Predictors of constrictive pericarditis after tuberculous pericarditis

Novel role of cardiovascular MRI to contextualise tuberculous pericardial inflammation and oedema as predictors of constrictive pericarditis

Tuberculosis (TB) and human immunodeficiency virus/acquired immunodeficiency syndrome have reached epidemic proportions, particularly affecting vulnerable populations in low- and middle-income countries of sub-Saharan Africa. TB pericarditis is the commonest cardiac manifestation of TB and is the leading cause of constrictive pericarditis, a reversible (by surgical pericardiectomy) cause of diastolic heart failure in endemic areas. Unpacking the complex mechanisms underpinning constrictive haemodynamics in TB pericarditis has proven challenging, leaving various basic and clinical research questions unanswered. Subsequently, risk stratification strategies for constrictive outcomes have remained unsatisfactory. Unique pericardial tissue characteristics, as identified on cardiovascular magnetic resonance imaging, enable us to stage and quantify pericardial inflammation and may assist in identifying patients at higher risk of tissue remodelling and pericardial constriction, as well as predict the degree of disease reversibility, tailor medical therapy, and determine the ideal timing for surgical pericardiectomy.

Predictors of tamponade and constriction in patients with pericardial disease undergoing interventional and surgical treatment

OBJECTIVE

The aim of our study was to define predictors of cardiac compression development including clinical, electrocardiographic, echocardiographic, chest-X-ray and perioperative parameters and their diagnostic value.

METHODS

Overall 243 patients with pericardial disease, among them 123 with compression (tamponade, constriction) and 120 without signs of compression were included in the study. Clinical, laboratory, electrocardiographic, chest-X-Ray, echocardiographic and perioperative data were included in the logistic regression analysis to define predictors of tamponade/constriction development.

RESULTS

Logistic regression analysis demonstrated large effusion (> 20 mm) (OR 5.393, 95%CI 1.202-24.199, p = 0.028), cardiac chamber collapse (OR 31.426, 95%CI 1.609-613-914, p = 0.023) and NYHA class > 3 (OR 8.671, 95%CI 1.730-43.451, p = 0.009) were multivariable predictors of compression development. The model including these three variables allowed predicting compression in 91.7% of cases. ROC analyses demonstrated that all three variables had significant diagnostic value with sensitivity of 75.6% and specificity of 74.2% for large effusion, low sensitivity and high specificity for cardiac chamber collapse (35% and 92%) and NYHA class (32.5% and 94.2%).

CONCLUSION

The independent predictors of compression development are presence of large effusion > 20 mm, cardiac chamber collapse and high NYHA class. The model including all three parameters allows correctly predicting compression in 91.4% of cases. The diagnostic accuracy of each parameter is characterized by high sensitivity and specificity of large effusion, high specificity of cardiac chamber collapse and NYHA class.

[Acute pericarditis and tamponade: An unusual revelation of a visceral tuberculosis]

Tuberculosis is a common pulmonary disease, which is still endemic in disadvantaged communities. Pericarditis is a rare but very lethal visceral localization. The authors report the case of a 58-year-old man, without neither medical history nor social risk, who presented a cardiac tamponade as the first and atypic manifestation of a visceral tuberculosis.

Definite and probable septic pericarditis in hemodialysis

INTRODUCTION

Although the incidence of septic pericarditis in hemodialysis populations is less frequent in the modern antibiotic era, it is still a cause of death partly because diagnosis is sometimes difficult and uncertain.

METHODS

From 2002 to 2006, 12 out of a total of 12,213 maintenance hemodialysis patients were referred for management of septic pericarditis. Patients were diagnosed as either definite or probable septic pericarditis. A definite diagnosis of septic pericarditis is based on the discovery of pathogenic bacteria in pericardial effusion, whereas a probable diagnosis is based on the proof of bacterial infection elsewhere in a patient with otherwise unexplained pericarditis, or appropriate response to a trial of systemic antibiotics.

