Lesson of the week: Restrictive-constrictive heart failure masquerading as liver disease

Restrictive cardiomyopathy or pericardial constriction should be considered as a cause of hepatomegaly before liver biopsy is undertaken The clinical features of restrictive or constrictive heart disease can be non-specific, 1 2 and this may delay diagnosis. We describe three patients with heart disease whose initial presentation led to a wrong diagnosis of primary hepatic disease. Potentially hazardous investigations, including liver biopsies, were performed or planned in each case. The true diagnosis was usually prompted by further clinical examination, and all three patients responded well to appropriate treatment. The importance of making the correct diagnosis is emphasised by the potential for surgical cure in these patients. ### Case 1 An 18year old man presented with a five month history of fatigue, anorexia, abdominal distension, and dyspnoea on exertion. Physical examination showed that he was icteric, with an enlarged liver and ascites. Findings at cardiovascular examination were reported as normal, although his jugular venous pressure was not seen. Liver ultrasound and computed tomography showed diffuse hepatic enlargement, and dilated venous sinuses and septal fibrosis were seen in a liver biopsy specimen. The diagnosis remained unclear, but a raised jugular venous pressure and gallop rhythm were detected at further clinical examination. An electrocardiogram showed widened QRS complexes (>140 msec) and diffuse, non-specific repolarisation changes, and chest radiography showed cardiomegaly and pulmonary oedema. There was no evidence of pericardial thickening in thoracic computed tomograms, and at cardiac catheterisation the haemodynamic profile of a restrictive cardiomyopathy was found. The patient was treated with diuretic drugs and subsequent cardiac transplantation was successful. ### Case 2 A 49year old man had an …