Echocardiography-Based Deep Learning Model to Differentiate Constrictive Pericarditis and Restrictive Cardiomyopathy

BACKGROUND

Constrictive pericarditis (CP) is an uncommon but reversible cause of diastolic heart failure if appropriately identified and treated. However, its diagnosis remains a challenge for clinicians. Artificial intelligence may enhance the identification of CP.

OBJECTIVES

The authors proposed a deep learning approach based on transthoracic echocardiography to differentiate CP from restrictive cardiomyopathy.

METHODS

Patients with a confirmed diagnosis of CP and cardiac amyloidosis (CA) (as the representative disease of restrictive cardiomyopathy) at Mayo Clinic Rochester from January 2003 to December 2021 were identified to extract baseline demographics. The apical 4-chamber view from transthoracic echocardiography studies was used as input data. The patients were split into a 60:20:20 ratio for training, validation, and held-out test sets of the ResNet50 deep learning model. The model performance (differentiating CP and CA) was evaluated in the test set with the area under the curve. GradCAM was used for model interpretation.

RESULTS

A total of 381 patients were identified, including 184 (48.3%) CP, and 197 (51.7%) CA cases. The mean age was 68.7 ± 11.4 years, and 72.8% were male. ResNet50 had a performance with an area under the curve of 0.97 to differentiate the 2-class classification task (CP vs CA). The GradCAM heatmap showed activation around the ventricular septal area.

CONCLUSIONS

With a standard apical 4-chamber view, our artificial intelligence model provides a platform to facilitate the detection of CP, allowing for improved workflow efficiency and prompt referral for more advanced evaluation and intervention of CP.

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.

Ultrasound analysis of cervical thoracic duct for patients with constrictive pericarditis and chylothorax

PURPOSE

To analyze ultrasound features of cervical thoracic duct for patients with constrictive pericarditis and chylothorax.

METHODS

Patients were retrospectively assessed. The patients were divided into a non-pleural effusion (PE) group (n = 54), a chylothorax group (n = 23), and non-chylothorax group (n = 28). Conventional ultrasound was used to obtain the maximum inner diameter and collapse of the inferior vena cava, the inner diameter of left cervical thoracic duct, and the frequency of opening of the valve at the end of the left thoracic duct. Contrast ultrasonography was used to score the reverse flow of the thoracic tube.

RESULTS

The percentage of PE was 48.5%, and the percentage of chylothorax was 21.9%. The three groups had significant differences in five parameters. The inner diameter of left cervical thoracic duct was correlated with the degree of central venous pressure. Contrast ultrasonography was effective in quantitative assessment of the degree of intravenous-thoracic cord reverse flow which correlated with all parameters of central venous pressure.

CONCLUSION

Thoracic duct dilation and regurgitation secondary to central venous pressure can lead to chyloreflux disorder and may be the mechanism of chylothorax occurrence in constrictive pericarditis.

Corrigendum: Case Report: Epstein-Barr virus and constrictive pericarditis-an unusual combination

[This corrects the article DOI: 10.3389/fped.2023.1215928.].

Clinical symptoms, pathogenesis and postoperative course of non-specific constrictive pericarditis with dumbbell-shaped heart

Non-specific chronic constrictive pericarditis is a rare and debilitating chronic infection in developed countries and its rapid diagnosis and treatment has not affected its outcome and complication. A 15-year-old male, well nourished, negative HIV test, and without a history of previous pulmonary tuberculosis, was admitted to our hospital for exertional dyspnea (New York Heart Association, NYHA, functional class II). Our patient had had no pulmonary tuberculosis during childhood, had received anti-tuberculosis treatment, and was referred to our center for further surgical pericardiectomy.

Pericardiectomy for Constrictive Pericarditis with or without Cardiopulmonary Bypass

Aim

We aim to access the effect of pericardiectomy for constrictive pericarditis with or without cardiopulmonary bypass.

Methods

This was a review of pericardiectomy for constrictive pericarditis.

Results

Cardiopulmonary bypass is actually an important maneuver to attain complete relief of the constriction. The short additional time of cardiopulmonary bypass during the procedure has very little effect on the risk of morbidity of the main operation.

Conclusion

Incomplete pericardiectomy perhaps was the cause of postoperative remnant constriction and high diastolic filling pressure leading to multiorgan failure. Complete pericardiectomy (removal of phrenic-to-phrenic and the postero-lateral and inferior wall pericardial thickening) using cardiopulmonary bypass should be the routine for total relief of the constriction of the heart.

Multimodal Imaging of Constrictive Pericarditis Induced by Long-term Pergolide Treatment for Parkinson's Disease

We herein report the first case of constrictive pericarditis (CP) induced by long-term pergolide treatment for Parkinson's disease that was assessed using multimodal imaging in a 72-year-old patient with leg edema and dyspnea. The patient was correctly diagnosed with CP using multimodal imaging and successfully treated with pericardiectomy. The treatment history of Parkinson's disease and pathological findings of the removed pericardium suggested that long-term pergolide was the cause of CP. Properly recognizing pergolide as the cause of CP and accurately diagnosing CP using multimodal imaging may contribute to the early detection and treatment of pergolide-induced CP.

Cardiovascular Toxicities of Radiation Therapy and Recommended Screening and Surveillance

Radiation therapy is a key part of treatment for many cancers. Vast advancements in the field of radiation oncology have led to a decrease in malignancy-related mortality, which has uncovered some of the long-term side effects of radiation therapy. Specifically, there has been an increase in research looking into the cardiovascular side effects of chest radiation therapy for cancers of the esophagus, breast, and lung tissue as well as lymphomas. The manifestations of cardiac injury from irradiation range from short-term complications, such as pericarditis, to long-term damage including cardiomyopathy, valvular disease, and conduction disturbances. The aims of this article are to describe the cardiovascular side effects and the associated risk factors, to discuss risk reduction strategies, and to provide guidance in pre-radiation screening, post-radiation surveillance, and the management of these conditions.

