Constrictive Pericarditis: A Medical or Surgical Disease?

Constrictive pericarditis requiring pericardiectomy: an unusual first presentation of extra-articular rheumatoid arthritis-a case report

Background

We report an unusual case of rheumatoid arthritis presenting for the first time with pericardial constriction and bilateral pleural calcification, in the absence of prior articular disease.

Case summary

A 46-year-old Caucasian male, who initially presented with shortness of breath, intermittent chest tightness and general malaise, underwent extensive diagnostic workup over a period of six months involving multiple hospital admissions. He was found to have pericardial constriction on echocardiogram and ultimately required surgical pericardiectomy due to decompensation. After multiple diagnostic tests and specialist opinion, the aetiology of pericardial disease was ultimately confirmed to be extra-articular rheumatoid disease without synovitis.

Discussion

Significant pericardial constriction can occur as the initial presentation of rheumatoid disease and anti-CCP is a highly specific confirmatory test. Pericardial pathological specimen can be unhelpful in determining this aetiology, and constrictive physiology can occur due to chronic inflammation/fibrosis in the absence of significant calcification.

Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review

Remarkable advances have occurred in the understanding of the pathophysiology of pericardial diseases and the role of multimodality imaging in this field. Medical therapy and surgical options for pericardial diseases have also evolved substantially. Pericardiectomy is indicated for chronic or irreversible constrictive pericarditis, refractory recurrent pericarditis despite optimal medical therapy, or partial agenesis of the pericardium with a complication (eg, herniation). A multidisciplinary evaluation before pericardiectomy is essential for optimal patient outcomes. Overall, given the good outcomes reported, radical pericardiectomy on cardiopulmonary bypass, if feasible, is the preferred approach. Due to patient complexity, as well as the technical aspects of the surgery, pericardiectomy should be performed at high-volume centers that have the required expertise. The current review highlights the essential features of this multidisciplinary approach from diagnosis to recovery in patients undergoing pericardiectomy.

Perioperative management of constrictive pericarditis with cardiac cirrhosis: A case report

INTRODUCTION

The interactions between the heart and liver have been known for a long time, pericarditis constrictive could cause congestive hepatopathy via right-sided heart failure. Liver cirrhosis correlates with a high risk of mortality so perioperative management greatly influences outcomes.

CASE PRESENTATION

An Indonesian man, 50 years old, complained of breath shortness. The patient had a history of pulmonary tuberculosis and was declared cured 30 years ago. The patient began experiencing fatigue 14 years ago, and the patient was diagnosed with constrictive pericarditis 5 years ago. Currently, the patient has an increased jugular venous pressure of 9 cmH2O and abnormal laboratory indicators, including a platelet count of 121,000/μL, albumin count of 3.41 g/L, direct bilirubin count of 0.7 mg/dL, total bilirubin count of 1.4 mg/dL, and INR of 1.4. Echocardiography revealed left ventricle hypertrophy, diastolic dysfunction, and right ventricle failure. Cardiac CT scan showed pericardial calcification. Abdominal ultrasound showed liver congestive and splenomegaly. Transient elastography showed severe fibrosis in liver and stiffness in spleen. The patient underwent pericardiectomy with CTP score of 6 and MELD of 12. The surgery was successful, and the complaint was reduced. The patient experienced an improvement in his condition and able to carry out activities well after 2 years post-surgery.

DISCUSSION

The patient has no contraindications to pericardiectomy, CTP class A (5-6) and MELD score <13.5 has a low risk of mortality.

CONCLUSION

CTP and MELD scores predict life expectancy in post-surgery cardiac cirrhosis patients.

Surgical treatment of constrictive pericarditis at a single center: 10 years of experience

BACKGROUND

Constrictive pericarditis (CP) is a pericardial disease characterized by the pericardium becoming calcified or fibrotic as a result of chronic inflammation, which impairs diastolic filling by compressing the cardiac chambers. Pericardiectomy is a promising surgical option for treating CP. In this study, we reviewed over 10 years of preoperative, perioperative, and short-term postoperative follow-ups of patients who underwent pericardiectomy for constrictive pericarditis at our clinic.

