CONSTRICTIVE PERICARDITIS – Dr. Akif Baig

Description

Constrictive Pericarditis

Constrictive pericarditis (CP) is a chronic condition characterized by the thickening, scarring, and sometimes calcification of the pericardium, leading to impaired diastolic filling of the heart. It results from the loss of pericardial elasticity, causing a reduction in the heart’s ability to expand during diastole, which can lead to symptoms of heart failure despite relatively preserved systolic function.

Pathophysiology

• The pericardium becomes fibrotic and, in some cases, calcified.
• The loss of elasticity in the pericardium impedes normal diastolic filling.
• As the ventricles attempt to fill, the inelastic pericardium limits expansion, causing an abrupt halt in filling.
• This results in equalization of pressures in all four chambers of the heart during diastole.
• Eventually, this leads to elevated systemic and pulmonary venous pressures, causing congestion.

Etiology

Constrictive pericarditis can develop following any cause of pericarditis or pericardial injury. Common causes include:

1. Idiopathic (most common): Often presumed to be viral.
2. Infectious:
   • Tuberculosis (common in developing countries).
   • Bacterial (e.g., purulent pericarditis).
3. Post-cardiac surgery: Following pericardiotomy.
4. Radiation therapy: For malignancies such as breast cancer, lymphoma.
5. Connective tissue disorders: Rheumatoid arthritis, systemic lupus erythematosus.
6. Neoplastic disease: Secondary involvement of the pericardium.
7. Uremic pericarditis: Associated with chronic renal failure.

Clinical Presentation

• Symptoms:
  • Fatigue and exercise intolerance due to reduced cardiac output.
  • Dyspnea on exertion.
  • Ascites and edema due to right-sided heart failure.
  • Elevated jugular venous pressure (JVP).
  • Hepatomegaly and splenomegaly.
  • Pulsus paradoxus (less common in constrictive pericarditis compared to tamponade).
  • Pericardial knock: An early diastolic sound heard due to sudden cessation of ventricular filling.
• Physical Examination:
  • Kussmaul’s sign: A paradoxical rise in JVP on inspiration.
  • Pericardial knock: An early diastolic sound heard due to the sudden cessation of ventricular filling.

Diagnosis

The diagnosis of constrictive pericarditis involves a combination of clinical, imaging, and hemodynamic assessments:

1. Chest X-ray: May show pericardial calcifications in chronic cases.
2. ECG: Nonspecific, may show low voltage or nonspecific ST-T wave changes.
3. Echocardiogram:
   • Thickened pericardium.
   • Septal “bounce” indicating interventricular dependence.
   • Dilated inferior vena cava with limited respiratory variation.
4. Cardiac MRI or CT:
   • Demonstrates pericardial thickening and calcification.
   • Useful for differentiating constrictive pericarditis from restrictive cardiomyopathy.
5. Cardiac catheterization:
   • Demonstrates equalization of diastolic pressures in all cardiac chambers.
   • Square root sign in ventricular pressure tracings (dip-and-plateau pattern).

Differential Diagnosis

• Restrictive Cardiomyopathy: Similar symptoms, but the primary pathology lies within the myocardium rather than the pericardium.
• Pericardial Tamponade: Both conditions can present with elevated JVP and hypotension, but tamponade has more dramatic pulsus paradoxus and muffled heart sounds.

Feature	Constrictive Pericarditis	Restrictive Cardiomyopathy
Pericardial thickening	Present	Absent
Septal bounce (Echocardiography)	Present	Absent
BNP (Brain Natriuretic Peptide)	Normal or mildly elevated	Markedly elevated
Kussmaul’s sign	Present	Absent
Pulsus paradoxus	Less common	Absent

Treatment

1. Medical Management:
   • Diuretics: To manage fluid overload (e.g., furosemide).
   • Anti-inflammatory agents: Occasionally used in early cases with active inflammation.
2. Definitive Treatment – Pericardiectomy:
   • Surgical removal of the thickened and constricting pericardium.
   • Indicated in symptomatic patients with chronic constrictive pericarditis.
   • High-risk surgery but can significantly improve symptoms and survival in carefully selected patients.

Prognosis

• Without treatment, constrictive pericarditis can be debilitating and progressive, leading to severe heart failure.
• Surgical pericardiectomy improves survival and symptoms in most patients, but outcomes depend on the underlying cause and the extent of the disease.