RESULTS

Four (33.3%) patients were diagnosed as definite pericarditis, whereas eight (66.7%) patients as probable pericarditis. It was found that although oxacillin-resistant Staphylococcus aureus (ORSA) (4/12 or 33.3%) and tuberculous (4/12 or 33.3%) pericarditis were common, salmonella pericarditis (2/12 or 16.7%) was also not uncommon. Pericardiocentesis, or pericardial window with pericardiectomy, was performed in three (25%) and two (16%) of patients with cardiac tamponade, respectively. Two patients died because of severe ORSA (1/12 or 8%) and salmonella (1/12 or 8%) sepsis. Finally, there were four (33%) patients who developed constrictive pericarditis after follow-up.

CONCLUSIONS

These data are important because the spectrum of septic pericarditis was clearly different between Taiwan and other developed countries. Furthermore, it is the only report in which patients were diagnosed as either definite or probable septic pericarditis, therefore improving the sensitivity of diagnosis as in the case of tuberculous pericarditis.

Prognostic value of initial echocardiographic features in patients with tuberculous pericarditis

BACKGROUND AND OBJECTIVES

Tuberculous (TB) pericarditis is a major cause of constrictive pericarditis requiring pericardiectomy. We sought to determine initial prognostic factors in patients with TB pericarditis.

SUBJECTS AND METHODS

We evaluated initial presentation and clinical outcomes (mean follow-up 32±27 months) in 60 consecutive patients newly diagnosed with TB pericarditis.

RESULTS

Initial presentations were pericardial effusion (PE), effusive-constrictive pericarditis, and constrictive pericarditis in 45 (75%), 9 (15%), and 6 (10%) patients, respectively. Of the 54 patients without initial constrictive pericarditis, 32 (59%) showed echogenic materials in PE, including frond-like exudative coating and fibrinous strands. These patients had a longer disease duration before diagnosis, were initially more symptomatic, in a more advanced state, showed more persistent pericardial constrictions (38% vs. 0%, p<0.001) despite anti-TB medications, and tended to require pericardiectomy more often (19% vs. 0%, p=0.07, p<0.05 by Kaplan-Meier). All patients with effusive-constrictive pericarditis showed echogenic PE. Of the 60 total patients, 10 (17%) underwent pericardiectomies during follow-up. All of these patients showed initial pericardial constrictions, whereas no patient without initial pericardial constriction underwent pericardiectomy (p<0.001). Seven patients showed transient pericardial constrictions that resolved without pericardiectomy.

CONCLUSION

Initial pericardial constriction and echogenic PE are poor prognostic signs for persistent pericardial constriction and pericardiectomy in patients with newly diagnosed TB pericarditis. These results suggest that early diagnosis and prompt anti-TB medication may be critical.

Constrictive pericarditis impressing and narrowing the ascending aorta

A 77-year-old male patient was admitted to our institution with 1-year history of progressive dyspnea on exertion, and lower extremity edema. His chest x-ray showed a circumferential pericardial calcification and right-sided pleural effusion. The electrocardiography revealed atrial fibrillation with low voltage in all derivations and diffuse nonspecific T-wave inversions. The transesophageal echocardiography showed a thickened pericardium with biatrial enlargement and normal right and left ventricular systolic functions. A thick echogenic structure that caused impression and narrowing of the ascending aorta was observed. Simultaneous right and left heart catheterization showed elevation and equalization of right-sided and left-sided diastolic filling pressures, with characteristic dip and plateau. Aortic angiogram showed the ascending aorta was impressed and narrowed by calcified pericardium. Cine magnetic resonance imaging showed pericardial calcifications impressing and narrowing of the ascending aorta. All these findings were consistent with constrictive pericarditis. The patient had no history of tuberculosis, cardiac surgery, or mediastinal irradiation. His HIV antibody test was negative. Marked pericardial thickening and calcifications were evident during pericardiectomy. Histological analysis of the pericardium showed dense collageneous matrix, mild chronic inflammation and calcification. The culture of pericardial tissue revealed no identifiable cause including tuberculosis. The patient was diagnosed as idiopathic constrictive pericarditis. The patient's symptoms and edema decreased remarkably after pericardial stripping. He remained well at 1-year follow-up.

