Constrictive Pericarditis: A Practical Clinical Approach

doi:10.1016/j.pcad.2016.12.008

Progress in Cardiovascular Diseases

Volume 59, Issue 4, January–February 2017, Pages 369-379

https://doi.org/10.1016/j.pcad.2016.12.008 Get rights and content

Abstract

Constrictive pericarditis (CP) represents a form of severe diastolic heart failure (HF), secondary to a noncompliant pericardium. The true prevalence of CP is unknown but it is observed in 0.2–0.4% of patients who have undergone cardiac surgery or have had pericardial trauma or inflammation due to a variety of etiologies. Despite its poor prognosis if untreated, CP is a potentially curable disease and surgical pericardiectomy can now be performed at low perioperative mortality in tertiary centers with surgical expertise in pericardial diseases. Cardiologists should have a high index of suspicion for CP in patients presenting with predominant right-sided (HF), particularly when a history of cardiac surgery, pericarditis or pericardial effusion is present. Transthoracic two-dimensional and Doppler echocardiography is usually the first diagnostic tool in the evaluation of HF and can reliably identify CP in most patients by characteristic real-time motion of the heart and hemodynamic features. Computerized tomography and magnetic resonance imaging provide incremental data for the diagnosis and management of CP and are especially helpful when clinical or echocardiographic findings are inconclusive. Cardiac catheterization has been the gold-standard for the diagnosis of CP, but may not be necessary if non-invasive test(s) demonstrate diagnostic features of CP; it should then be reserved for selected cases or for assessment of concomitant coronary disease. Although most patients with CP require pericardiectomy, anti-inflammatory therapy may be curative in patients presenting with subacute symptoms, especially when evidence of marked ongoing inflammation is seen.

Introduction

Constrictive pericarditis (CP) represents a form of severe diastolic dysfunction, secondary to a poorly compliant, inelastic pericardium. As the name implies, the heart is constricted to a limited diastolic filling by the inflamed and/or scarred pericardium. The true prevalence of CP is unknown but it is reported in 0.2–0.4% of patients following cardiac surgery1., 2. and it can also occur after pericardial trauma or inflammation due to a variety of etiologies. The diagnosis of CP is frequently overlooked and patients frequently undergo numerous non-cardiac and cardiac tests as its manifestations mimic myocardial, coronary artery, pulmonary, or even gastrointestinal conditions. Physicians should consider CP in all patients presenting with symptoms of heart failure (HF), especially when left ventricular ejection is preserved. It should be actively sought since it is a potentially curable entity and carries significant morbidity and mortality if left untreated.³

Section snippets

Pathophysiology

The pericardium is normally an avascular, thin sac composed by two layers (serosal and fibrous). A physiologic amount of pericardial fluid (30–50 ml) allows the heart to move freely within the pericardial sac. The pericardium prevents acute distension of cardiac chambers and optimizes diastolic filling. In CP, varying degrees of inflammation and fibrosis affect the pericardium; increased pericardial thickness is present in 80% of affected patients⁴ (Fig 1). As a consequence, the pericardium

Etiology

The epidemiology of CP in the United States has changed markedly over the past 50 years, as the incidence of tuberculosis decreased and the number of cardiac surgeries substantially increased. Tuberculous pericarditis (TP), once representing almost 50% of cases of CP,⁶ is now exceedingly rare. In a review of pericardiectomies performed at Mayo Clinic between 1985 and 1995,⁷ idiopathic and post-cardiac surgery cases were the two most common etiologies (accounting for more than half of cases),

Clinical presentation and physical examination

The classic presentation of CP is of right-sided HF – leg edema, abdominal distention, hepatomegaly, and ascites. CP should always be suspected in patients with right-sided HF with an otherwise structurally normal heart, with a history of cardiac surgery or when HF appears out of proportion to echocardiographic findings. Not infrequently patients report a history of multiple paracenteses refractory to diuretic therapy. Fatigue secondary to low-cardiac output is common and dyspnea secondary to

