Constrictive Pericarditis due to Asbestos Exposure: A Comprehensive Radiologic and Clinical Case Review

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 Constrictive Pericarditis due to Asbestos Exposure: A Comprehensive Radiologic and Clinical Case Review

석면 노출로 인한 수축성 심낭염: 포괄적인 방사선학적 및 임상적 증례 검토


Keywords: constrictive pericarditis, asbestos exposure, pericardial calcification, dip-and-plateau pattern, echocardiography, cardiac catheterization, pericardiectomy

Introduction

Constrictive pericarditis (CP) is a chronic inflammatory condition of the pericardium resulting in pericardial thickening, fibrosis, and calcification, leading to impaired diastolic filling of the heart. The etiologies of CP range from idiopathic to infectious and occupational exposures, with asbestos being a rare but well-documented cause.

This blog post presents a rare case of constrictive pericarditis in a 69-year-old woman with a significant history of asbestos exposure. The article explores the clinical presentation, multimodal imaging findings, hemodynamic patterns, and definitive management via pericardiectomy, supported by international literature.

Case Summary

A 69-year-old female patient presented to the emergency department with a 3-year history of exertional dyspnea. Her occupational history revealed long-term employment in an insulation manufacturing facility with confirmed exposure to asbestos. She had previously been diagnosed with localized pleural plaques.

Clinical Findings

On physical examination, prominent signs of volume overload were noted, including elevated jugular venous pressure, peripheral edema, and hepatomegaly. These findings raised clinical suspicion for constrictive physiology.

Radiologic Evaluation

Figure A. Chest Radiography – Lateral View


Chest radiograph (lateral view) showing pericardial calcification, bilateral pleural effusion, and interstitial pulmonary edema.

The chest X-ray revealed extensive pericardial calcification, bilateral pleural effusion, and signs of pulmonary interstitial edema, suggestive of chronic cardiac compromise due to restrictive filling dynamics.

Figure B. Computed Tomography

Non-contrast chest CT showing dense, circumferential pericardial calcification.

CT imaging confirmed extensive circumferential pericardial calcification, a hallmark feature of chronic constrictive pericarditis. The image highlights the importance of cross-sectional imaging in delineating the extent and distribution of calcification.

Cardiac Hemodynamic Evaluation

Echocardiography Findings

Transthoracic echocardiography (TTE) revealed preserved left ventricular ejection fraction with abnormal septal motion. A distinct interventricular septal “bounce” during early diastole was observed, reflecting ventricular interdependence. Notably, expiratory hepatic vein diastolic flow reversal was recorded, a strong indicator of constrictive physiology.

Simultaneous Left and Right Heart Catheterization

Figure C. Hemodynamic Tracings

Simultaneous pressure tracings of RV and LV during inspiration and expiration, showing discordance and the classic dip-and-plateau (“square root”) sign.

During invasive hemodynamic testing, simultaneous right and left ventricular pressure tracings showed marked ventricular interdependence: during inspiration, RV pressure peaked while LV pressure dropped, and vice versa during expiration. A classic "dip-and-plateau" pattern was noted in diastole, a hallmark of constrictive pericarditis.

Diagnosis

A definitive diagnosis of constrictive pericarditis secondary to asbestos-induced pleural disease was made. Differential diagnoses, including restrictive cardiomyopathy and tuberculous pericarditis, were considered but excluded based on tissue histology and negative acid-fast bacilli staining.

Treatment and Outcome

The patient underwent successful pericardiectomy. Histologic analysis of the excised pericardium showed dense fibrosis and calcification without evidence of granulomas or mycobacterial infection. Postoperatively, the patient showed significant clinical improvement. At a 2-year follow-up, she remained symptom-free with restored functional capacity.

Discussion

Constrictive pericarditis is often underdiagnosed, especially when the etiology is atypical, such as asbestos exposure. Asbestos-related CP likely results from chronic pleural inflammation extending into the pericardium, culminating in fibrosis and calcification.

Key diagnostic imaging includes:

  • Chest X-ray: Detects pericardial calcification, though non-specific.

  • CT/MRI: Superior in assessing pericardial thickness (>4 mm is suggestive).

  • Echocardiography: Septal bounce, annulus reversus, and hepatic vein flow reversal.

  • Cardiac catheterization: Pathognomonic findings include ventricular discordance and the dip-and-plateau sign.

Early recognition and surgical intervention are vital to restoring hemodynamics and preventing irreversible myocardial atrophy or progression to heart failure.

Quiz

1. What is the hallmark hemodynamic pattern observed in constrictive pericarditis during cardiac catheterization?

A. Pulsus paradoxus
B. Electrical alternans
C. Dip-and-plateau (square root) sign
D. Kussmaul sign

2. Which echocardiographic feature is most characteristic of ventricular interdependence in constrictive pericarditis?

A. Septal flattening in systole
B. Septal bounce in early diastole
C. Pericardial effusion
D. Mitral valve prolapse

Answer & Explanation

1. Correct Answer: C. Explanation: The dip-and-plateau or square root sign is observed during diastole in CP due to rapid early diastolic filling followed by abrupt cessation, reflecting a non-compliant pericardium.

2. Correct Answer: B. Explanation: The interventricular septal “bounce” is a key finding in CP, caused by the abrupt shifting of the septum in response to respiratory cycle-induced pressure changes, reflecting ventricular interdependence.

Conclusion

This case underscores the critical role of multimodal imaging and hemodynamic studies in diagnosing constrictive pericarditis, particularly when caused by rare etiologies like asbestos exposure. Timely pericardiectomy can lead to significant symptomatic and functional improvement. Awareness of occupational hazards and their delayed cardiovascular effects remains crucial for both diagnosis and prevention.

References

  1. Ling, L. H., et al. "Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy." Circulation, vol. 100, no. 13, 1999, pp. 1380–1386.

  2. Welch, T. D. "Constrictive pericarditis: diagnosis, management and clinical outcomes." Heart, vol. 104, no. 9, 2018, pp. 725–731.

  3. Syed, F. F., and Schaff, H. V. "Constrictive pericarditis—a curable diastolic heart failure." Nature Reviews Cardiology, vol. 10, 2013, pp. 530–544.

  4. Talreja, D. R., et al. "Constrictive pericarditis versus restrictive cardiomyopathy: a reappraisal of pathophysiologic differences." JACC: Cardiovascular Imaging, vol. 1, no. 1, 2008, pp. 15–24.

  5. Nishimura, R. A., et al. "Hemodynamics in constrictive pericarditis and restrictive cardiomyopathy: a review." Heart Failure Clinics, vol. 5, no. 2, 2009, pp. 219–229.

  6. Bogaert, J., and Francone, M. "Pericardial disease: value of CT and MR imaging." Radiology, vol. 253, no. 3, 2009, pp. 707–725.

  7. Maisch, B., et al. "Guidelines on the diagnosis and management of pericardial diseases." European Heart Journal, vol. 25, no. 7, 2004, pp. 587–610.

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