Constrictive Pericarditis

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Contents 1 Introduction 2 Etiology 3 Pathology 4 Clinical-manifestations 5 Laboratory 6 Radiology 7 Differential-diagnosis 8 Management 9 More General Terms 10 Additional Terms 11 References

Introduction

• Constrictive pericarditis may occur as a late complication of pericarditis.

Etiology

• most cases are idiopathic
• post pericardiotomy syndrome following:

• cardiac surgery
• mediastinal irradiation

• tuberculous pericarditis

Pathology

• non compliant pericardium
• impairment of ventricular filling
• elevation of central venous pressure

Clinical-manifestations

• insidious onset

• fatigue
• exercise intolerance
• venous congestion

• jugular venous distention ( JVD)

• prominent y descent
• prominent x descent generally absent
• inspiratory elevation in JVD ( Kussmaul's sign)

• peripheral edema
• ascites
• pericardial knock during diastole (S3)
• absence of pulmonary congestion [4]

Laboratory

• serum B-type natriuretic peptide ( serum BNP)

• mean value 130 pg/mL [4] (> 800 pg/mL for restrictive cardiomyopathy)
• sensitive, but not specific test for distinguishing constrictive pericarditis from restrictive cardiomyopathy

Radiology

• chest X-ray may show pericardial calcification
• echocardiography

• pericardial thickening
• reduced diastolic filling
• diagnosis from exaggerated respiratory variation in mitral & tricuspid flow velocities
• no pericardial effusion
• right ventricular size generally normal
• myocardial thickness generally normal
• no right atrial & right ventricular diastolic collapse
• early mitral flow velocity increased

• CT or MRI of thorax - may show pericardial thickening
• cardiac catheterization

• demonstration of elevated & equalized diastolic pressures in all 4 cardiac chambers

• radionuclide ventriculography

• more rapid early diastolic filling in patients with constrictive pericarditis relative to restrictive cardiomyopathy

Differential-diagnosis

• restrictive cardiomyopathy*

• distinction is critical since surgery is not indicated for restrictive cardiomyopathy

• pericardial tamponade
• right ventricular myocardial infarction
  

• * see features distinguishing constrictive pericarditis

Management

• definitive therapy requires complete pericardiectomy
• perioperative mortality 5-10%
• clinical improvement in 2-6 months (90%)
• minimally symptomatic patients

• sodium & fluid restriction
• diuretics
• closely monitor for hemodynamic deterioration

• patient education

• hemodynamic & symptomatic relief in 2-6 months (90%)

• follow-up: all patients to identify patients with extension to epicardium & myocardium

More General Terms

• pericarditis

Additional Terms

• features distinguishing constrictive pericarditis

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 135
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 268-70
3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 51-52
4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
5. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1097

constrictive pericarditis