Case report: Successful treatment of malignant pericardial effusion with pericardiocentesis, concurrent anti-inflammatory therapy and cancer therapy

Despite significant advancements in systemic anticancer therapies, cardiac tamponade remains a serious and potentially life-threatening complication in metastatic breast cancer (MBC). However, there is a paucity of comprehensive research investigating alternative management approaches, such as pericardiocentesis and anti-inflammatory therapy (AIT), to effectively address cardiac tamponade and mitigate the risk of heart failure arising from constrictive physiology (CP) in patients with MBC when traditional systemic anticancer drugs fail to yield favorable outcomes. Herein, we describe two cases of MBC with cardiac tamponade that occurred despite the administration of effective systemic anticancer drugs. In each case, pericardial effusion was detected in a patient who was undergoing palliative anticancer therapy for human epidermal growth factor receptor 2 (HER2)-positive MBC. The patients in these cases were successfully treated with pericardiocentesis and AIT (prednisolone and colchicine) for subsequent CP without substitution with their systemic anticancer drugs. Cardiac tamponade and CP are regarded as signs of advanced cancer and are associated with a worse clinical outcome in general; however, they can still be treated with an effective anticancer drug, pericardiocentesis, and management of CP by cardiooncology specialists.

Pericardiectomy for Successful Treatment of Constrictive Pericarditis in a Pediatric Patient

A 15-year-old girl with history of asthma and obesity presented with recurrent anasarca without systolic heart failure or significant renal disease. She was diagnosed with constrictive pericarditis and successfully underwent pericardiectomy with pericardial stripping and a waffle procedure. (Level of Difficulty: Advanced.).

Pericardial mesothelioma presenting as constrictive pericarditis

A 46-year-old woman underwent pericardiocentesis and pericardial window for recurrent pericardial effusion. She presented 17 months later with signs and symptoms consistent with constrictive pericarditis. Cardiac magnetic resonance imaging revealed an infiltrative mass surrounding the pericardium. A transcutaneous core needle biopsy of the pericardium confirmed the diagnosis of pericardial mesothelioma.

Early life threatening constrictive pericarditis following off-pump CABG

We present a unique case of aggressive symptomatic constrictive pericarditis within one month following off pump coronary artery bypass grafting surgery. The patient had a medical history of Hodgkin's lymphoma treated with radiotherapy and chemotherapy 20 years ago. Investigations confirmed constrictive pericardium with patent grafts and good biventricular function. Pericardiectomy was successful with remarkable recovery of symptoms.

Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

Acute fibrinous constrictive pericarditis and large pericardial effusion as the first manifestation of systemic lupus erythematsous disease in an adult male patient

Systemic lupus erythematosus (SLE) can have various manifestations. Although cardiac involvement is very common in SLE patients, a severe acute pericarditis as the first manifestation of SLE in a male patient is relatively rare. A 36-year-old male was admitted to our hospital with acute pericarditis, large circumferential fibrinous pericarditis, and major criteria of a high-risk case of acute pericarditis. After a complete investigation, the underlying disease was revealed to be SLE. All of his symptoms were completely resolved after 6 weeks of treatment with non-steroidal anti-inflammatory drugs and corticosteroids with no need for a pericardiocentesis. Patients with acute fibrinous pericarditis should be considered and precisely investigated for multiorgan autoimmune process such as SLE, to avoid unnecessary intervention, and minimize the risk of recurrence and chronicity of the condition.

An Unusual Case of Parasitic Constrictive Pericarditis

Parasitic constrictive pericarditis is a rare entity. We present a case of a 75-year-old man who presented with dyspnea, ascites, and pedal edema and was found to have constrictive pericarditis on multimodality imaging with positive serology for Strongyloides Stercoralis. Treatment required ivermectin and radical pericardiectomy with significant clinical improvement. (Level of Difficulty: Intermediate.).

A Rare Case of Constrictive Pericarditis: Inflammatory Myofibroblastic Tumor

A previously healthy 15-year-old adolescent female presented with dependent edema, ascites, and dyspnea on exertion. The result of her initial evaluation was consistent with constrictive pericarditis in the setting of local low-grade spindle cell sarcoma. She was unresponsive to traditional medical management and required concurrent mass resection and radical pericardiectomy for definitive treatment. (Level of Difficulty: Intermediate.).

Case report: Epstein-Barr virus and constrictive pericarditis-An unusual combination

Constrictive pericarditis is a chronic inflammatory process that can lead to heart failure if not diagnosed and treated correctly. Although Epstein-Barr virus (EBV)-related pericarditis is a very rare condition, it should still be considered for a differential diagnosis. We report the case of an 18-year-old male, who was surgically treated for constrictive pericarditis, in which in situ hybridization to Epstein-Barr virus-encoded RNA (EBER) probe of the excised pericardium led to the subsequent etiological diagnosis of chronic pericarditis caused by EBV.

Diagnosis and Surgical Management of Pericardial Constriction after Cardiac Surgery

OBJECTIVES

Prior cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment.

METHODS

We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation.

RESULTS

Median patient age was 64 (56-72) years, and the median interval between prior operation and pericardiectomy was 2.7 years (range: 0-54 years). Previous operations included CABG 114 (43%), valve surgery 85 (32%), combined CABG and valve surgery 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate to severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P= 0.013), diabetes (P=0.019), and non-elective pericardiectomy within two years of cardiac surgery (P<0.001) were associated with decreased long-term survival.