Diagnosis

a.
Electrocardiography

There are no pathognomic electrocardiographic findings for the diagnosis of CP. Nonspecific ST-T wave abnormalities are frequently present and AF is not uncommon. Broad notched P-waves in lead II (P mitrale), classically encountered in rheumatic mitral stenosis, have also been described in CP.¹⁹ This is felt to be secondary to LA enlargement towards the oblique sinus, an area where the pericardium is absent.

b.
Chest radiography

The presence of pericardial calcification supports

Unusual forms of CP

a.
Transient CP and effusive-CP

Transient constrictive pericarditis was initially described in patients who developed constrictive hemodynamics in the resolving phase of acute pericarditis.⁴² Those patients had a benign prognosis and did not require pericardiectomy. The definition of transient constriction has evolved and some investigators have defined transient constriction as CP that resolved after administration of anti-inflammatory therapy.¹⁵ This definition is supported by the European

Treatment

a.
Medical

The treatment for CP is still surgical pericardiectomy. However, in subacute cases where evidence of ongoing inflammation is present, therapy with non-steroidal anti-inflammatory agents, colchicine or corticosteroids or triple therapy might be attempted. Elevated serum inflammatory markers (sedimentation rate and C-reactive protein) and cardiac MRI might be helpful in identifying patients that might respond to medical therapy.¹⁵ Patients with greater degree of gadolinium enhancement by

Conclusion

CP is a potentially curable disease; pericardiectomy can be performed at a low perioperative risk in experienced centers. Physicians should have a high index of suspicion for CP in patients presenting with predominant right-sided HF, particularly with a history of cardiac surgery or other conditions causing pericardial inflammation or trauma. TTE is currently the main diagnostic tool in the evaluation of CP, and other modalities such as CT, MRI or cardiac catheterization provide incremental

Statement of conflict of interest

None of the authors have any conflicts of interests with regard to this publication.

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Cited by (66)

