394 Brief Communications February, ,984

American Heart Journal

Constrictive pericarditis associated with sarcoidosis

John Garrett, M.B., Hilary O’Neill, M.B., and Sean Blake, M.D. Dublin, iretand

Sarcoidosis may involve virtually every organ of the body. Clinical recognition of pericarditis is uncommon; sarcoid- osis in constrictive pericarditis has not been reported. We describe one such case. In 1973 a 25-year-old man with a 3-month history of malaise was referred for examination. He had enlargement of the liver and spleen. A chest x-ray film showed marked bilateral hilar adenopathy. The Man- toux test was negative. Direct examination and culture of sputum and gastric washings showed no evidence of tuberculosis. The latex fixation test for rheumatoid dis- ease was negative. Mediastinoscopy disclosed enlarged paratracheal glands, which on biopsy showed numerous, noncoalescing, noncaseating granulomas typical of sar- coidosis. No special therapy was instituted.

In 1979 he was readmitted to the hospital with symp- toms of pericardial constriction. He had experienced progressive dyspnea on exertion over the previous 6 months but no orthopnea or paroxysmal nocturnal dysp- nea. He had edema of the legs and an enlarged, tender liver. His jugular venous pressure was markedly elevated and was increased by inspiration. Cardiac impulses were impalpable and there was a loud third sound. He had atria1 fibrillation, and the ECG showed generalized non- specific T wave changes. A diagnosis of severe constrictive pericarditis was made and was supported by the findings on cardiac catheterization. The right atrial pressure trac- ing showed a V wave of 27 mm Hg with a sharp Y descent and a plateau typical of constriction. The mean pulmo- nary wedge pressure was 23 mm Hg. Angiography showed a thickened right atria1 wall. At pericardiectomy the heart was encased in a thick calcified pericardium with obliter- ation of the pericardial space. Following pericardiectomy there was an immediate increase in the amplitude of myocardial contraction. The excised pericardium showed a dense, acellular, collagenous tissue with extensive calci- fication. There were no features to indicate the original nature of the inflammatory process. Three years after the operation the patient remains asymptomatic and there are no cardiovascular abnormalities.

In sarcoidosis, involvement of the myocardium is increasingly recognized on postmortem examination and may have a prevalence as high as 25% .I Involvement of the pericardium is regarded as a rare postmortem finding but may be more common than is generally thought.2 The recognition of pericarditis clinically is certainly uncom-

From the Department of Cardiology, Mater Misericordiae Hospital.

Reprint requests: Dr. John Garrett, Department of Cardiology, Mater Misericordiae Hospital, Dublin 7, Ireland.

mon. A few cases of pericardial effusion have been re- ported,3 but there has been no report of constrictive pericarditis. The relative infrequency of sarcoidosis and constrictive pericarditis argues for a causative relationship in this case. Furthermore recognized causes of pericardial constriction such as tuberculosis, rheumatoid disease, postpericardiotomy syndrome, Dressler’s syndrome, peri- cardial trauma, and pericardial neoplasm can be confi- dently excluded in this instance. That the histology of the excised pericardium disclosed no specific changes of sar- coidosis does not affect the issue. In 80% of cases of constrictive pericarditis the histologic findings are non- specific: showing only dense connective tissue with sparse inflammatory cells. In rheumatoid cases, for instance, specific histologic findings are exceptional.5 It seems likely that damage to the pericardium whether traumatic or inflammatory may, in a small number of susceptible individuals, lead eventually to pericardial fibrosis and constriction. We believe that the initiating factor in this case was sarcoidosis.

REFERENCES

1. Silverman KJ, Hutchins GM, Bulkley BH: Cardiac sarcoid: A clinicopathologic study of 84 unselected patients with sys- temic sarcoidosis, Circulation 58:1204, 1978.

2. Fleming HA: Sarcoid heart disease, Br Heart J 36:54, 1974. 3. Roberts WC, MC Allister HA, Ferrans VJ: A clinicopatholog-

ical study of 35 necropsy patients (Group 1) and review of 78 previously described necropsy patients (Group 2), Am J Med 63:86, 1977.

4. Vignola P, Johnson RA, Scannell JG: Pericardial diseases. In Johnson RA, Haber E, Austen WG, editors: The practice of cardiology. Boston, 1980, Little, Brown & Co, p 664.

5. Cooper DK, Cleland WP, Bentall HH: Collagen diseases as a cause of constrictive pericarditis, Thorax 33:368, 1978.

Effects of laser irradiation on cardiac valves: Transcatheter in vivo vaporization of aortic valve

Garrett Lee, M.D., Abraham Embi, B.S., Daniel Stobbe, Ming C. Chan, M.D., William Bommer, M.D., Thomas A. Riemenschneider, M.D., Roland0 Mendizabal, M.D., Daniel L. Seckinger, M.D., Richard M. Ikeda, M.D., Anthony Vazquez, Robert L. Reis, M.D., and Dean T. Mason, M.D., Miami, Fla. and San Francisco, Calif.

The potential uses of lasers in the treatment of cardiovas- cular disease are expanding. Relief of arterial atheroscle-

From the Cardiovascular Laser Research Laboratory Cedars Medical Center; and Western Heart Institute, St. Mary’s Hospital & Medical Center.

Reprint requests: Garrett Lee, M.D., Cedars Medical Center, 1295 N.W. 14th Street, Suite K, Miami, FL 33125.