Constrictive pericarditis

Constrictive pericarditis
Other namesPericarditis – constrictive
Constrictive pericarditis is defined by a thickened pericardium and decreased elasticity
SpecialtyCardiology 
SymptomsFatigue, difficulty breathing
CausesTuberculosis, Idiopathic/viral
Diagnostic methodCT scan, MRI
TreatmentAnti-inflammatory medication, Surgery

Constrictive pericarditis is a condition characterized by decreased elasticity and an increased thickening of the pericardium.[1] These changes reduce the ability of the heart to fill with blood and can lead to symptoms of heart failure.[1]

This condition may result from various disease processes which can have similar symptoms, and has been historically difficult to diagnose.[2] Understanding the differing etiologies and disease processes is important as it can lead to a timely diagnosis and appropriate treatment.[3]

Signs and symptoms

Constrictive pericarditis can present with symptoms such as difficulty breathing, fatigue, abdominal swelling, or swelling of legs.[1] Physical examination findings can include elevated Jugular venous pressure (JVP), Kussmaul's sign, Peripheral edema, Ascites, Hepatomegaly.[1] Auscultation of the heart may reveal a high-pitched sound during the heart's relaxation phase (Diastole) known as a pericardial knock.

Causes

In areas of the world where Tuberculosis is endemic, it is the most common cause of constrictive pericarditis.[4] Outside of these areas the next most common cause is typically idiopathic or viral in nature.[3] Causes of constrictive pericarditis can include:

Pathophysiology

The pathophysiological characteristics of constrictive pericarditis are due to a thickened, fibrotic pericardium that forms a non-compliant shell around the heart. This shell prevents the heart from expanding when blood enters it. As pressure on the heart increases, the Stroke volume decreases as a result of a reduction in the ability of the heart to fill blood during Diastole. [7] This results in significant changes in blood flow based on the stage of respiration.[8]

During inspiration, pressure in the thoracic cavity decreases but is not relayed to the left atrium which can lead to a reduced flow to the left atrium and ventricle. During diastole, less blood flow in the left ventricle allows for more room for filling in right ventricle and therefore a septal shift occurs.[9]

During expiration, the amount of blood entering the left ventricle will increase, allowing the interventricular septum to bulge towards the right ventricle, decreasing the right heart ventricular filing.[10]

Classification

Constrictive pericarditis can be categorized into general syndromes that reflect the nature of the disease development and course.[11]

  • Transient (subacute) constrictive pericarditis: constrictive pathophysiology may be reversible due to a transient inflammatory state that resolves without significant fibrosis.[3]
  • Advanced (chronic) constrictive pericarditis: constrictive pathophysiology may be irreversible due to significant fibrosis and loss of elasticity over a longer period of time (often 3-6 months).[3]
  • Effusive-constrictive pericarditis: similar yet distinct disease process to constrictive pericarditis characterized by a constrictive pathophysiology and the presence of a pericardial effusion.[3]

Diagnosis

The diagnosis of constrictive pericarditis is often difficult to make. In particular, restrictive cardiomyopathy has many similar clinical features to constrictive pericarditis, and differentiating them in a particular individual is often a diagnostic dilemma.[12]

  • Chest X-Ray - pericardial calcification (common but not specific), pleural effusions are common findings.[13]
  • Echocardiography - the principal echographic finding is changes in cardiac chamber volume.[13]
  • CT and MRI - CT scan is useful in assessing the thickness of pericardium, calcification, and ventricular contour. Cardiac MRI may find pericardial thickening and pericardial-myocardial adherence. Ventricular septum shift during breathing can also be found using cardiac MRI. Late gadolinium enhancement can show enhancement of the pericardium due to fibroblast proliferation and neovascularization.[10]
  • BNP blood test - tests for the existence of the cardiac hormone brain natriuretic peptide, which is only present in restrictive cardiomyopathy but not in constrictive pericarditis[14]
  • Conventional cardiac catheterization[15]
  • Physical examination - can reveal clinical features including Kussmaul's sign and a pericardial knock.[15]

Treatment and Prognosis

Transient or subacute constrictive pericarditis is treated with anti-inflammatory medication and can resolve without surgical intervention in many cases.[3] Cases that do not resolve with medication may be treated similar to chronic constrictive cases which often require surgical intervention.[3] In these cases the outcome of surgery may be improved as the pericardial inflammation would be decreased due to the medication trial.[3]

The definitive treatment for advanced or chronic constrictive pericarditis is a radical Pericardiectomy, which is a surgical procedure in which the entire pericardium is peeled away from the heart. This procedure has significant risk involved,[16] with mortality rates of 6% or higher in major referral centers.[17]

A poor outcome is often the result after a pericardiectomy is performed for radiation-induced constrictive pericarditis, and some patients may develop heart failure post-operatively.[18]

Epidemiology

Constrictive pericarditis is a rare complication of many pericardial diseases.[11] It seen as a complication in approximately 1% of idiopathic pericarditis cases, and even fewer cases post cardiac surgery.[11]