A modern approach to tuberculous pericarditis

The human immunodeficiency virus (HIV) epidemic has been associated with an increase in all forms of extrapulmonary tuberculosis including tuberculous pericarditis. Tuberculosis is responsible for approximately 70% of cases of large pericardial effusion and most cases of constrictive pericarditis in developing countries, where most of the world's population live. However, in industrialized countries, tuberculosis accounts for only 4% of cases of pericardial effusion and an even smaller proportion of instances of constrictive pericarditis. Tuberculous pericarditis is a dangerous disease with a mortality of 17% to 40%; constriction occurs in a similar proportion of cases after tuberculous pericardial effusion. Early diagnosis and institution of appropriate therapy are critical to prevent mortality. A definite or proven diagnosis is based on demonstration of tubercle bacilli in pericardial fluid or on histologic section of the pericardium. A probable or presumed diagnosis is based on proof of tuberculosis elsewhere in a patient with otherwise unexplained pericarditis, a lymphocytic pericardial exudate with elevated biomarkers of tuberculous infection, and/or appropriate response to a trial of antituberculosis chemotherapy. Treatment consists of 4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months regardless of HIV status. It is uncertain whether adjunctive corticosteroids are effective in reducing mortality or pericardial constriction, and their safety in HIV-infected patients has not been established conclusively. Surgical resection of the pericardium is indicated for those with calcific constrictive pericarditis or with persistent signs of constriction after a 6 to 8 week trial of antituberculosis treatment in patients with noncalcific constrictive pericarditis.

Pericarditis

Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. New diagnostic techniques have improved the sampling and analysis of pericardial fluid and allow comprehensive characterisation of cause. Despite this advance, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently self-limiting, and non-steroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. Differentiation of constrictive pericarditis from restrictive cardiomyopathy remains a clinical challenge but is facilitated by tissue doppler and colour M-mode echocardiography. Most pericardial effusions can be safely managed with an echo-guided percutaneous approach. Pericardiectomy remains the definitive treatment for constrictive pericarditis and provides symptomatic relief in most cases. In the future, the pericardial space might become a conduit for treatments directed at the pericardium and myocardium.

Pericardiectomy for chronic constrictive tuberculous pericarditis: risks and predictors of survival

We performed this study to determine the predictors of early and long-term survival in the surgical treatment of tuberculous pericarditis and to examine the risks of pericardiectomy and the functional outcome in patients after surgery. A retrospective analysis was undertaken in 36 consecutive patients, 26 female and 10 male, with a mean age 32.2 +/- 16.3, who underwent pericardiectomy for chronic constrictive pericarditis from February 1985 to February 2002. All patients received antitubercular therapy in the postoperative period. The operative mortality rate was 6% (2 patients); the cause of death in both cases was severe low-cardiac-output syndrome. Nonfatal intraoperative complications affected 3 patients (8%). The median stay in the intensive care unit was 3.7 +/- 3.1 days. The median hospital stay was 14 +/- 2.6 days. The median ventilation time was 11.9 +/- 1.8 hours. The median volume of blood transfused was 2.1 +/- 1.6 units. Advanced age, atrial fibrillation, concomitant tricuspid insufficiency, inotropic support and low cardiac output were significant negative predictors of survival, according to univariate analysis. There were 4 late deaths. Actuarial survival at 5 years was 75.9% +/- 9.14%. At the 1-year follow-up examination, improved functional status was noted in 88% of patients. We suggest that pericardiectomy be performed early and as radically as possible, in an effort to prevent chronic illness. A combination of chemotherapy and surgery yields gratifying results in the treatment of tuberculous pericarditis.

