Table of Contents
- Definition of Constrictive Pericarditis
- Epidemiology of Constrictive Pericarditis
- Etiology of Constrictive Pericarditis
- Pathology and Pathophysiology of Constrictive Pericarditis
- Symptoms of Constrictive Pericarditis
- Diagnosis of Constrictive Pericarditis
- Differential Diagnoses of Constrictive Pericarditis
- Therapy of Constrictive Pericarditis
- Progression and Prognosis of Constrictive Pericarditis
Definition of Constrictive Pericarditis
Constrictive pericarditis is the limiting of the heart’s ability to function normally due to a thickening and scarring of the pericardial sac that surrounds the heart. This prevents proper diastolic filling.
Epidemiology of Constrictive Pericarditis
Constrictive pericarditis is much less common compared to acute pericarditis. Approximately only 10 % of acute pericarditis progress to chronic pericarditis. Amongst those with viral pericarditis, constrictive pericarditis has been reported in < 0.5% of cases. Middle-aged males are the most predominant group.
Etiology of Constrictive Pericarditis
In the past, constrictive pericarditis was associated with bacterial pericarditis and purulent pericarditis. In the developed world, this is a rare finding. Constrictive pericarditis is often iatrogenic following open-heart surgery or radiation therapy for the treatment of mastocarcinoma and other cancers. Radiation-induced constrictive pericarditis usually presents 10 years after therapy. Pericarditis can also develop post-myocardial infarction. In the developing world, tuberculosis is a common cause of constrictive pericarditis in endemic regions.
Pathology and Pathophysiology of Constrictive Pericarditis
Inflammation of the pericardial sac results in the release of fibrin and the production of effusion. If this prolongs, the parietal and visceral linings will become thickened and fuse. This sclerotic pericardium cannot expand and will prevent the heart from filling during diastole, resulting in right-sided heart failure.
Symptoms of Constrictive Pericarditis
Constrictive pericarditis results in right-sided heart failure. Symptoms include:
- Edema of the extremities
- Swollen abdomen: hepatomegaly, ascites
- Hepatic congestion: right upper quadrant pain of the abdomen
- Other symptoms include: fatigue, chest pain, palpitations
On physical exam, a pericardial knock may be heard at the left sternal border in early diastole. Kussmaul sign may be detected as well as symptoms of reduced cardiac output. Hepatomegaly and hepatic pulsations are also findings of constrictive pericarditis.
Diagnosis of Constrictive Pericarditis
ECG findings are usually nonspecific and include a low voltage QRS complex in all leads and T wave inversions. Kussmaul’s sign, a rise in jugular venous pressure with inspiration (normally it should drop with inspiration) is a nonspecific finding and is found in restrictive pericarditis, restrictive cardiomyopathy, and tricuspid stenosis.
Echocardiography is the preferred method to diagnose constrictive pericarditis. Abnormalities of chamber filling and pericardial distortions will be visible. Chest X-ray may show pericardial calcification or pleural effusions.
Cardiac catheterization can identify abnormal cardiac filling pressure, another sign of constrictive pericarditis. It is invasive and not a first-line diagnostic procedure. Classically the diastolic waveform has a shape of square root sign.
Differential Diagnoses of Constrictive Pericarditis
- Acute pericarditis
- Atrial myxoma
- Cardiac tamponade
- Cirrhosis of the liver
- Dilated cardiomyopathy
- Myocardial infarction
- Pericardial effusion
- Restrictive cardiomyopathy
Therapy of Constrictive Pericarditis
Medical management is usually ineffective. However, diuretics are helpful early in the disease. Definitive treatment is pericardiectomy or pericardial stripping. This procedure has a significant risk associated with it. In pericardiectomy, some or most of the pericardium is surgically removed.
Progression and Prognosis of Constrictive Pericarditis
The best strategy in treating constrictive pericarditis is to recognize it and start treatment as early as possible. Constrictive pericarditis responds poorly to medical intervention, while surgical treatment is definitive but risky. Long-term prognosis depends on etiology. Idiopathic constrictive pericarditis has the best prognosis, followed by post-surgery constriction. Post radiation constriction has the worst prognosis.