Multimodality Imaging in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy: A Comprehensive Overview for Clinicians and Imagers
2023, Journal of the American Society of Echocardiography
In the evaluation of heart failure, 2 differential diagnostic considerations include constrictive pericarditis and restrictive cardiomyopathy. The often outwardly similar clinical presentation of these 2 pathologic entities routinely renders their clinical distinction difficult. Consequently, initial assessment requires a keen understanding of their separate pathophysiology, epidemiology, and hemodynamic effects. Following a detailed clinical evaluation, further assessment initially rests on comprehensive echocardiographic investigation, including detailed Doppler evaluation. With the combination of mitral inflow characterization, tissue Doppler assessment, and hepatic vein interrogation, initial differentiation of constrictive pericarditis and restrictive cardiomyopathy is often possible with high sensitivity and specificity. In conjunction with a compatible clinical presentation, successful differentiation enables both an accurate diagnosis and subsequent targeted management. In certain cases, however, the diagnosis remains unclear despite echocardiographic assessment, and additional evaluation is required. With advances in noninvasive tools, such evaluation can often continue in a stepwise, algorithmic fashion noninvasively, including both cross-sectional and nuclear imaging. Should this additional evaluation itself prove insufficient, invasive assessment with appropriate expertise may ultimately be necessary.
Pattern of pericardial calcification determines mid-term postoperative outcomes after pericardiectomy in chronic constrictive pericarditis
2023, International Journal of Cardiology
Although pericardiectomy is an effective treatment for constrictive pericarditis (CP), clinical outcomes are not always successful. Pericardial calcification is a unique finding in CP, although the amount and localization of calcification can vary. We investigated how the pattern and amount of pericardial calcification affect mid-term postoperative outcomes after pericardiectomy to treat CP.
All patients of total pericardiectomy in our hospital from 2010 to 2020 were enrolled. Preoperative Computed tomography (CT) scans of 98 consecutive patients were available and analyzed. Medical records were reviewed retrospectively. Cardiovascular events were defined as cardiovascular death or hospitalization associated with a heart failure symptom, and all-cause events were defined as any event that required admission. CT scans were analyzed, and the volume and localization pattern of peri-calcification were determined. Pericardium calcium scores are presented using Agatston scores.
Of the 98 patients, 25 (25.5%) were hospitalized with heart failure symptoms after pericardiectomy. The median follow-up duration for all patients was 172 weeks. The group with a cardiovascular event had a lower calcium score than patients without an event. Multivariate Cox proportional analysis showed that high ln(calcium score+1) before pericardiectomy was a dependent predictor of cardiovascular event (hazard ratio, 0.90; p = 0.04) after pericardiectomy. When we set the cut-off value (ln(calcium score+1) = 7.22), there was a significant difference in cardiovascular events in the multivariate Cox proportional analysis (p = 0.04).
A low burden of pericardial calcification was associated with a high rate of mid-term clinical events after pericardiectomy to treat CP.
Pericardial Immune Cells and Their Evolving Role in Cardiovascular Pathophysiology
2023, Canadian Journal of Cardiology
The pericardium plays several homeostatic roles to support and maintain everyday cardiac function. Recent advances in techniques and experimental models have allowed for further exploration into the cellular contents of the pericardium itself. Of particular interest are the various immune cell populations present in the space within the pericardial fluid and fat. In contrast to immune cells of the comparable pleura, peritoneum and heart, pericardial immune cells appear to be distinct in their function and phenotype. Specifically, recent work has suggested these cells play critical roles in an array of pathophysiological conditions including myocardial infarction, pericarditis, and post-cardiac surgery complications. In this review, we spotlight the pericardial immune cells currently identified in mice and humans, the pathophysiological role of these cells, and the clinical significance of the immunocardiology axis in cardiovascular health.
Le péricarde joue plusieurs rôles sur le plan homéostatique pour le soutien et le maintien de la fonction cardiaque au jour le jour. Les récentes avancées dans les techniques et les modèles expérimentaux ont permis de pousser plus loin l’exploration de la constitution cellulaire du péricarde lui-même. Les diverses populations de cellules immunitaires présentes dans cet espace, tant dans le liquide que les tissus adipeux péricardiques, revêtent un intérêt particulier. Les cellules immunitaires du péricarde semblent avoir une fonction et un phénotype différents de ceux des cellules immunitaires de structures comparables comme la plèvre, le péritoine et le cœur. Plus précisément, des travaux récents indiquent que les cellules immunitaires du péricarde pourraient jouer un rôle crucial dans un ensemble d’affections physiopathologiques, dont l’infarctus du myocarde, la péricardite et les complications après une chirurgie cardiaque. Dans cette analyse, nous examinons les cellules immunitaires du péricarde identifiées chez la souris et chez l’humain, le rôle physiopathologique de ces cellules et la signification clinique de l’axe immunocardiolo-gique dans la santé cardiovasculaire.
Evaluation of Pericardial Thickening and Adhesion Using High-Frequency Ultrasound