Tuberculous pericarditis: optimal diagnosis and management

Pericarditis is a rare manifestation of tuberculous disease. The appropriate diagnostic workup and optimal therapeutic management are not well defined. We present 10 new cases of tuberculous pericarditis and review the relevant literature. The specific topics addressed are (1) the importance of tissue for diagnosis, (2) the optimal surgical management, (3) the role of corticosteroids, and (4) the impact of human immunodeficiency virus (HIV) on the management of this disease. The cases and the literature suggest that the optimal management includes an open pericardial window with biopsy, both for diagnosis and to prevent reaccumulation of fluid. Corticosteroids probably offer some benefit in preventing fluid reaccumulation as well. The data are inconclusive regarding whether open drainage or corticosteroid use prevents progression to constrictive pericarditis. No studies have addressed these issues specifically in HIV-positive patients, but the 3 HIV-positive patients in our series had an excellent response to drainage and antituberculous therapy.

Calcific constrictive pericarditis: is it still with us?

BACKGROUND

The presence of pericardial calcification on a plain radiograph strongly suggests constrictive pericarditis in patients with heart failure. However, calcific constrictive pericarditis is considered rare in the United States since tuberculosis incidence has decreased, and doubt has therefore been raised about the importance of this radiologic finding in modern cardiovascular practice.

OBJECTIVE

To determine the clinical and prognostic significance of pericardial calcification on radiography in patients with constrictive pericarditis.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

A consecutive series of 135 patients (mean age +/- SD, 56 +/- 16 years) who from 1985 through 1995 had constrictive pericarditis confirmed surgically (n = 133) or by autopsy (n = 2). Patients were divided into two groups: those with pericardial calcification on chest radiography (group I) and those without (group II).

MEASUREMENTS

Clinical and diagnostic findings were compared in both groups, and outcome was compared in 132 patients who had pericardiectomy.

RESULTS

Pericardial calcification was seen in 36 patients (27%). The cause of constrictive pericardial disease was indeterminate in 67% of patients in group I and in 21% of patients in group II (P < 0.001). Patients in group I had had symptoms for a longer period and were more likely to have pericardial knock, larger atrial size, and atrial arrhythmia. Significantly more perioperative deaths were seen in group I, but incidence of late survival and incidence of noncalcific disease were similar in both groups.

CONCLUSIONS

Pericardial calcification is a common finding in patients with constrictive pericarditis. It is often associated with idiopathic disease and other markers of disease chronicity and is an independent predictor of increased perioperative mortality rates.

Constrictive pericarditis: clinical and pathophysiologic characteristics

Constrictive pericarditis is an uncommon disorder with various causes. Although most often idiopathic, it may also occur after cardiovascular surgery, radiation therapy, and tuberculosis, especially in developing countries. The encasement of the heart by a rigid, nonpliable pericardium results in characteristic pathophysiologic effects, including impaired diastolic filling of the ventricles, exaggerated ventricular interdependence, and dissociation of intracardiac and intrathoracic pressures during respiration. Constrictive pericarditis typically presents with chronic insidious signs and symptoms of predominantly systemic venous congestion. Notoriously difficult to diagnose and distinguish from restrictive cardiomyopathy (RCM), the use of cardiac catheterization, echocardiography (transthoracic and transesophageal), central venous (hepatic and pulmonary) and transvalvular Doppler measurements, and magnetic resonance imaging should secure the diagnosis in most cases, eliminating the need for diagnostic thoracotomy. Although medical treatment may temporarily alleviate symptoms of heart failure, patients do poorly without pericardiectomy.

Case presentation and review: constrictive pericarditis

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Inflammatory disorders of the heart. Pericarditis, myocarditis, and endocarditis

The emergency physician frequently sees patients with cardiac complaints. Too often, ischemic heart disease is overwhelmingly considered to the exclusion of other diagnostic possibilities such as inflammatory cardiac disorders. These disorders can cause considerable discomfort, have long-term implications, or lead to more serious cardiac disorders. Emergency physicians must have a practical understanding of the diagnostic evaluation and therapeutic approach to patients with inflammatory cardiac disorders.

An unusual case of cardiac tamponade following electrical cardioversion

The clinical presentation of cardiac tamponade may uncover underlying pericardial disease. We describe a patient who was being treated for lone atrial fibrillation. In this case, direct current cardioversion for recurrence of atrial fibrillation was complicated by a life-threatening hemopericardium. A history of asbestos exposure was subsequently related to the subclinical pericarditis.