METHODS

Between January 2012 and May 2022, 44 patients were diagnosed with constrictive pericarditis. Twenty-six patients underwent pericardiectomy for CP. Median sternotomy is the surgical approach of choice because it provides easy access for complete pericardiectomy.

RESULTS

The patient median age was 56 (min: 32, max: 71), and 22 out of 26 patients (84.6%) were male. Twenty-one patients (80.8%) complained of dyspnea, which was the most common reason for admission. Twenty-four patients (92.3%) were scheduled for elective surgery. Cardiopulmonary bypass (CPB) was used during the procedure in six patients (23%). The duration of intensive care stay was two days (min: 1, max: 11), and the total hospitalization was six days (min: 4, max: 21). No in-hospital mortality was observed.

CONCLUSION

The median sternotomy approach provides a critical advantage in terms of performing a complete pericardiectomy. Although CP is a chronic condition, early diagnosis and planning of pericardiectomy before irreversible deterioration of cardiac function leads to a notable reduction in mortality and morbidity.

Constrictive pericarditis in the new millennium

Constrictive pericarditis (CP) is a complex clinical syndrome in which an inflamed pericardium becomes fibrotic and non-compliant, ultimately reducing cardiac pump performance. Although we have known about CP for centuries, it remains a challenge to diagnose. Recent advances in cardiac imaging, along with an expanding armamentarium of treatment options, have improved the quality and precision of care for patients with CP. This article reviews important historical and contemporary perspectives on the pathophysiology of CP, as well as our approach to diagnosis and management.

Esophageal Perforation by Fish Bone Ingestion Causing Purulent Pericarditis

A previously healthy 38-year-old woman presented with new-onset sudden chest pain radiating to the back, associated with cough, dyspnea, nausea, vomiting, and gastric fullness after eating a bony fish. A diagnosis of gastroesophageal reflux disease was made. After a week of progressive worsening of her symptoms, she was referred to the specialist hospital. There, computed tomography imaging strongly suggested that a likely fishbone had penetrated the esophagus into the mediastinal structures; it seemed to have produced a pneumopericardium. Other tests suggested diffuse changes in ventricular repolarization, pericardial thickening, and diastolic restriction. Exploratory thoracotomy confirmed esophageal-pericardial perforation by the fishbone and purulent pericarditis. Despite appropriate surgical repair, the patient died on fifth postoperative day from an asystolic cardiac arrest that was refractory to repeated attempts to resuscitate her.

Transient pericardial constriction: A not so rare entity

Constrictive pericarditis is a rare, potentially treatable, cause of heart failure with preserved ejection fraction that is characterized by insidious onset, challenging diagnosis and dismal prognosis, even following complete surgical pericardiectomy, particularly in advanced disease stages. In recent years it has been proposed that transient pericardial constriction may occur, with an even rarer frequency, during early phases of acute pericarditis and may resolve following specific treatment without progressing to the chronic, irreversible form. We recently observed two cases of well-documented transient pericardial constriction. In the present work we describe these two cases and provide a review on this rare condition, that, if unrecognized and left untreated, may lead to irreversible constrictive pericarditis.

A case series of constrictive pericarditis and suggested echocardiographic diagnostic criteria

BACKGROUND

The diagnosis of constrictive pericarditis (CP) is challenging as there are currently no standard echocardiographic diagnostic criteria. In this retrospective case series, we analyzed and summarized the features of 25 patients with CP and proposed echocardiographic diagnostic criteria. It is hoped that the suggested criteria help professionals make decisions in their daily practice so that patients receive timely diagnosis and effective treatment.

METHODS

Twenty-five patients with CP were selected for this retrospective study. The clinical and echocardiographic imaging data were analyzed and summarized, and echocardiographic diagnostic criteria for CP were proposed.

RESULTS

The main clinical manifestations were fatigue, breathlessness, exertional dyspnea (88%), lower-limb edema (84%), hepatomegaly, and jugular vein filling (84%). Echocardiographic features comprised pericardial thickening (88%) and calcification (60%), pulmonary hypertension (52%), inferior vena cava dilation (80%), left and/or right atrial enlargement (100%), diastolic flattening of the left ventricular (LV) posterior wall (72%), septal shudder and bounce (64%), restrictive LV and right ventricular diastolic filling pattern (100%), early filling changes of mitral and tricuspid flow (80% and 60%, respectively), and mitral annulus reversus (73%).