CONCLUSIONS

Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.

Case report: Constrictive pericarditis after coronary artery perforation during percutaneous coronary intervention

A 77-year-old man underwent percutaneous coronary intervention (PCI) at the right coronary artery, which was complicated by coronary artery perforation (CAP). After prolonged balloon tamponade proximal to the CAP there was no more contrast extravasation, and the CAP was thought to have resolved. Computed tomography (CT) and echocardiography the following day did not find evidence of continued bleeding, and the patient was discharged. Echocardiograms and chest CT scans obtained one week and two months after PCI detected no remarkable interval change. The patient complained of progressive dyspnea and abdominal distension seven months after PCI however, and echocardiography found an increased amount of pericardial effusion and constrictive physiology. The patient underwent pericardiectomy due to congestive hepatopathy, and progressive dyspnea. The pericardium was thickened and adhesive, and a dark bloody effusion was found. Pathology was unremarkable except for thick fibrosis. After the operation the patient made full recovery, and is stable three years after surgery.

Malignant pleural mesothelioma with constrictive pericarditis as the first manifestation: A case report

Pleural mesothelioma (PM) with pericardial involvement is extremely rare. We now report a rare case of malignant PM with constrictive pericarditis as the first presentation. A 59-year-old male diagnosed with constrictive pericarditis underwent pericardiectomy and pericardial pathology revealed mesothelial hyperplasia. Eight months after surgery, the patient was admitted to the hospital with chest tightness and wheezing for 5 days. Computed tomography scan of the chest showed a left lung expansion insufficiency, limited bilateral pleural thickening, pericardial thickening with a small amount of pericardial effusion, and multiple enlarged lymph nodes in the mediastinum, bilateral supraclavicular fossa, bilateral cervical roots, and right axilla. The pleural malignancy should be possibly considered. Pathology after pleural puncture showed malignant PM. Pathology after left supraclavicular lymph node puncture biopsy showed metastatic malignant mesothelioma. The diagnosis of this patient was clear. Although malignant PM rarely involves the pericardial constriction, we cannot ignore the fact that malignant PM involves the pericardium. The patient has been diagnosed with constrictive pericarditis, accompanied by pleural thickening and pleural effusion. Without other pathogenic factors, pleural biopsy should be aggressively performed in patients with constrictive pericarditis to determine the cause.

Constrictive Pericarditis: A Diagnostic Conundrum

A 65-year-old male presented with chest pain, tachycardia, tachypnea, and diminished breath sounds. His lab investigations revealed an elevated leukocyte count, erythrocyte sedimentation rate, and B-type natriuretic peptide. Transthoracic echocardiography and chest imaging revealed the presence of pericardial effusion without tamponade and he was treated for presumed acute idiopathic pericarditis. He was started on indomethacin and colchicine but he stopped them prematurely due to side effects. Subsequently, he developed pleural effusions and ascites requiring multiple thoracenteses and paracenteses. Due to equivocal echocardiographic findings, he underwent invasive hemodynamic measurements which demonstrated equalization of filling pressures and ventricular interdependence, confirming constrictive pericarditis. Due to ongoing pericardial inflammation on cardiovascular magnetic resonance imaging, he was treated with a prednisone taper. Due to persistent symptoms and fibrosis of the pericardium on cross-section imaging, he underwent pericardiectomy. He did well with the procedure and has had an uneventful clinical follow-up.

Constrictive pericarditis heart failure in a patient with atrial fibrillation: A diagnostic challenge

Constrictive pericarditis is an infrequent cause of heart failure. Diagnosis is challenging and requires a high level of suspicion. Subtle echocardiographic findings, as the pericardial bounce, could be the clue to diagnosis.

Evaluation of Pericardial Thickening and Adhesion using High Frequency Ultrasound

BACKGROUND

Routine echocardiography using a standard frequency ultrasound (SFU) probe has insufficient spatial resolution to clearly visualize the parietal pericardium (PP). High frequency ultrasound (HFU) has an enhanced axial resolution. This study aimed to use commercially available high frequency linear probe (HFLP) to evaluate the apical PP thickness (PPT) and pericardial adhesion (PA) in both normal pericardium and/or pericardial diseases.

METHODS

From April 2002 to March 2022, 227 healthy individuals, 205 patients with apical aneurysm (AA) and 80 patients with chronic constrictive pericarditis (CP) were recruited to participate in this study. All subjects received both SFU and HFU to image the apical PP (APP) and pericardial adhesion (PA). Some subjects received CT scans.

RESULTS

The apical PPT was measured by HFU and found to be 0.60±0.01 (0.37∼0.87) mm in normal controls, 1.22±0.04 (0.48∼4.53) mm in patients with AA, and 2.91±0.17 (1.13∼9.01) mm in patients with CP. A tiny physiologic effusion was observed in 39.2% of normal individuals. PA was detected in 69.8% of patients with local pericarditis of AA and 97.5% of patients with CP. Visibly thickened visceral pericardium was observed in six CP patients. The apical PPT measurements obtained by HFU correlated well with those obtained by CT in those CP patients. However, CT could only clearly visualize the APP in 45% of normal individuals and 37% of patients with AA. In 10 patients with CP, both HFU and CT demonstrated equal ability to visualize the very thickened APP.

CONCLUSIONS

The apical PPTs measured by HFU in normal controls was 0.40∼1.00 mm, consistent with previous reports from necropsy studies. HFU had a higher resolution in distinguishing local pericarditis of the APP from normal individuals. We found that HFU was superior to CT in imaging APP lesions, as CT failed to visualize APP in more than half of both normal individuals and patients with AA. The fact that all 80 patients with CP in our study had significantly thickened APP raises doubt regarding the previously reported findings that 18% of CP patients had normal PPT.

