• Images in cardiology

A 34 year old taxi driver was admitted to hospital after having been repeatedly stabbed in the chest with a screwdriver by a client. On arrival at the accident department he was in sinus rhythm, and his systolic blood pressure was 95 mm Hg. The stab wound to the anterior chest divided a costal cartilage. He was resuscitated with intravenous fluids, treated with antibiotics, analgesia, and tetanus toxoid injection. Chest radiography did not show cardiomegaly. Echocardiography was not performed. He was discharged home well after 12 days.

Sixteen years later he was readmitted having had numerous admissions with “heart failure” in the previous 10 years. He described a long history of leg swelling, decreased exercise tolerance, and orthopnoea. On examination he was in atrial fibrillation, with a heart rate of 90 beats/min; his venous pressure was elevated to 10 cm above the sternal angle and rose on inspiration. Auscultation of the precordium revealed a pericardial knock; blood pressure was 100/70 mm Hg with no paradox. Chest examination revealed signs of a right pleural effusion. There was pronounced peripheral, sacral, and scrotal oedema. A diagnosis of constrictive pericarditis was made on the clinical findings. Computed tomographic scanning showed dense pericardial calcification (below left) and haemodynamic data supported this diagnosis, demonstrating equivalence of left and right ventricular diastolic pressures (below right).

Pericardectomy was performed; at surgery the pericardium was found to be 1 cm thick and heavily calcified in places, forming a definite constriction over the right atrium and right ventricle. Two layers of calcium were found with a layer of altered blood in between suggesting the aetiology of the constriction to be haemopericardium. Haemopericardium is rare after stabbing, being reported as infrequently as 0.3% of cases in one series; constrictive pericarditis is a rare complication of haemopericardium.