Investigation and treatment of constrictive pericarditis

Constrictive pericarditis--a curable diastolic heart failure

Constrictive pericarditis can result from a stiff pericardium that prevents satisfactory diastolic filling. The distinction between constrictive pericarditis and other causes of heart failure, such as restrictive cardiomyopathy, is important because pericardiectomy can cure constrictive pericarditis. Diagnosis of constrictive pericarditis is based on characteristic haemodynamic and anatomical features determined using echocardiography, cardiac catheterization, cardiac MRI, and CT. The Mayo Clinic echocardiography and cardiac catheterization haemodynamic diagnostic criteria for constrictive pericarditis are based on the unique features of ventricular interdependence and dissociation of intrathoracic and intracardiac pressures seen when the pericardium is constricted. A complete pericardiectomy can restore satisfactory diastolic filling by removing the constrictive pericardium in patients with constrictive pericarditis. However, if inflammation of the pericardium is the predominant constrictive mechanism, anti-inflammatory therapy might alleviate this transient condition without a need for surgery. Early diagnosis of constrictive pericarditis is, therefore, of paramount clinical importance. An improved understanding of how constrictive pericarditis develops after an initiating event is critical to prevent this diastolic heart failure. In this Review, we discuss the aetiology, pathophysiology, and diagnosis of constrictive pericarditis, with a specific emphasis on how to differentiate this disease from conditions with similar clinical presentations.

Disproportionate elevation of jugular venous pressure in pleural effusion

Constrictive pericarditis is characterized by elevation in jugular venous pressure disproportionate to the severity of concurrent breathlessness. As pleural effusion may be an associated feature it is recommended that jugular venous pressure should be documented in all patients who present with pleural effusion.

Inflammatory constriction following complete pericardiectomy in tuberculous constrictive pericarditis

A 13-year-old boy with active tuberculous constrictive pericarditis underwent complete pericardiectomy together with antituberculous therapy and a short course of steroids. Six weeks following the surgery, he was seen with clinical and hemodynamic findings of recurrent pericardial constriction, presumably due to an inflammatory collection around the heart. Symptoms gradually resolved within six months with resumption of steroid therapy. Repeat hemodynamic study showed normal hemodynamics. The case demonstrates the production of cardiac constriction by nonpericardial inflammatory tissue and the possible benefits of steroid therapy in the treatment of tuberculous constrictive pericarditis.

Diseases of the pericardium: morphologic study of surgical specimens from 35 patients

The gross and microscopic features of 35 pericardial surgical specimens are described. Nineteen specimens were associated with pericardial effusion, and microscopic study showed nonspecific fibrous changes in eight, tuberculous granulomatous inflammation in four, purulent inflammation in four, neoplastic involvement in four, and siderosis of the pericardium in one. Twelve of these were clinically associated with constriction. Calcification of the pericardium was the predominant feature in eight of the specimens. None of these eight specimens showed features of tuberculous infection. Of the remaining four, two showed chronic fibrinous changes and the other two showed granulomatous inflammation of presumed tuberculous origin. Four pericardial cysts were seen. Pericardial disease was an incidental finding in 13 instances (37 per cent), suggesting the frequent underdiagnosis and asymptomatic nature of disease of the pericardium. The associations of infections, trauma, hemopericardium, and collagen diseases and pericardial diseases are discussed.

Surgical management of pericarditis in Zaria, Nigeria

Over eight years, 58 rural Nigerians with pericarditis were treated surgically in Zaria using basic surgical facilities. Eighteen patients had purulent pericarditis, associated with staphylococcal pneumonia in children, or pneumococcal pneumonia in adults. Treatment with antibiotics and prompt pericardiectomy appeared to be superior to drainage, since a quarter of those initially treated with surgical drainage developed early constriction and required pericardiectomy soon after. Thirteen patients had chronic pericardial effusions, of whom one had epicardial constriction and two had cardiomyopathy. Twenty-seven patients had chronic constrictive pericarditis but tuberculosis was confirmed histologically in three only. Echocardiographic findings remained unchanged in five patients evaluated before and after pericardiectomy. Eight of the 13 patients who died had already developed myocardial or hepatic insufficiency before operation, because of late presentation or diagnosis. Greater awareness of the significance of precordial pain in this rural population where ischaemic heart disease is rare would help in making an earlier diagnosis.

Collagen diseases as a cause of constrictive pericarditis

Seven patients with constrictive pericarditis associated with collagen disease underwent pericardiectomy with good results in all but one. The collagen disease was confirmed as rheumatoid arthritis in five patients, but in two its nature remained obscure. In one case the illness was marked by a persistent eosinophilia and eosinophilic infiltration of the pericardium. The association of constrictive pericarditis with rheumatoid arthritis and other collagenoses is briefly discussed.

A comparison between ketamine and diazepam as induction agents for pericardiectomy

Ketamine 1 · 0 mg/kg and diazepam 0 · 3 mg/kg was used to induce anaesthesia in patients requiring pericardiectomy. A significant rise in blood pressure in patients receiving ketamine was noted. In contrast, a fall in blood pressure was seen when diazepam was administered. Changes in cardiac output, cardiac index, central venous pressure and systemic vascular resistance are discussed.

Ketamine appears to be a more satisfactory agent for induction of anaesthesia in patients for pericardiectomy, whereas diazepam should be used with caution.

Constrictive pericarditis in childhood

Five children with constrictive pericarditis are described. All underwent surgery to release the restricted heart, and two died. Tuberculosis still plays a major role in the aetiology of this disease; it was proven in one patient and suspected in two others. No other aetiological factors were identified. Clinically, constrictive pericarditis does not differ from the disease described in adults. Protein-losing enteropathy as a result of the constricted pericardium was present in the youngest patient in this series. The degenerative changes taking place in the myocardium, secondary to the pericardial involvement, mainly determine the outcome of surgery. Pericardiectomy and decortication of the constricted pericardium should be performed without delay, as soon as this diagnosis is established.