Advances in multi-modality imaging for constrictive pericarditis and pericardial inflammation: role of imaging-guided therapy

INTRODUCTION

Constrictive pericarditis (CP) can result from uncontrolled inflammation of the pericardium. This can be due to various etiologies. CP can lead to both left- and right-sided heart failure with associated poor quality of life, so early recognition is key. The evolving role of multimodality cardiac imaging allows for earlier diagnosis and facilitates management to help mitigate this adverse outcome.

AREAS COVERED

This review discusses the pathophysiology of constrictive pericarditis, chronic inflammation and autoimmune etiologies, clinical presentation of CP, and advances in multimodality cardiac imaging for diagnosis and management. Echocardiography and cardiac magnetic resonance (CMR) imaging remain cornerstone modalities to evaluate this condition, whereas additional imaging modalities such as computed tomography and FDG-positron emission tomography can provide complementary information.

EXPERT OPINION

Advances in multimodality imaging allow for a more precision diagnosis of constrictive pericarditis. There has been a paradigm shift in pericardial disease management with advances in multimodality imaging, especially CMR, to detect subacute and chronic inflammation. This has enabled imaging-guided therapy (IGT) to both help prevent and potentially reverse established constrictive pericarditis.

Intrapericardial Fibrinolytic Therapy in Purulent Pericarditis: A Review of Two Cases

Purulent pericarditis is the infection of the pericardial space with pus formation. High mortality and morbidity can be explained by cardiac tamponade and septic shock in the acute phase, while chronically, it can lead to recurrent purulent pericarditis and constrictive pericarditis. We present two cases of purulent pericarditis treated with intrapericardial recombinant tissue plasminogen activator (r-tPA) for three consecutive days in addition to surgical pericardial drainage. In both instances, loculated effusions and re-accumulation of pericardial fluid persisted despite adequate antibiotic coverage and surgical drainage. Intrapericardial fibrinolysis was considered a less invasive alternative to extensive surgery to prevent constrictive pericarditis and improve clinical outcomes. Both patients had complete clinical recovery and there was no evidence of constrictive pericarditis during follow-up. There is scant literature regarding r-tPA therapy for purulent pericarditis, most of which is limited to case reports or case series. The most commonly used regimen is three doses of tPA administered into the pericardial space over three days. It is a safe and potentially effective therapy in preventing constrictive pericarditis and need of pericardiectomy.

Severely Calcified Pericardium Causing Constrictive Pericarditis

Constrictive pericarditis (CP) is a type of diastolic heart failure caused by an inelastic pericardium that impairs cardiac filling. Diagnosing CP can be challenging, and a variety of imaging techniques may be necessary. We present a unique case of severely calcified pericardium leading to CP.

Multi-Modality Imaging Approach to a rare form of Biventricular Ring-Shaped Constrictive Pericarditis

A 48-year-old man with AIDS/HIV and a previous history of tuberculous pericarditis 25 years earlier was admitted to our department of infectious diseases because of P. carinii pneumonia. A CT (computed tomography) scan described diffuse pericardial thickening with extensive pericardial calcifications on both ventricles. A transthoracic echocardiogram showed all the typical hemodynamic features of pericardial constriction. A review of the CT with 3D reconstruction revealed the presence of ring-shaped pericardial calcification at the basal segments of right and left ventricles extending over the inferior atrioventricular groove, the inferior interventricular groove and the cranial wall of the right atrium. Only a few cases of ring-shaped constrictive pericarditis have been reported and both global ventricular constriction and localized segmental constriction have been described. Our case wants to underline how important a comprehensive multi-modality imaging approach is to this rare form of constrictive pericarditis.

Left Ventricular Angiogram in Constrictive Pericarditis

A 14-year-old boy presented with dyspnea on exertion and easy fatiguability for 1 year. He also had an episode of pedal edema 6 months prior, which resolved with diuretics. He had a history of tuberculosis treated with a 6-month course of antitubercular therapy. After a series of tests and analyses, it was evident that longitudinal contraction of the left ventricle was preserved, whereas the circumferential contraction was severely impaired. Pericardial calcification also could be seen encircling the left and right ventricles. Pericardial calcification is evident in around 25% of cases of constrictive pericarditis and predominantly seen in those with tubercular and pyogenic etiology. The subepicardial myocardial fibers are responsible for radial shortening and subendocardial fibers are responsible for longitudinal shortening. In constrictive pericarditis, the involvement of the subepicardial fibers leads to reduction in the circumferential shortening. The patient was referred for pericardiectomy.

Constrictive Pericarditis with Cardiac Ascites Caused Spontaneous Bacterial Peritonitis

Patients with constrictive pericarditis (CP) typically present with symptoms related to right-sided heart failure, such as cardiac ascites. Spontaneous bacterial peritonitis (SBP) usually arises in association with ascites secondary to hepatic cirrhosis. We herein report a rare case of CP in which SBP developed due to cardiac ascites, even in the absence of cirrhosis. In this case, pericardiectomy improved both the hemodynamics and the ascites, while therapy with diuretics alone was insufficient. It is important to consider SBP in the differential diagnosis when any abdominal symptoms or an inflammatory response is found in patients with heart failure and cardiac ascites.

Constrictive pericarditis caused by pericardial substitution using expanded polytetrafluoroethylene

BACKGROUND

Expanded polytetrafluoroethylene (ePTFE) is commonly used as a pericardial substitute during cardiac surgery to prevent cardiac injury during re-sternotomy. However, although rare, constrictive pericarditis associated with ePTFE has been reported.

