Constrictive Pericarditis Treatment & Management

Updated: Dec 23, 2014
  • Author: John L Parks, MD; Chief Editor: Richard A Lange, MD, MBA  more...
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Treatment

Approach Considerations

Definitive care is primarily surgical (ie, pericardiectomy). Operative therapy typically leads to rapid hemodynamic and symptomatic improvements. Medical management, such as careful observation or symptomatic treatment, has been suggested in less severe cases; however, this option is controversial.

Diuretics have been used in the early stages of the disease to improve pulmonary and systemic congestion. However, these should be used cautiously because any drop in intravascular volume may cause a corresponding drop in cardiac output (see the Cardiac Output calculator). Complications may arise with failure to diagnose or treat constrictive pericarditis (and any existing underlying etiology) adequately.

Outpatient care may be appropriate in the early stages, particularly when the diagnosis is still uncertain and the symptoms are relatively stable. A low salt, fluid-restricted diet is probably beneficial. Although no specific restrictions are needed, activity can often be severely limited by symptoms.

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Pharmacologic Therapy

In the vast majority of cases, medical management is ineffective unless a prominent inflammatory component is present. In this respect, constrictive pericarditis differs from acute pericarditis, in which the use of nonsteroidal anti-inflammatory agents (NSAIDs), cyclooxygenase (COX)-2 inhibitors, colchicine, corticosteroids, or a combination thereof may provide benefit. [31] However, even after optimal therapy of acute pericarditis, constriction may develop over time. Transient constrictive pericarditis has been described, so those individuals with a diagnosis of constriction who are medically stable may be given a trial of conservative treatment for 2-3 months (using NSAIDs and/or steroids). This should be only considered in those individuals with an optimized volume status and controlled symptoms. [25]

Other considerations related to medical treatment of constrictive pericarditis are as follows:

  • Subacute constrictive pericarditis may respond to steroids if treated before pericardial fibrosis occurs
  • Diuretics (particularly loop diuretics) are the mainstay to relieve congestion and optimize clinical volume status; however, they may decrease preload to the point of reducing cardiac output and thus require careful monitoring (see the Cardiac Output calculator)
  • Any other medications used to treat patients with constrictive pericarditis would be specific to the underlying cause of the pericardial disease
  • Any therapy directed toward the causative disease (eg, antituberculosis medication) is appropriate
  • Complications (eg, atrial arrhythmias) require their own therapy as appropriate
  • In general, beta-blockers and calcium channel blockers should be avoided, because the sinus tachycardia that commonly occurs in constrictive pericarditis has a compensatory function, maintaining cardiac output in a setting of fixed stroke volume (secondary to fixed diastolic filling)
  • Individuals with significantly advanced symptoms related to constriction may derive little benefit from pericardiectomy; these are often the same patients who have particularly high surgical risk. [25]
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Pericardiectomy

Complete pericardiectomy is the definitive therapy and is a potential cure. [32, 33, 34] 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 must be exercised because patients who are in New York Heart Association (NYHA) class I (ie, asymptomatic) or who have early NYHA stage II symptoms may be clinically stable for years.

Pericardiectomy can be a long and often technically complex procedure. The 2 standard approaches are via an anterolateral thoracotomy and via a median sternotomy. Pericardial decortication should be as extensive as possible, especially at the diaphragmatic-ventricular contact regions. An excimer laser can be used should severe adhesions occur between the pericardium and epicardium. [34] Complications may include excessive bleeding, atrial and ventricular arrhythmias, and ventricular wall ruptures.

In published reports, surgical mortality ranges from 5-15%, with one report citing a 30-day perioperative mortality of 6.1%. The causes of death include progressive heart failure, sepsis, renal failure, respiratory failure, and arrhythmia. Between 80% and 90% of patients who undergo pericardiectomy achieve NYHA class I or II postoperatively.

Even though symptoms are commonly alleviated after a pericardiectomy, evidence of abnormal diastolic filling (which can be correlated with clinical status) often remains. One study found that only 60% of patients showed complete normalization of cardiac hemodynamics. [34] Although some patients improved with time, persistent diastolic filling abnormalities tended to occur in those who had a longer history of preoperative symptoms, supporting the view that early operation is advisable in symptomatic patients. Those patients who have symptoms that persist even after successful pericardiectomy may have a more mixed constrictive-restrictive picture.

Of 58 patients who underwent total pericardiectomy 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.

Different methods of accessing the pericardial space, such as video-assisted thoracoscopy, are being investigated. Further development of such devices may help improve diagnostic and therapeutic options in patients with pericardial disease. [35]

Cardiac mortality and morbidity seem to be related to preoperative myocardial atrophy or fibrosis, which can be detected by means of computed tomography (CT). Excluding these patients keeps the mortality rate at the lower end of the range (5%). [34]

Postoperatively, low cardiac output may occur in patients who are debilitated and who have ascites or other findings of fluid retention. Patients with low cardiac output may require maintenance of high left atrial pressure, sympathomimetic infusions, or both. Mechanical support of the circulation, such as extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon counterpulsation, can be used in patients who are critically ill.

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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.

Referral to a specialized center may be required. If adequate diagnostic or therapeutic modalities are not available, transfer to an appropriate facility is warranted.

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