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The Abdominal Aorta and ConstrictivePericarditis: Abdominal Aortic Respiratory

Variation as an Echocardiographic Finding in

Constrictive PericarditisCindy W. Tom, MD, Jae K. Oh, MD, and Peter C. Spittell, MD, Rochester, Minnesota

Constrictive pericarditis has characteristic respira-tory variation in ventricular filling readily recognizedby echocardiography. These two cases describe anovel finding of respiratory variation in the pulsedDoppler investigation of the abdominal aorta duringechocardiographic evaluation that has not been

previously described.

CASE REPORTS

Case 1

A 68-year-old man with a history of pericarditis was

referred for evaluation of dyspnea and 6 months of

recurrent paroxysmal atrial fibrillation. He initially pre-

sented with sweating, fatigue, chest tightness, and abdom-

inal bloating. At the time, an electrocardiogram revealed

atrial fibrillation with rapid ventricular response (190/

min). He was rate controlled and then underwent success-ful electrical cardioversion to sinus rhythm. An echocar-

diogram demonstrated a moderate pericardial effusion.

Two months later, with recurrent similar symptoms, an

electrocardiogram demonstrated atrial flutter. A trans-

esophageal echocardiogram was performed to rule out

atrial thrombi. It demonstrated a thickened pericardium, a

tiny pericardial effusion, and no thrombus. He again

underwent successful electrical cardioversion to sinus

rhythm.

His medical history was significant for a cerebrovascu-

lar accident 3 years prior with residual left-sided paresthe-

sias. His medications included furosemide, metoprolol,

diltiazem, propafenone, spironolactone, atorvastatin, rofe-

coxib, aspirin, and clonazepam.

Physical examination was notable for a blood pressure

of 110/80 mm Hg without pulsus paradoxus; pulse was

92/min and regular. The first and second heart sounds

were normal. A positive Kussmaul sign and hepatojugular

reflux were present. There were dry rales at both lung

bases and bilateral lower extremity edema.

A transthoracic echocardiogram demonstrated charac-teristic respiratory changes in the mitral inflow, left ven-

tricular outflow tract, and hepatic vein inflow ( Figure 1,

A ). Doppler tissue interrogation revealed an elevated

mitral annular velocity of 0.15 m/s ( Figure 1, B ). A septal

shudder was present and the inferior vena cava was

dilated without significant respiratory variation. Pericar-

dial thickness was 1.0 cm. Pulsed wave Doppler interro-

gation of the abdominal aorta ( Figure 1, C ) was remarkable

for phasic respiratory changes.

Cardiac catheterization showed moderately elevated

mean right atrial pressures with prominent “x” and “y”

descents and end-diastolic equalization of intracardiac

pressures, consistent with constrictive pericarditis. Thepatient subsequently underwent radical pericardiectomy.

Intraoperatively, the pericardium was particularly thick

over the right ventricle and his hemodynamics improved

after removal of the pericardium. He did well in the

postoperative period and his symptoms resolved.

Case 2

A 42-year-old man presented with a 2-week history of

dyspnea, chest pressure, and lower extremity edema. He

reported initial flu-like symptoms with fever and head

congestion that resolved after several days. Furosemide,

lisinopril, and naproxen were started without significant

improvement of symptoms. He was referred for further evaluation.

Physical examination was remarkable for a blood pres-

sure of 130/100 mm Hg without pulsus paradoxus and a

pulse of 92/min. Jugular venous pressure was 6 cm of

water. The first and second heart sounds were normal and

there were no extra sounds. There were decreased breath

sounds in both lung bases. His abdomen was soft and

nontender without hepatomegaly or ascites and he had

bilateral lower extremity edema. His chest radiograph

showed bilateral pleural effusions. Computed tomography

demonstrated a thickened pericardium.

Transthoracic echocardiography revealed a diffusely

thickened pericardium measuring 5- to 6-mm thick with a

From the Mayo Graduate School of Medicine (C.W.T.) and Divi-sion of Cardiovascular Diseases and Internal Medicine, MayoClinic.

Reprint requests: Peter C. Spittell, MD, Mayo Clinic Division of Cardiovascular Diseases, 200 First St SW, Rochester, MN 55905(E-mail: [email protected] ).

J Am Soc Echocardiogr 2005;18:282-4.

0894-7317/$30.00

Copyright 2005 by the American Society of Echocardiography.

doi:10.1016/j.echo.2004.10.021

282

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moderate pericardial effusion and Doppler findings con-

sistent with an effusive-constrictive pericarditis with char-

acteristic respiratory changes on Doppler interrogation of

the transmitral, left ventricular outflow tract, hepatic

venous, and superior vena cava flow patterns. Doppler

tissue interrogation of the mitral annulus revealed elevated

annular velocities that varied with respiration ( Figure 2,

A ). He also had phasic respiratory changes in the abdom-

inal aortic flow patterns ( Figure 2, B

).