MATERIAL, METHODS AND RESULTS

Here, we report a rare case of constrictive pericarditis developed due to severe restriction of cardiac motion associated with the ePTFE membrane used as a pericardial substitute. Hemodynamic improvement has been achieved by surgical removal of the ePTFE membrane and exudates within the overlapped portion of the ePTFE membranes, and dissection of the epicardial fibrous thickening.

CONCLUSION

Considering the risk of constrictive pericarditis, we believe that the use of ePTFE membranes as a pericardial substitute should be carefully indicated for only selected patients.

“Turtle cage” method in the cardiac surgical treatment of constrictive pericarditis – our short-term results

Összefoglaló. Bevezetés: A pericarditis constrictiva egy krónikus gyulladásos folyamat révén kialakuló betegség, melynek során a pericardium elveszíti rugalmasságát, gátolja a szív működését, végső soron szívelégtelenséghez vezet. Egyetlen oki terápiája sebészi. A műtéti megoldásként legelterjedtebben alkalmazott teljes pericardiectomia hosszú időtartamú műtét, amely akár 18%-os műtéti kockázattal járhat, és amelyhez az esetek jelentős részében szívmotor alkalmazása szükséges. Célkitűzés: Egy, az irodalomból már ismert, de csak ritkán és a legtöbbször csak a hagyományos pericardiectomia kiegészítéseként alkalmazott műtéti eljárás, a "turtle cage" pericardiectomia hatásosságának, eredményeinek, lehetséges előnyeinek vizsgálata. Módszer: 2008 és 2021 között Klinikánkon 33 "turtle cage" műtétet végeztünk pericarditis constrictiva miatt. A posztoperatív 30 napos időszak eredményeit több, a nemzetközi irodalomban megjelent közlemény adataival hasonlítottuk össze. Eredmények: Az intraoperatív kép alapján minden esetben sikeres volt a beavatkozás, a 33 beteg egyikénél sem volt szükség szívmotor alkalmazására (0%), szemben a vizsgált közleményekkel. A 33 beavatkozás során 1 beteget veszítettünk el (3%), valamint 1 páciensnél volt szükség vérzés miatti reoperációra (3%), 4 betegnél dialízisre (12,1%). Ezen eredményeink összevethetők a nagy esetszámot felvonultató közleményekkel, és szignifikánsan jobbak az egyik megjelenített európai centrum eredményeinél. Következtetés: Az általunk alkalmazott "turtle cage" pericardiectomia önmagában is megfelelő eljárás a pericarditis constrictiva szívsebészeti kezelésére. Alkalmazásával minimalizálható a szívmotor használatának szükségessége, ezáltal a műtéti kockázat. Eredményeink a technikának köszönhetően még a nagy esetszámú, sok tapasztalattal rendelkező centrumok eredményeivel is összevethetők, azokkal megegyezők. Orv Hetil. 2022; 163(10): 393-399.

SUMMARY

INTRODUCTION

Constrictive pericarditis is a disease caused by a chronic inflammatory process, which is characterized by the pericardium's loss of flexibility, inhibiting the function of the heart, ultimately causing heart failure. The only definitive therapy is surgical. Total pericardiectomy, which is the most common surgical approach, is a lengthy procedure with up to 18% operative risk, and it often requires the use of cardiopulmonary bypass.

OBJECTIVE

The evaluation of the effectiveness, results and possible advantages of a surgical technique, "turtle cage" pericardiectomy, which is described in the literature, although rarely used, mainly in addition to conventional pericardiectomy.

METHOD

Between 2008 and 2021, we performed 33 "turtle cage" procedures on patients with constrictive pericarditis in our Institute. We compared the results of the 30-day postoperative period with internationally published data from multiple sources.

RESULTS

Based on intraoperative findings, the procedure was successful in all cases, there were no instances when the use of cardiopulmonary bypass was required (0%). During the 33 procedures, we lost 1 patient (3%), reoperation was necessary for postoperative bleeding in 1 case (3%), and postoperative dialysis was necessary in 4 cases (12.1%). These results are comparable to those published by high-volume centres, and significantly better than those of one of the European centres published.

CONCLUSION

The "turtle cage" pericardiectomy, as performed in our Institute, is suitable for the treatment of constrictive pericarditis on its own. With its use, we were able to minimize the use of cardiopulmonary bypass and the operative risk. Our results with this technique are comparable to those of the high-volume, highly experienced centres. Orv Hetil. 2022; 163(10): 393-399.

Incidentally detected dual right coronary artery in patient with constrictive pericarditis

We report a case of a 29-year-old man with constrictive pericarditis where CT angiography incidentally demonstrated a dual right coronary artery (RCA). The present case highlights the diagnostic criterion for dual RCA as well as the potential clinical implications of the anomaly.

Case Report: Protein-Losing Enteropathy in Association With Tuberculosis-Related Constrictive Pericarditis

Protein-losing enteropathy (PLE) is a clinical disorder in which an excessive amount of serum protein is lost into the gastrointestinal tract, resulting in hypoproteinemia and malnutrition. PLE is associated with a wide range of gastrointestinal disorders and the rare complication of constrictive pericarditis. We report a case in which pericardiectomy achieved marked improvement of extremely severe hypoalbuminemia caused by PLE associated with tuberculosis-related constrictive pericarditis. The formation of diarrhea and edema was aggravated by PLE, resulting in hypoalbuminemia. Cardiac computed tomography showed a calcified pericardium. Echocardiography showed decreased cardiac function underlying PLE. Functional imaging with technetium-99m serum albumin identified the region of protein leakage as the intestine. After pericardiectomy, the diarrhea ceased completely. Serum albumin concentrations were increased (3.3-3.7 g/dL), which indicated resolution of the PLE.