CONCLUSIONS

Echocardiography is a simple and valuable examination for CP. The echocardiographic diagnostic criteria are valid and worth promoting.

Constrictive pericarditis following inactivated virus COVID-19 vaccine: a case report with review of the literature

Cardiac adverse effects of the COVID-19 vaccine are very rare, myocarditis and pericarditis are the most common amid them, and constrictive pericarditis (CP) is reported to be restricted to a few cases following mRNA COVID-19 vaccines. We report a case of a 72-year-old male patient who developed symptoms of right-sided heart failure, which started after 8 days of receiving the third dose of inactivated virus COVID-19 vaccine and his diagnostic tests comprising transthoracic echocardiography, chest CT scan, cardiac magnetic resonance were in favor of CP. Ultimately, invasive cardiac catheterization confirmed the diagnosis of CP. Due to the lack of satisfactory response to corticosteroid therapy, pericardiectomy was performed, which gave rise to symptom relief progressively and substantially. Considering the temporal course of the patient's symptoms and exclusion of other possible etiologies based on the patient's medical history and diagnostic evaluation, immunization with the COVID-19 vaccine was recognized as a culprit for developing CP. Despite being a scarce phenomenon, the COVID-19 vaccine could have a tendency to provoke pericardial inflammation in so far as causing CP. Hence, physicians should have a high index of suspicion in these circumstances and accelerate the diagnostic investigation.

Immunoglobulin G4-related constrictive pericarditis and the importance of a thorough workup: a case report

Background

Constrictive pericarditis remains a problematic diagnosis and a thorough investigation is critical. Among possible aetiologies, immunoglobulin-G4 (IgG4)-related pericardial disease is an unusual cause of pericardial constriction. We report a challenging diagnostic case of pericardial constriction due to IgG4-related disease.

Case presentation

A 68-year old male with a history of inferior myocardial infarction with right ventricle (RV) involvement was thrice-hospitalized due to marked ascites and peripheral oedema. Systemic congestion was initially attributed to RV dysfunction due to previous infarction. Yet, at the final admission, a re-assessment echocardiogram followed by cardiac computed tomography, magnetic resonance and right heart catheterization raised a possible diagnosis of constrictive pericarditis with a finding of abnormal pulmonary venous return. Patient therefore underwent pericardiectomy and surgical correction of pulmonary venous return. Pericardium histology revealed an IgG4-related pericardial constriction. Patient was later discharged on corticosteroids with marked symptomatic improvement.

Conclusion

IgG4-related disease remains a rare cause of pericardium constriction while also presenting a challenging diagnosis in everyday clinical practice. This case exemplifies the difficulties faced by clinicians when reviewing a possible case of constrictive pericarditis, while highlighting the importance of a multimodality assessment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02468-1.

A novel model of constrictive pericarditis associated with myocardial fibrosis in rats

An efficient animal model is fundamental for studies on the underlying mechanisms of constrictive pericarditis (CP). A novel CP rat model was established by pericardial injection composing of lipopolysaccharides (LPS) and talcum powder without thoracotomy. Pathological changes were confirmed by histological staining. E-flow Doppler of mitral valve, tissue Doppler E' in the medial mitral annular (E'sep ) and the lateral mitral annular (E'lat ) were measured to assess ventricular filling function. Circumferential, longitudinal, and radial strains (SC, SL and SR) and the respective strain rates (SrC, SrL and SrR) were analyzed in interventricular septum (IVS) and left ventricular free wall (LVFW). Rat cardiac fibroblasts (CFs) were treated with LPS. The activation of transforming growth factor β1 (TGF-β1) was confirmed by Q-PCR and western blot assays. Thickening of pericardium and fibrosis in pericardium and subepicardial myocardium were showed in the model group. Diastolic dysfunction in the CP group was indicated by decreased E'lat and E'lat /E'sep , increased E/E'lat , decreased EFW of SrC and SrL, increased AIVS and decreased E/A of SrC, SrL and SrR. Systolic dysfunction was indicated by decreased SCFW and SLFW in CP rats. The levels of TGF-β1, p-Smad2/3, α-smooth muscle actin (α-SMA), and collagen-I/III (COL-I/III) were increased in the CP group. The increased TGF-β1 that induced by LPS activated and phosphorylated Smad2/3 resulting in the secretion of α-SMA and COL-I/III. This model is of vital importance in studying the pathogenesis of CP.