He underwent radical pericardiectomy with complete

resolution of his symptoms. Postoperative echocardio-

gram showed no Doppler evidence of constrictive physi-

ology and resolution of the phasic respiratory changes in

the abdominal aortic flow pattern.

DISCUSSION

Echocardiography was first used to diagnose con-strictive pericarditis in the 1970s with evaluation of abnormalities in inter ventricular septal motion andpericardial thickness.1,2 Subsequently, Doppler ul-trasound has been used to characterize variation of mitral and tricuspid flow velocities in constrictivepericarditis.3,4 The diagnostic value of a septalbounce, vena cava plethora, and pericardial adhe-sion on 2-dimensional echocardiography h a ve alsobeen reported in constrictive pericarditis.5 Pulsed

wave Doppler echocardiography of hepatic vein

inflow and expiratory reversal of flow in late systole

Figure 1 A , Pulsed wave Doppler of hepatic vein inflow shows phasic changes in waveform with expiration. B,

Doppler tissue of mitral annulus reveals elevated annular velocity of 0.15 m/s. C, Pulsed wave Doppler with sample volume in abdominal aorta reveals respiratory variation inabdominal waveform.

Figure 2 A , Doppler tissue interrogation of mitral annulus

revealed elevated annular velocities varying from 0.13 m/s with inspiration to 0.18 m/s with expiration. B, Pulsed wave Doppler of abdominal aorta shows phasic respiratory changes in abdominal aortic flow patterns.

Journal of the American Society of Echocardiography Volume 18 Number 3 Tom, Oh, Spittell 283

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and diastole has also been associated with constric-tive pericarditis.4,6

This article describes the first reports of Doppler recording of phasic respiratory changes in the ab-dominal aortic waveforms in association with con-

strictive pericarditis. The respiratory changes in theproximal abdominal aortic waveform were similar tothose reported in the left ventricular outflow tractand transmitral flow patterns in constrictive pericar-ditis with an inspiratory decrease and an expiratory increase in forward systolic flow. Detection of thesechanges required use of a respirometer, mainte-nance of a very stable sample volume position, andoptimization of angle .

This report of respiratory variation in the proxi-mal abdominal aortic flow in constrictive pericardi-tis may have use in the overall echocardiographicassessment of pericardial constriction and in post-

operative surveillance. In addition, the finding of significant respiratory variation in the proximal ab-dominal aortic flow may help to identify patients

with constrictive pericarditis referred to abdominalultrasound for the evaluation of ascites, edema, or abnormal liver function tests (common abnormali-ties in patients with constrictive pericarditis). If thecharacteristic respiratory changes in flow described

herein are found on abdominal ultrasound evalua-tion, it may warrant referral for evaluation of possi-ble constrictive pericarditis with transthoracic echo-cardiography (comprehensive 2-dimensional andDoppler echocardiogram).

REFERENCES

1. Yoshikawa J, Owaki T, Kato H, Yanagihara K, Takagi Y. “Clin-ical significance of echocardiographic interventricular septalmotion. [in Japanese]” Kokyu To Junkan 1977;25:985-96.

2. Schnittger I, Bowden RE, Abrams J, Popp RL. Echocardiogra-phy: pericardial thickening and constrictive pericarditis. Am J

Cardiol 1978;42:388-95.3. Hatle LK, Appleton CP, Popp RL. Differentiation of constric-

tive pericarditis and restrictive cardiomyopathy by Dopplerechocardiography. Circulation 1989;79:357-70.

4. Oh JK, Hatle LV, Seward JB, Danielson GK, Schaff HV,Reeder GSDiagnostic role of Doppler echocardiography in

constrictive pericarditis. J Am Coll Cardiol 1994;23:154-62.5. Himelman RB, Lee E, Schiller NB. Septal bounce, vena cavaplethora, and pericardial adhesion: informative two-dimen-sional echocardiographic signs in the diagnosis of pericardialconstriction. J Am Soc Echocardiogr 1988;1:333-40.

6. von Bibra H, Schober K, Jenni R, Busch R, Sebening H,Blomer H. Diagnosis of constrictive pericarditis by pulsedDoppler echocardiography of the hepatic vein. Am J Cardiol1989;63:483-8.

Journal of the American Society of Echocardiography 284 Tom, Oh, Spittell March 2005

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