Ascitic Fluid Analysis Leading to the Diagnosis of Constrictive Pericarditis in 2 Patients

Although well documented, constrictive pericarditis is a rare entity and an uncommon cause of heart failure. A stiff and noncompliant pericardium creates the disease's unique hemodynamics and leads to elevated venous pressures, hepatic sinusoidal congestion, and draining of protein-rich fluid into the peritoneal cavity presenting as ascites. The low incidence in addition to its varied and subtle clinical presentations can often lead to a delay in diagnosis. Here, we present 2 clinical cases of constrictive pericarditis in which ascitic fluid analysis was important-one patient who presented with new-onset ascites with concern for cirrhosis and another patient who presented with symptoms concerning for heart failure with ascites. Through their hospital course and workup, we highlight the importance of diagnostic sampling of ascitic fluid to prompt the consideration of constrictive pericarditis followed by utilizing advanced diagnostics, such as echocardiogram and cardiac catheterization to reach the correct diagnosis in an otherwise often overlooked pathology.

Natriuretic peptides to differentiate constrictive pericarditis and restrictive cardiomyopathy: A systematic review and meta-analysis

Previous studies have shown that natriuretic peptide levels are increased in patients with restrictive cardiomyopathy (RCM) but not in constrictive pericarditis (CP). We performed a systematic review and meta-analysis to evaluate the diagnostic utility of B-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) to differentiate CP and RCM. We searched electronic databases from inception to January 07, 2021. Studies involving adult patients that assessed the utility of natriuretic peptides to differentiate CP and RCM were included. All meta-analyses were performed using a random-effects model. Seven studies (four case-control and three cohorts) involving 204 patients were included. The mean age ranged between 25.7 and 64.1 years and 77% of patients were men. BNP levels were significantly lower (standardized median difference [SMD], -1.48; 95% confidence interval [CI], -2.33 to -0.63) in patients with CP compared to RCM. The pooled area under the curve (AUC) of the BNP level was 0.81 (95% CI, 0.70-0.92). NT-proBNP (SMD, -0.86; 95% CI, -1.38 to -0.33) and log NT-proBNP (SMD, -1.89; 95% CI, -2.59 to -1.20) levels were significantly lower in patients with CP compared to RCM. Our review shows that BNP and NT-proBNP levels were significantly lower in patients with CP compared to RCM. The pooled AUC of BNP level showed a good diagnostic accuracy to differentiate both conditions.

Two-dimensional transthoracic echocardiographic demonstration of reduction in fibrin content in purulent pericarditis following intrapericardial fibrinolytic agent administration

We describe an adult patient who presented with purulent pericarditis (PP) in whom two-dimensional transthoracic echocardiography demonstrated a marked decrease in the area of the right ventricular (RV) wall together with the overlying fibrin following intrapericardial administration of a fibrinolytic agent. Documentation of this decrease by measurements performed and illustrated on two-dimensional images has not been reported previously in an adult patient with PP, to the best of our knowledge.

Constrictive pericarditis following heart transplantation: Reality or fiction?

Constrictive pericarditis (CP) is a curable cause of diastolic heart failure with prior cardiac surgery being a recognizable etiology. We report a patient who developed CP one year following heart transplantation. Several clinical and imaging related factors may lead to diagnostic delays in similar patients, including the mistaken belief that transplanted hearts are devoid of pericardium and thus do not develop constriction. Post-transplantation pericardial effusion, mediastinitis, and cardiac rejection predispose to future CP. Caretakers should consider this entity in allograft recipients who develop heart failure symptoms of unclear etiology.

Pericardiectomy for constrictive pericarditis in a resource constraint setting

Introduction

Constrictive pericarditis is the endpoint of the natural history of acute pericarditis of different aetiologies where a chronic inflammatory process results in a thickened, fibrotic and inelastic pericardium with consequent impairment of diastolic function and systemic congestion.

Aim

To evaluate the clinical features, diagnosis, surgical management and outcome of patients with constrictive pericarditis as managed in a local setting of a tertiary hospital in Ghana.

Material and methods

A retrospective review of the medical records of patients who had undergone pericardiectomy for constrictive pericarditis at a teaching hospital.

Results

Ten patients underwent pericardiectomy for the period of study. There were 8 (80%) males and 2 (20%) females. The mean age was 20.4 ±17.2 years. Six of the patients 6 (60%) were in NYHA class III. Preoperative diagnostics included chest X-ray, echocardiography, and computed tomography scan. The surgical approach for the pericardiectomy was median sternotomy. The mean operative time was 159.9 ±43.0 min. The mean postoperative days spent before being discharged was 6.9 ±2.3 days. Nine (90%) of the patients were in NYHA class I after a mean follow-up of 19.3 ±16.7 months. One patient died 6 weeks after surgery with heart failure and one patient was lost to follow-up.

Conclusions

Surgical pericardiectomy via median sternotomy is still the standard modality of treatment for constrictive pericarditis with excellent results even in resource constraint settings.