The geographic distribution of constrictive pericarditis can be categorized based on etiology, with idiopathic or viral pericarditis considered to be the leading cause in Western countries.[11]In Western countries the remaining causes tend to be post-surgical, post-radiation, infectious, and connective tissue disorders.[11] In some developing countries Tuberculosis has been noted as the leading cause of constrictive pericarditis.[4]

References

  1. ^ a b c d Wang, Tom Kai Ming; Klein, Allan L.; Cremer, Paul C.; Imazio, Massimo; Kohnstamm, Sarah; Luis, Sushil Allen; Mardigyan, Vartan; Mukherjee, Monica; Ordovas, Karen; Vakamudi, Sneha; Wohlford, George F. (2025-12-23). "2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis". JACC. 86 (25): 2691–2719. doi:10.1016/j.jacc.2025.05.023. PMID 40767817.
  2. ^ Gillombardo, C. Barton; Hoit, Brian D. (April 2024). "Constrictive pericarditis in the new millennium". Journal of Cardiology. 83 (4): 219–227. doi:10.1016/j.jjcc.2023.09.003. ISSN 0914-5087. PMID 37714264.
  3. ^ a b c d e f g h i Schulz-Menger, Jeanette; Collini, Valentino; Gröschel, Jan; Adler, Yehuda; Brucato, Antonio; Christian, Vanessa; Ferreira, Vanessa M; Gandjbakhch, Estelle; Heidecker, Bettina; Kerneis, Mathieu; Klein, Allan L; Klingel, Karin; Lazaros, George; Lorusso, Roberto; Nesukay, Elena G (2025-10-22). "2025 ESC Guidelines for the management of myocarditis and pericarditis". European Heart Journal. 46 (40): 3952–4041. doi:10.1093/eurheartj/ehaf192. ISSN 0195-668X. PMID 40878297.
  4. ^ a b Dunn, Brian (2013). Manual of cardiovascular medicine (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 653. ISBN 978-1-4511-3160-4. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
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  6. ^ Lloyd, Joseph (2013). Mayo Clinic cardiology : concise textbook (4th ed.). Oxford: Mayo Clinic Scientific Press/Oxford University Press. p. 718. ISBN 978-0-199915712. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  7. ^ Yadav NK, Siddique MS. Constrictive Pericarditis. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459314/ Archived 2024-01-21 at the Wayback Machine
  8. ^ Crouch, Michael A. (2010). Cardiovascular pharmacotherapy : a point-of-care guide. Bethesda, Md.: American Society of Health-System Pharmacists. p. 376. ISBN 978-1-58528-215-9. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  9. ^ Camm, Demosthenes G. Katritsis, Bernard J. Gersh, A. John (2013). Clinical cardiology : current practice guidelines (1st ed.). Oxford: Oxford University Press. p. 388. ISBN 978-0-19-968528-8. Archived from the original on 12 January 2023. Retrieved 21 September 2015.{{cite book}}: CS1 maint: multiple names: authors list (link)
  10. ^ a b Welch, Terrence D.; Oh, Jae K. (November 2017). "Constrictive Pericarditis". Cardiology Clinics. 35 (4): 539–549. doi:10.1016/j.ccl.2017.07.007. PMID 29025545.
  11. ^ a b c d e Restelli, Davide; Carerj, Maria Ludovica; Bella, Gianluca Di; Zito, Concetta; Poleggi, Cristina; D’Angelo, Tommaso; Donato, Rocco; Ascenti, Giorgio; Blandino, Alfredo; Micari, Antonio; Mazziotti, Silvio; Minutoli, Fabio; Baldari, Sergio; Carerj, Scipione (October 2023). "Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis". Journal of Cardiovascular Echography. 33 (4): 161–170. doi:10.4103/jcecho.jcecho_61_23. ISSN 2211-4122. PMC 10936705. PMID 38486689.
  12. ^ "Restrictive pericarditis". eMedicine. MedScape. Archived from the original on 30 September 2015. Retrieved 21 September 2015.
  13. ^ a b "Imaging in Constrictive pericarditis". eMedicine. MedScape. Archived from the original on 5 September 2015. Retrieved 21 September 2015.
  14. ^ Semrad, Michal (2014). Cardiovascular Surgery. Charles University. p. 114. ISBN 978-80-246-2465-5. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  15. ^ a b Khandaker, Masud H.; Espinosa, Raul E.; Nishimura, Rick A.; Sinak, Lawrence J.; Hayes, Sharonne N.; Melduni, Rowlens M.; Oh, Jae K. (June 2010). "Pericardial Disease: Diagnosis and Management". Mayo Clinic Proceedings. 85 (6): 572–593. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
  16. ^ Cinar B, Enc Y, Goksel O, Cimen S, Ketenci B, Teskin O, Kutlu H, Eren E (2006). "Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy". Int J Tuberc Lung Dis. 10 (6): 701–6. PMID 16776460.
  17. ^ Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, Seth S, Mishra PK, Pradeep KK, Sathia S, Venugopal P (2006). "Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques". Ann Thorac Surg. 81 (2): 522–9. doi:10.1016/j.athoracsur.2005.08.009. PMID 16427843.
  18. ^ Greenberg, Barry H. (2007). Congestive heart failure (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. p. 410. ISBN 978-0-7817-6285-4. Archived from the original on 12 January 2023. Retrieved 21 September 2015.

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