Experimental Research on the Evaluation of Left Ventricular Function by Layered Speckle Tracking in a Constrictive Pericarditis Rat Model

OBJECTIVES

In animal models with constrictive pericarditis (CP), detecting the function of cardiac systole by conventional noninvasive ultrasound is a challenge. We aimed to detect cardiac dysfunction in rat models with CP in the early stage by layered speckle tracking.

METHODS

We compared a rat CP model (n = 23, injected with a solution of 1-mg/mL lipopolysaccharides [0.5 mL] and a 10% talc suspension [0.5 mL]) with a control group (n = 20, no injection). After 8 weeks, conventional echocardiography and layered speckle tracking were used to assess the left ventricular structures and functions in the groups.

RESULTS

The global circumferential strain (CS) and longitudinal strain (LS) were decreased in the CP group (P < .05). The CS of the epicardial and middle layers in the CP group was decreased (P < .05), but the endocardial layer was not statistically different. The LS of the epicardial layer was decreased (P < .05), but the middle and endocardial layers were not statistically different. The global free-wall and septal-wall CS of the CP group was decreased (P < .05), mainly due to the decrease of CS of the epicardial and middle layers. The global free-wall LS of the CP group was decreased (P < .05), mainly due to the decrease of LS of the epicardial and middle layers. There were no significant differences between the groups in global LS of the septal wall.

CONCLUSIONS

In the early stage of CP, subepicardial myocardial damage precedes that of the subendocardial myocardium, and free-wall damage precedes that of the septal wall.

Anakinra for constrictive pericarditis associated with incessant or recurrent pericarditis

Objective

Frequent flares of pericardial inflammation in recurrent or incessant pericarditis with corticosteroid dependence and colchicine resistance may represent a risk factor for constrictive pericarditis (CP). This study was aimed at the identification of CP in these patients, evaluating the efficacy and safety of anakinra, a third-line treatment based on interleukin-1 inhibition, to treat CP and prevent the need for pericardiectomy.

Methods

Consecutive patients with recurrent or incessant pericarditis with corticosteroid dependence and colchicine resistance were included in a prospective cohort study from 2015 to 2018. Enrolled patients received anakinra 100 mg once daily subcutaneously. The primary end point was the occurrence of CP. A clinical and echocardiographic follow-up was performed at 1, 3, 6 months and then every 6 months.

Results

Thirty-nine patients (mean age 42 years, 67% females) were assessed, with a baseline recurrence rate of 2.76 flares/patient-year and a median disease duration of 12 months (IQR 9–20). During follow-up, CP was diagnosed in 8/39 (20%) patients. After anakinra dose of 100 mg/day, 5 patients (63%) had a complete resolution of pericardial constriction within a median of 1.2 months (IQR 1–4). In other three patients (37%), CP became chronic, requiring pericardiectomy within a median of 2.8 months (IQR 2–5). CP occurred in 11 patients (28%) with incessant course, which was associated with an increased risk of CP over time (HR for CP 30.6, 95% CI 3.69 to 253.09).

Conclusions

In patients with recurrent or incessant pericarditis, anakinra may have a role in CP reversal. The risk of CP is associated with incessant rather than recurrent course.

Constrictive Pericarditis: A Commonly Missed Cause of Treatable Diastolic Heart Failure

Constrictive pericarditis arises as a result of the fibrous thickening of the pericardium due to chronic inflammatory changes from various injuries. Increased pulmonary and systemic venous pressures manifest clinical features of left and right heart failure. Idiopathic or post-viral pericarditis is the most common cause followed by postpericardiotomy, radiation-induced causes. Right-sided heart failure symptoms predominate over left-sided heart failure symptoms due to the equalization of pressures. No single diagnostic test can provide a definitive diagnosis or evidence of constrictive pericarditis. Medical management is difficult for constrictive pericarditis. The treatment of choice for constrictive pericarditis is pericardiectomy.