Pericardiectomy for Constrictive Tuberculous Pericarditis: A Systematic Review and Meta-analysis on the Etiology, Patients' Characteristics, and the Outcomes

Tuberculosis (TB) is the most common etiology of constrictive pericarditis in the developing world. In this study, we collected currently available data to evaluate the outcomes following pericardiectomy in patients with constrictive tuberculous pericarditis. We retrieved electrical databases, including PubMed and PubMed Central, from 1985 AD and onwards. We included articles that had more than 80% TB as the etiology and articles with mixed etiologies. Pooled analysis was done in Review Manager (RevMan) version 5.2 (The Nordic Cochrane Centre, Copenhagen). and Stata Statistical Software, Release 16 ( StataCorp LLC, College Station, TX). We compared the mortality in patients after pericardiectomy due to TB with other etiologies. In-hospital mortality versus one-year mortality was analyzed in studies with constrictive pericarditis of mixed etiologies. We also compared pre-operative New York Heart Association (NYHA) grade to post-operative NYHA grade one year after pericardiectomy. We calculated the pooled mean of postoperative hospital stay, postoperative intensive care unit (ICU) stay, and in-hospital mortality. A total of 12 articles and 859 patients were included in the final analysis. Pericardiectomy was performed mostly on middle-aged men with or without previous comorbidity. Total pericardiectomy was the preferred surgical procedure performed on a mean of 93% of patients. The pooled analysis shows a significant decrease in all-cause mortality in patients with TB as compared to other etiologies (pooled risk ratios (RR) 0.34 CI [0.12,1.01] I2 = 61%) and a lower but insignificant in-hospital mortality in comparison to one-year mortality in studies with mixed etiologies (RR 0.59 [0.11,3.11] I2= 61%). There was a significant improvement in the NYHA grade of the patients one year following pericardiectomy (RR 8.04, CI [5.20,12.45], I2= 0%). The mean postoperative hospital stay and the postoperative ICU stay were calculated and reported in terms of days. The mean postoperative hospital stays in studies with more than 80% of TB cases is 13.34 (10.21, 16.47) with a mean standard deviation of 4.46 (2.87, 6.05). The mean postoperative ICU stay is 1.93 (1.47, 2.39), with a mean standard deviation of 3.26 (2.51, 4.00), and the mean in-hospital mortality is 0.07 (0.02, 0.12). Similarly, the mean postoperative hospital stay in studies with mixed etiologies is 19.40 (11.93, 26.87) with a mean standard deviation of 8.26 (4.21, 12.52). The mean postoperative ICU stay is 3.52 (1.93, 5.10) with a mean standard deviation of 2.34 (1.36, 3.32). The mean in-hospital mortality is 0.06 (0.04, 0.08). There is significant heterogeneity along with a number of methodological concerns, and therefore, generalization of the data should be done with caution, and a randomized controlled trial in the future may be beneficial.

Effects of Intraoperative Fluid Management on Postoperative Outcomes After Pericardiectomy

Background: The effects of intraoperative fluid management on the patients with constrictive pericarditis undergoing pericardiectomy remain unclear. This study explored the relationship between intraoperative fluid management and postoperative outcomes in these patients.

Methods: We retrospectively studied 92 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to the restrictive group and the liberal group according to the intraoperative total fluid infusion rate. Postoperative outcomes were compared between the two groups. Binary logistic regression analysis was performed to determine the relationship between the intraoperative total fluid infusion rate and postoperative outcomes.

Results: There were 46 (50.0%) cases in the restrictive group and 46 (50.0%) cases in the liberal group. Compared with the liberal group, the restrictive group had significantly lower incidences of postoperative complications and cardiac complications (P = 0.005 and P = 0.006, respectively). Binary logistics regression analysis also showed the increased risks of postoperative complications (OR, 3.551; 95% CI, 1.192–10.580; P = 0.023) and cardiac complications (OR, 6.037; 95% CI, 1.472–25.052; P = 0.013) at the liberal group. In addition, the restrictive group had shorter postoperative hospital stay (P = 0.026) in comparison to the liberal group.

Conclusion: In patients with constrictive pericarditis undergoing pericardiectomy the intraoperative total fluid infusion rate was significantly associated with postoperative outcomes. Restrictive fluid management strategy was related to the positive effects on enhanced recovery after surgery and could be advised as the preferred intraoperative fluid management policy.

Pericarditis and Sacroiliitis in a World Traveler

A 65-year-old immunocompromised woman presented with progressive dyspnea and sacroiliac joint pain. Cardiac magnetic resonance showed abnormal right ventricular filling with septal bounce and abnormal pericardial enhancement, suggestive of constrictive pericarditis. Cultures from pericardium following pericardiectomy grew Coccidioides immitis. She was diagnosed with coccidioidomycosis and responded to pericardiectomy and amphotericin. (Level of Difficulty: Intermediate.)

Prognostic importance of mitral e' velocity in constrictive pericarditis

AIMS

Increased medial mitral annulus early diastolic velocity (e') plays an important role in the echocardiographic diagnosis of constrictive pericarditis (CP) and mitral e' velocity is also a marker of underlying myocardial disease. We assessed the prognostic implication of mitral e' for long-term mortality after pericardiectomy in patients with CP.

METHODS AND RESULTS

We studied 104 surgically confirmed CP patients who underwent echocardiography and cardiac catheterization within 7 days between 2005 and 2013. Patients were classified as primary CP (n = 45) or mixed CP (n = 59) based on the clinical history of concomitant myocardial disease. On multivariable analysis, medial e' velocity and mean pulmonary artery pressure were independently associated with long-term mortality post-pericardiectomy. There were significant differences in survival rates among the groups divided by cut-off values of 9.0 cm/s and 29 mmHg for medial e' and mean pulmonary artery pressure, respectively (both P < 0.001). Ninety-two patients (88.5%) had elevated pulmonary artery wedge pressure (PAWP) (≥15 mmHg); there was no significant correlation between medial E/e' and PAWP (r = 0.002, P = 0.998). However, despite the similar PAWP between primary CP and mixed CP groups (21.6 ± 5.4 vs. 21.2 ± 5.8, P = 0.774), all primary CP individuals with elevated PAWP had medial E/e' <15 as opposed to 34 patients (57.6%) in the mixed CP group (P < 0.001).

