For further details on “Acute Pericarditis”, please see our separate article on that subject.
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Pericarditis calcarea x-ray

Image: “X-ray of Pericarditis calcarea” by Hellerhoff. License: CC BY-SA 3.0

Definition of Constrictive Pericarditis


Image: “Figure A: the location of the heart and pericardium. The inset image is an enlarged cross-section of the pericardium with its two layers of tissue and fluid. Figure B: heart with pericarditis. The inset image is an enlarged cross-section that shows the inflamed and thickened layers of the pericardium.” by National Heart Lung and Blood Institute (NIH). License: Public Domain

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:

  • Dyspnea
  • 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.

MR appearences of constrictive pericarditis

Image: “MR findings of constrictive pericarditis. A: Right ventricular vertical long-axis image showing circumferential pericardial thickening, enlarged inferior vena cava; B: short-axis image showing circumferential pericardial thickening, encysted pericardial effusion. C: four-chamber image showing focal pericardial thickening in front of the right ventricle lateral wall, encysted pericardial effusion, enlarged right atrium; D: short-axis image showing focal pericardial thickening in front of the left ventricular inferior and lateral wall. E: short-axis tagging image showing focal pericardial thickening and adherence in front of the left ventricular lateral wall. F: four-chamber late gadolinium enhancement image showing enhancing pericardium.” by openi. License: Public Domain CC BY 2.0

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

Note: It is difficult to distinguish constrictive pericarditis and 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.

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