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September 3, 1997

Pericardial Disease-Reply

Author Affiliations

Stanford University Medical Center Stanford, Calif

JAMA. 1997;278(9):704. doi:10.1001/jama.1997.03550090028026

I appreciate Dr Spodick's interesting comments. The areas of disagreement may be rather small, especially regarding the issues of low voltage and myocardial ischemia. These mechanisms continue to be debated in the absence of methods for definitive proof.

I hold out on the issue of paradoxical pulse. By definition, pericardial effusion is present in effusive-constrictive pericarditis. However, there are patients with constrictive pericarditis, usually of subacute nature, with no pericardial effusion in whom paradoxical pulse is a prominent feature.1I have termed this the elastic form of pericardial constriction. Echocardiograms sometimes report effusion in such cases, whereas surgical exploration reveals none; the thickened edematous pericardium may represent organization of a previously existing effusion.

I also hold out a little on arrhythmias. Could the common arrhythmias after cardiac surgery result from pericarditis? Indeed, a sterile postoperative pericarditis is now used as an experimental model of atrial flutter.2

I am