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suggestive of pericardial constriction Thickened pericardium, however, is not essential for the diagnosis of constriction.61–63,65,113 The pericardium maybe normal in one-fifth of cases with proven pericardial constriction.113 Cine CT and MRI can also demonstrate septal bounce and ventricular interdependence.4,114 Differentiating From Restrictive Cardiomyopathy Restrictive cardiomyopathy is an important differential diagnosis in children with right heart failure Clinical presentation is similar to pericardial constriction despite fundamental differences in pathophysiology The restriction to ventricular filling is limited to late diastole due to diseased myocardium and manifests as dip and plateau or square root sign Unlike pericardial constriction, however, the early diastolic pressure is elevated and the pattern of ventricular filling is quite variable There is equalization of filling pressure in all cardiac chambers but with the left ventricular end diastolic pressure more (>5 mm Hg) than the right ventricular end diastolic pressure.102,103 Unlike pericardial constriction, there is no hindrance to the transmission of thoracic pressure As a result, there is no ventricular interdependence and discordance Echocardiography, cardiac catheterization, and MRI allow distinction in a majority of cases Nevertheless an accurate diagnosis remains elusive in some cases Elevated serum levels of NT pro-BNP makes the diagnosis of restrictive cardiomyopathy more likely.115 Table 57.2 summarizes differences in cardiac tamponade, pericardial constriction, and restrictive cardiomyopathy Table 57.2 Differences and Similarities in Cardiac Tamponade, Pericardial Constriction, and Restrictive Cardiomyopathy CLINICAL Pulsus paradoxus Jugular venous pulse Mean Waveforms Inspiratory fall in pressure Cardiac Tamponade Pericardial Constriction Restrictive Cardiomyopathy Present Present in one-third of cases Absent Elevated Blunted y descent Normal x descent Present Elevated Prominent y descent Normal x descent Elevated Variable y descent Normal x descent Absent (Kussmaul sign) Absent (Kussmaul sign) Pericardial knock ECHOCARDIOGRAPHY Atrial enlargement Abnormal myocardium Cardiac chamber collapse Septal bounce Mitral inflow respiratory variation >25% Hepatic vein flow reversal Mitral annular tissue velocity (E′) COMPUTED TOMOGRAPHY Thickened pericardium CARDIAC CATHETERIZATION Right atrial pressure Mean pressure Waveform Respiratory variation Right ventricle pressure Square root sign/dip and plateau Systolic pressure LVEDP-RVEDP RVEDP/RVSP Pulmonary capillary wedge pressure Left ventricle pressure Early diastolic pressure Rapid filling wave LVEDP-PCWP respiratory variation Simultaneous LV and RV pressure Change in systolic pressure Systolic area index Absent Present Absent Absent Absent Present Present Present + Rare Absent Present Present ++ Common Absent Absent Absent Expiratory Normal Expiratory Normal or increased Inspiratory Reduced Absent Common Absent Elevated Absent y descent Present Elevated “M” contour 3 mm Hg Absent 5 mm Hg 7 mm Hg >5 mm Hg Elevated ≤7 mm Hg 1.1 Discordant >1.1 Concordant
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