Constrictive Pericarditis

In many cases, constrictive pericarditis is a late sequela of an inflammatory condition of the pericardium . Once detected, a pericardial effusion must be evaluated to determine its etiology and hemodynamic significance The inflammatory condition is usually an infection that involves the pericardium, but it may be after a heart attack or after heart surgery. Combined pericardiocentesis and cardiac catheterization were performed in all patients, and pericardiectomy was performed in those with persistent constriction. Stretch-sensitive mechanoreceptors sense changes in cardiac volume and tension and may be responsible for transmitting pericardial pain. The complex pathophysiology, combined with the fact that the condition is most commonly idiopathic, is why having a working knowledge of constrictive pericarditis is important. All patients presented with clinical tamponade; however, concomitant constriction was recognized in only seven patients. At catheterization, all patients had elevated intrapericardial pressure (median, 12 mm Hg; interquartile range, 7 to 18) and elevated right atrial and end-diastolic right and left ventricular pressures.

Constrictive pericarditis is a disorder caused by inflammation of the pericardium (the sac-like covering of the heart) with subsequent thickening, scarring, and contracture of the pericardium. A total of 1184 patients with pericarditis were evaluated, 218 of whom had tamponade. Of these 218, 190 underwent combined pericardiocentesis and catheterization. Fifteen of these patients had effusive�constrictive pericarditis and were included in the study.

Constrictive pericarditis occurs when a thickened fibrotic pericardium, of whatever cause, impedes normal diastolic filling During inspiration, the negative pressure in the thoracic cavity will cause increased blood flow into the right ventricle. If fluid (usually blood) accumulates rapidly, even small amounts (eg, 150 mL) may produce tamponade because the pericardium cannot stretch quickly enough to accommodate Chronic pericarditis (defined as persisting > 6 mo) develops more slowly; its prominent feature is effusion Usually, approximately 50 mL of fluid (plasma ultrafiltrate) is present in the intrapericardial space to minimize friction during cardiac motion.

Causes of Constrictive Pericarditis

The common causes of Constrictive Pericarditis :

• Although still rare in absolute terms, sarcoidosis, amyloidosis, and hemochromatosis are the most commonly encountered infiltrative processes that lead to restrictive physiology.
• Right-sided valvular abnormalities that increase venous pressure, such as tricuspid stenosis or tricuspid regurgitation, can be confusing upon examination but can usually be diagnosed based on echocardiography.
• Drugs, including hydralazine (Apresoline), procainamide (Procan SR), and phenytoin (Dilantin)
• Radiation
• Cancer (usually lung, breast, and lymphoma)
• Auto-immune diseases (such as rheumatoid arthritis, lupus, or scleroderma)
• The most common causes of constrictive pericarditis are conditions that induce chronic inflammation of the pericardium: tuberculosis , radiation therapy to the chest, and cardiac surgery.
• Following Pericarditis Associated with Acute Myocardial Infarction
• Incomplete Drainage of Purulent pericarditis
• Infectious disease - Particularly in immunocompromised states (most commonly tuberculosis and fungal)

Symptoms of Constrictive Pericarditis

Some common symptoms of Constrictive Pericarditis :

• Difficulty breathing ( dyspnea ) that develops slowly and progressively worsens
• Chest pain (less than that seen with acute pericarditis)
• weakness
• Swelling in the ankles or legs, or a bluish tint to lips, fingernails, or skin
• dry cough
• most comfortable position is upright (standing or sitting)
• Fever
• Increase in heart-rate
• splinting of ribs with deep breathing (requiring the need to bend over or hold chest when breathing deeply)
• broken blood vessels (hemorrhages) in the mucus membrane of the eyes, the back, the chest, fingers, and toes
• feelings of anxiety

Treatment of Constrictive Pericarditis

• Depending on putative etiology, steroids, nonsteroidal anti-inflammatory agents, or antibiotics may be needed.
• In patients who may have a high mortality rate with thoracotomy yet have a significant chance of effusion recurrence with needle drainage alone, a pericardial-peritoneal window is an effective treatment for recurrent pericardial effusions.
• Analgesics may be needed to control pain.
• This may include antibiotics, anti-tuberculosis medications, or other treatments.
• Patients should be monitored for development of effusion and tamponade or constrictive pericarditis, which require drainage and surgical pericardectomy respectively.
• Anti-arrhythmics if necessary, to treat any heart arrhythmias, such as atrial fibrillation
• Pericardiectomy � in some cases, the stiff pericardium may need to be removed from the heart surgically
• Subacute constrictive pericarditis may respond to steroids if treated before pericardial fibrosis occurs.

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