CONCLUSION

Increased mitral e' velocity is associated with better outcomes in patients with CP. A paradoxical distribution of the relationship between E/e' and PAWP is present in these patients but there is no direct inverse correlation between them.

Clinical significance of pulmonary hypertension in patients with constrictive pericarditis

OBJECTIVES

We investigated haemodynamics and clinical outcomes according to type of pulmonary hypertension (PH) in patients with constrictive pericarditis (CP).

BACKGROUND

As the prevalence of CP with concomitant myocardial disease (mixed CP) grows, PH is more commonly seen in patients with CP. However, haemodynamic and outcome data according to the presence or absence of PH are limited.

METHODS

150 patients with surgically confirmed CP who underwent echocardiography and cardiac catheterisation within 7 days at two tertiary centres were divided into three groups: no-PH, isolated postcapillary PH (Ipc-PH) and combined postcapillary and precapillary PH (Cpc-PH). Primary outcome was all-cause mortality during follow-up.

RESULT

In this retrospective cohort study, 110 (73.3%) had PH (mean pulmonary artery pressure ≥25 mm Hg). Cpc-PH, using defined cut-offs for pulmonary vascular resistance (>3 Wood units) or diastolic pulmonary gradient (≥7 mm Hg), was seen in 18 patients (12%). The Cpc-PH group had a higher prevalence of comorbidities (diabetes and atrial fibrillation) and concomitant myocardial disease as an aetiology of CP than other groups. Pulmonary vascular resistance had a significant direct correlation with medial E/e' by Doppler echocardiography (r=0.404, p<0.001). Survival rate was significantly lower in the Cpc-PH than the no-PH (p=0.002) and Ipc-PH (p=0.024) groups. On multivariable analysis, age, New York Heart Association functional class IV, medial e' velocity, Cpc-PH and Ipc-PH were independently associated with long-term mortality.

CONCLUSION

Combined postcapillary and precapillary PH develops in a subset of patients with CP and is associated with long-term mortality after pericardiectomy.

A rare case of constrictive pericarditis with Budd-Chiari syndrome due to right atrial thrombosis

Patients living with HIV (PLWH) with previous pulmonary tuberculosis, presenting with disproportionate ascites to peripheral congestion, should alert the clinician to consider constrictive pericarditis and Budd–Chiari syndrome (BCS). Constrictive pericarditis is the scarring and loss of the pericardial sac elasticity. The aetiology of constrictive pericarditis varies between developed and developing countries, with infective causes like tuberculosis being significant in South Africa. Budd–Chiari syndrome is a group of disorders characterised by hepatic venous outflow obstruction. The level of obstruction in Budd–Chiari syndrome varies globally. In Asia, South Africa, India, and China, obstruction is predominantly found in the inferior vena cava while in Western countries, hepatic vein obstruction occurs. Patients living with HIV are at increased risk of arterial and venous thromboembolism. The clinician must consider Budd–Chiari syndrome in patients living with HIV presenting with ascites. In patients living with HIV, tuberculosis co-infection has been associated with a higher risk of pericarditis. Both constrictive pericarditis and Budd–Chiari syndrome share a remarkably similar clinical presentation, with ascites and hepatomegaly. There is a dearth of literature on co-existent constrictive pericarditis and Budd–Chiari syndrome. We describe a 31-year-old HIV-infected female, on anti-retroviral therapy (CD4 count 208 cells/uL, undetected viral load), with previous pulmonary tuberculosis, who presented with a 2-month history of abdominal swelling, peripheral oedema, and New York Heart Association grade 4 dyspnoea. Examination revealed an elevated jugular venous pulsation with CV waves, atrial fibrillation, right-sided S3 gallop, pansystolic murmur (3/6) at the left sternal border, tender hepatomegaly, and massive ascites with minimal peripheral oedema. The discordant size of ascites prompted investigations, namely, ultrasound abdomen, echocardiogram, and computed tomography (chest and abdomen). These revealed constrictive pericarditis and Budd–Chiari syndrome with thrombus formation in the right atrium, hepatic vein, and inferior vena cava. She was initiated onto anti-coagulation, anti-tuberculosis therapy and referred for pericardiectomy. Clinicians must maintain a suspicion for constrictive pericarditis and Budd–Chiari syndrome in HIV-infected patients, especially in those with a previous tuberculosis, presenting with features of right heart failure.

Disseminated Tuberculosis With Cardiac Tamponade in an Immunocompetent Individual

We report a case of disseminated tuberculosis with cardiac tamponade in a 26-year-old man from northern Portugal. He was imprisoned for one year before the diagnosis and had no known immunosuppressing conditions. A high level of suspicion with a detailed review of risk factors and exposure history (e.g., in this case, imprisonment is a risk factor for tuberculosis) is necessary when pursuing a diagnosis of extrapulmonary tuberculosis and treatment should be started as soon as possible when life-threatening manifestations occur. We used a 12-month course of antituberculosis agents associated with steroids, in our case. The patient had a good clinical response and no signs of disease at the end of the treatment.

Heart failure as a first sign of disseminated tuberculosis

Tuberculous pericarditis is a rare extra-pulmonary manifestation of tuberculosis observed mainly in developed countries. It usually presents with concomitant tuberculous infection at a different site and, due to the lack of clinical specificity, diagnosis can be difficult. Thus, a diagnostic delay is frequent, entailing increased morbidity and mortality. The authors present a case of disseminated tuberculosis with predominantly cardiac symptoms with multiple negative samples for Mycobacterium tuberculosis, which evolved to constrictive pericarditis. With this case report, the authors emphasize the demand for a high index of suspicion for achieving a diagnosis and the importance of a multidisciplinary approach.