Constrictive Pericarditis Treatment & Management

  • Author: Darren S Sidney, MD, MS; Chief Editor: Joseph L Fredi, MD   more...
 
Updated: Nov 21, 2011
 

Medical Care

  • Medical management is generally ineffective in the vast majority of cases unless a prominent inflammatory component is present.
  • This is in contrast with acute pericarditis (see Pericarditis, Acute), in which the use of nonsteroidal anti-inflammatory agents, cyclooxygenase-2 inhibitors, colchicine, corticosteroids, or a combination thereof may provide benefit.[25] However, even after optimal therapy of acute pericarditis, over time, the possibility of developing constriction exists. Other medical considerations are as follows:
    • Subacute constrictive pericarditis may respond to steroids if treated before pericardial fibrosis occurs.
    • Diuretics are commonly used to relieve congestion if ventricular filling pressures are clinically elevated. However, this may decrease cardiac output and requires careful monitoring.
    • Any therapy directed toward the causative disease is appropriate, such as antituberculosis medication.
    • Complications, such as atrial arrhythmias, require their own therapy as needed.
    • In general, beta-blockers and calcium channel blockers should be avoided because the sinus tachycardia that commonly occurs in constrictive pericarditis is compensatory in nature, maintaining cardiac output in a setting of fixed stroke volume (secondary to fixed diastolic filling).
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Surgical Care

  • Complete pericardectomy is the definitive therapy and is a potential cure.[26, 27, 28]
    • Results are generally better if the procedure is performed earlier in the course, when less calcification is present and when the chance of abnormal myocardium or advanced heart failure is reduced.
    • Some judgment is required because patients who are asymptomatic (NYHA class I) or who have early NYHA stage II symptoms may be clinically stable for years.
    • Pericardial decortication should be as extensive as possible, especially at the diaphragmatic-ventricular contact regions. The surgical procedure can be long and is often technically complex. Complications may include excessive bleeding, atrial and ventricular arrhythmias, and ventricular wall ruptures. The 2 standard approaches are the anterolateral thoracotomy and a median sternotomy. Additionally, an excimer laser can be used severe adhesions occur between the pericardium and epicardium.[28]
    • The published surgical mortality rates range from 5-15%. Most recently, the perioperative mortality rate (within 30 days) was found to be 6.1%. The causes of death include progressive heart failure, sepsis, renal failure, respiratory failure, and arrhythmia. Significantly, 80-90% of patients who undergo pericardectomy achieve NYHA class I or II postoperatively.
    • Even though the symptoms following a pericardiectomy are commonly improved, evidence of abnormal diastolic filling (which can be correlated with clinical status) often remains. Only 60% of patients have complete normalization of cardiac hemodynamics.[28] Although some improved with time, persistent diastolic filling abnormalities tended to occur in patients who had a longer history of preoperative symptoms, supporting the concept of early operation in patients who are symptomatic.
    • In 58 patients who underwent total pericardectomy for constriction, 30% still had some significant symptoms after 4 years. These patients were more likely to have a persistent restrictive or constrictive pattern to their transmitral and transtricuspid Doppler signals as determined by respiratory recording.
    • New experimental devices are being investigated to access the pericardial space, including use in patients without significant effusions. Hopefully, the development of such devices, such as video-assisted thorascopy, can improve diagnostic and therapeutic options in patients with pericardial disease.[29]
    • Cardiac mortality and morbidity seems to be related to presurgical myocardial atrophy or fibrosis, which can be detected using CT. Excluding these patients keeps the mortality rate at the lower end of the range (5%).[28]
    • Postoperative low cardiac output can be treated in the usual fashion, including vasoactive pressors and intra-aortic balloon pump (IABP), if necessary.
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Consultations

  • A cardiologist can assist with obtaining and interpreting echocardiographic imaging, hemodynamic measurements, and, if necessary, endocardial or pericardial biopsies.
  • Consultation with a cardiothoracic surgeon is appropriate when a pericardial procedure is being considered.
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Diet

  • A low salt, fluid-restricted diet is probably beneficial.
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Activity

  • Although no specific restrictions are needed, activity can often be severely limited by symptoms.
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Contributor Information and Disclosures
Author

Darren S Sidney, MD, MS  Electrophysiology Fellow, Department of Medicine, Medical University of South Carolina

Disclosure: Nothing to disclose.

Coauthor(s)

Terrence X O'Brien, MD, FACC  Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric Vanderbush, MD, FACC  Chief, Department of Internal Medicine, Division of Cardiology, Harlem Hospital Center; Clinical Assistant Professor of Cardiology, Columbia University College of Physicians and Surgeons

Eric Vanderbush, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald J Oudiz, MD, FACP, FACC, FCCP  Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Joseph L Fredi, MD  Assistant Professor of Medicine, Director of Acute MI Program, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center

Joseph L Fredi, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Acknowledgments for this work include support by the Office of Research and Development, Medical Research Service, Ralph H. Johnson Department of Veterans Affairs Medical Center, and the Gazes Cardiac Research Institute, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina. Dr. Weems Pennington is also acknowledged for the contributions he made to the previous version of this article.

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Constrictive pericarditis. Anteroposterior and lateral chest radiograph from a patient with tuberculous constrictive pericarditis (arrows denote marked pericardial calcification).
Right atrial pressure tracing showing marked y descents (arrows) in a patient with constrictive pericarditis.
Simultaneous right and left ventricular pressure tracings showing diastolic equalization of pressures in both ventricles in a patient with constrictive pericarditis.
 
 
 
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