A G Ferreira Jr A doNascimentoMoraisW S Paz and FAA Silveira ldquoConstrictive chronic pericarditisin childrenrdquo Cardiology in the Young vol 11 no 2 pp 210ndash2132001
[3] S Talwar V V Nair S K Choudhary et al ldquoPericardiectomy inchildren lt15 years of agerdquo Cardiology in the Young vol 24 no4 pp 616ndash622 2014
[4] P P Sengupta M F Eleid and B K Khandheria ldquoConstrictivepericarditisrdquo Circulation Journal vol 72 no 10 pp 1555ndash15622008
[5] J Guitti ldquoConstrictive pericarditis in a 19-month-old childrdquoArquivos Brasileiros de Cardiologia vol 74 no 1 pp 47ndash542000
[6] D Silva L Sargento M Gato Varela M Lopes D Brito and HMadeira ldquoPericardite constritivamdashconstrictive pericarditismdashnew methods in the diagnosis of an old disease a case reportrdquoRevista Portuguesa de Cardiologia vol 31 pp 677ndash682 2012
[7] D R Talreja R A Nishimura J K Oh and D R HolmesldquoConstrictive pericarditis in the modern era Novel criteria fordiagnosis in the cardiac catheterization laboratoryrdquo Journal ofthe American College of Cardiology vol 51 no 3 pp 315ndash3192008
Case Reports in Cardiology 3
RA
(a)
RAIVC
SHV
(b)
+
25 cms50 cmslowast
(c)
14 cms
(d)
Figure 3 (a) Apical 4-chamber view with dilated right atria (RA) left deviated atrial septum (b) subcostal view of dilated inferior vena cava(IVC) and suprahepatic veins (SHV) (c) significant (50) transmitral flow variation with breathing increasing during expiration (lowast) anddecreasing during inspiration (+) (d) high protodiastolic mitral annulus velocity (septal 14 cms higher than lateral)
InspirationExpiration
114mm2107mm2
473mm2572mm2
Figure 4 Elevated and equalized telediastolic pressure in ventricles(20mmHg arrow head) systolic area index calculated as theratio between right ventricleleft ventricle systolic area in inspi-ration and right ventricleleft ventricle systolic area in expiration(114473)(107572) = 129
option for this patient It is useful to identify pericardial thick-ness and effusion to detect enlargement of the mediastinallymph nodes and to evaluate lung parenchyma which maybe important in patients suspected to have tuberculosis [3]
Cardiovascular catheterization although an invasivemethod and not always necessary is the gold standard forthe diagnosis of constriction and was crucial to confirmthe diagnosis A recent described criteria is the systolic area
Figure 5 Thickened and adherent pericardium during and imme-diately after pericardiectomy
index ratio of right ventricle to left ventricle systolic areaduring inspiration and expiration that predicts ventricularinterdependence with 97 sensitivity and 100 positivepredictive power when higher than 11 [7]
The case highlights the need to integrate all informationincluding clinical data electrocardiography chest radiogra-phy cardiac imaging data and even invasive hemodynamic
4 Case Reports in Cardiology
evaluation Cardiac catheterization is usually reserved forpatients in whom there is significant diagnostic doubt afternoninvasive evaluation since the confirmation of the diagno-sis is decisive for the therapeutic approach in order to ensurethat the expected benefit outweighs the potential risk
A correct and early diagnosis of constrictive pericarditisis extremely important since successful pericardiectomy canbe curative [3] In advanced disease surgery results are sub-optimal and mortality is higher which is also related to poorpreoperative general condition and advanced preoperativeNYHA class [3]
Ethical Approval
The identity of the patient was absolutely preserved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] L Marta M Alves M Peres et al ldquoEffusive-constrictivepericarditis as the manifestation of an unexpected diagnosisrdquoRevista Portuguesa de Cardiologia vol 34 no 1 pp 69e1ndash69e62015
[2] SM A G Ferreira A G Ferreira Jr A doNascimentoMoraisW S Paz and FAA Silveira ldquoConstrictive chronic pericarditisin childrenrdquo Cardiology in the Young vol 11 no 2 pp 210ndash2132001
[3] S Talwar V V Nair S K Choudhary et al ldquoPericardiectomy inchildren lt15 years of agerdquo Cardiology in the Young vol 24 no4 pp 616ndash622 2014
[4] P P Sengupta M F Eleid and B K Khandheria ldquoConstrictivepericarditisrdquo Circulation Journal vol 72 no 10 pp 1555ndash15622008
[5] J Guitti ldquoConstrictive pericarditis in a 19-month-old childrdquoArquivos Brasileiros de Cardiologia vol 74 no 1 pp 47ndash542000
[6] D Silva L Sargento M Gato Varela M Lopes D Brito and HMadeira ldquoPericardite constritivamdashconstrictive pericarditismdashnew methods in the diagnosis of an old disease a case reportrdquoRevista Portuguesa de Cardiologia vol 31 pp 677ndash682 2012
[7] D R Talreja R A Nishimura J K Oh and D R HolmesldquoConstrictive pericarditis in the modern era Novel criteria fordiagnosis in the cardiac catheterization laboratoryrdquo Journal ofthe American College of Cardiology vol 51 no 3 pp 315ndash3192008
4 Case Reports in Cardiology
evaluation Cardiac catheterization is usually reserved forpatients in whom there is significant diagnostic doubt afternoninvasive evaluation since the confirmation of the diagno-sis is decisive for the therapeutic approach in order to ensurethat the expected benefit outweighs the potential risk
A correct and early diagnosis of constrictive pericarditisis extremely important since successful pericardiectomy canbe curative [3] In advanced disease surgery results are sub-optimal and mortality is higher which is also related to poorpreoperative general condition and advanced preoperativeNYHA class [3]
Ethical Approval
The identity of the patient was absolutely preserved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] L Marta M Alves M Peres et al ldquoEffusive-constrictivepericarditis as the manifestation of an unexpected diagnosisrdquoRevista Portuguesa de Cardiologia vol 34 no 1 pp 69e1ndash69e62015
[2] SM A G Ferreira A G Ferreira Jr A doNascimentoMoraisW S Paz and FAA Silveira ldquoConstrictive chronic pericarditisin childrenrdquo Cardiology in the Young vol 11 no 2 pp 210ndash2132001
[3] S Talwar V V Nair S K Choudhary et al ldquoPericardiectomy inchildren lt15 years of agerdquo Cardiology in the Young vol 24 no4 pp 616ndash622 2014
[4] P P Sengupta M F Eleid and B K Khandheria ldquoConstrictivepericarditisrdquo Circulation Journal vol 72 no 10 pp 1555ndash15622008
[5] J Guitti ldquoConstrictive pericarditis in a 19-month-old childrdquoArquivos Brasileiros de Cardiologia vol 74 no 1 pp 47ndash542000
[6] D Silva L Sargento M Gato Varela M Lopes D Brito and HMadeira ldquoPericardite constritivamdashconstrictive pericarditismdashnew methods in the diagnosis of an old disease a case reportrdquoRevista Portuguesa de Cardiologia vol 31 pp 677ndash682 2012
[7] D R Talreja R A Nishimura J K Oh and D R HolmesldquoConstrictive pericarditis in the modern era Novel criteria fordiagnosis in the cardiac catheterization laboratoryrdquo Journal ofthe American College of Cardiology vol 51 no 3 pp 315ndash3192008