Constrictive Pericarditis

Just a bit more pericarditis…


Constrictive Pericarditis

Definition: the heart is encased in a rigid pericardium due to chronic inflammation, preventing adequate diastolic filling of the ventricles

Aetiology/ risk factors:

-often unknown (UK)

-TB is the main cause in developing countries

-after any pericarditis

-intrapericardial haemorrhage during heart surgery

Epidemiology: rare

relatively rare complication of pericardial insult

Symptoms:

-features of right heart failure: leg swelling, abdominal swelling, fatigue

-breathlessness

Signs:

-features of right heart failure:

 -raised JVP (with prominent x and y descents)

-Kussmaul’s sign (JVP rises with inspiration)

-pulsus paradoxus (reduced systolic BP by > 10 mmHg on inspiration)

-soft, diffuse apex beat

-quiet heart sounds

-S3 heart sound

-diastolic pericardial knock (due to rapid ventricular filling)

-atrial fibrillation

-hepatosplenomegaly

-ascites

-oedema

-decreased pulse pressure

-sinus tachycardia

Clinically, constrictive pericarditis cannot be distinguished from restrictive cardiomyopathy.

Investigations:

CXR- small heart +/- pericardial calcification (calcification best seen on lateral CXR or CT)

Image result for constrictive pericarditis

-CXR may show a pleural effusion

CT/MRI- pericardial thickening and calcification

Echo- changes in cardiac chamber volume

Cardiac catheterisation-changes in ventricular pressures, pattern useful in differentiating from restrictive cardiomyopathy

Management:

Surgical excision of the pericardium = pericardiectomy

Complications:

-portal hypertension, ascites

-heart failure

-shock (restricted cardiac filling)

-pleural effusion (transudate)

Prognosis: potentially curable if diagnosed early, can be fatal if overlooked. 

Longterm prognosis with medical therapy alone is poor.

Long-term survival after pericardiectomy depends on the underlying cause. Idiopathic constrictive pericarditis has the best prognosis (88% survival at 7 years). The worst postpericardiectomy prognosis occurs in postradiation constrictive pericarditis (27% survival at 7 years), probably as a reflection of confounding comorbidities.

References: Rapid Medicine, Cheese & Onion, Medscape

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