2023, Journal of the American Society of Echocardiography
Routine echocardiography using a standard-frequency ultrasound probe has insufficient spatial resolution to clearly visualize the parietal pericardium (PP). High-frequency ultrasound (HFU) has enhanced axial resolution. The aim of this study was to use a commercially available high-frequency linear probe to evaluate apical PP thickness (PPT) and pericardial adhesion in both normal pericardium and pericardial diseases.
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 underwent both standard-frequency ultrasound and HFU to image the apical PP (APP) and pericardial adhesion. Some subjects underwent computed tomography (CT).
Apical PPT was measured using HFU and found to be 0.60 ± 0.01 mm (0.37–0.87 mm) in normal control subjects, 1.22 ± 0.04 mm (0.48–4.53 mm) in patients with AA, and 2.91 ± 0.17 mm (1.13–9.01 mm) in patients with CP. Tiny physiologic effusions were observed in 39.2% of normal individuals. Pericardial adhesion was detected in 69.8% of patients with local pericarditis due to AA and 97.5% of patients with CP. Visibly thickened visceral pericardium was observed in six patients with CP. Apical PPT measurements obtained by HFU correlated well with those obtained by CT in those patients with CP. However, CT could clearly visualize the APP in only 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.
Apical PPT measured using HFU in normal control subjects ranged from 0.37 to 0.87 mm, consistent with previous reports from necropsy studies. HFU had higher resolution in distinguishing local pericarditis of the AA from normal individuals. HFU was superior to CT in imaging APP lesions, as CT failed to visualize the 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 finding that 18% of patients with CP had normal PPT.
Recent advances in pericarditis
2022, European Journal of Internal Medicine
Pericardial diseases are an heterogeneous group of entities, ranging from acute pericarditis to asymptomatic pericardial effusions. New advances in understanding the processes underlying them have been made.
In 2020 a prospective study defined the reference intervals of the component of normal pericardial fluid, that was found to be rich in nucleated cells, proteins, albumin and LDH, at levels compatible with the inflammatory exudates of other biological fluids such as pleural or peritoneal fluid; Light's criteria should not be used to evaluate it.
Recently we also analyzed systematically large chronic idiopathic non-inflammatory pericardial effusions, observing that a non-invasive wait-and-see approach may be the best choice in clinical practice in oligosymptomatic cases.
Concerning acute recurrent pericarditis (RP), an innovative interaction between cardiologists, internists and pediatric rheumatologists led to the intuition of a pivotal role of IL-1 in recurrent pericarditis characterized by an evident inflammatory recurrent phenotype, and recent data have shown the striking efficacy of anakinra and rilonacept in these patients. The proper selection of the patient is important; the ideal candidate for anti-IL-1 therapy is the patient with RP with high levels of serum C-reactive protein, high fever, neutrophil leukocitosis, pleuropulmonary involvement, frequent exacerbations and resistant to conventional therapy. On the contrary, anti-IL-1 drugs are not indicated in patients with pericardial effusion whose cause is not attributable to inflammatory phenomena.
Finally, many patients with RP are women of childbearing age, and the possibility for these women to become pregnant must be addressed by multidisciplinary teams.
Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes
2021, Journal of Cardiothoracic and Vascular Anesthesia
Constrictive pericarditis is caused by pericardial inflammation and fibrosis, leading to diastolic heart failure. The diagnosis requires a high index of suspicion because it often can mimic restrictive myocardial disease and cardiac tamponade and can be associated with severe tricuspid regurgitation and chronic liver disease. Patients who remain undiagnosed can experience a 90% mortality rate, and for those who undergo pericardiectomy, the survival rate varies significantly, depending on the underlying etiology and preoperative functional class of the patient. In this article, the authors review the pathophysiology, echocardiographic findings, management, and surgical outcomes of constrictive pericarditis to aid the cardiothoracic anesthesiologist in the perioperative management of this disorder.

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: Statement of Conflict of Interest: see page 377.

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Constrictive Pericarditis: A Practical Clinical Approach

Abstract

Introduction

Section snippets

Pathophysiology

Etiology

Clinical presentation and physical examination

Diagnosis

Unusual forms of CP

Treatment

Conclusion

Statement of conflict of interest

J Am Coll Cardiol

Am J Cardiol

Ann Thorac Surg

Int J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Chest

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

Clinical characteristics of patients with constrictive pericarditis after coronary bypass surgery

Jpn Circ J

Constrictive pericarditis in 26 patients with histologically normal pericardial thickness

Circulation

Myocardial atrophy in constrictive pericarditis

Proc Staff Meet Mayo Clin

Constrictive pericarditis with particular reference to etiology

Circulation

Detection of constrictive pericarditis: a single-Centre experience of 523 surgically confirmed cases [abstract]

J Am Coll Cardiol

Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy: 24 years of experience

Eur J Cardiothorac Surg

Recent surgical experience in chronic constrictive pericarditis

Tex Heart Inst J

Risk of constrictive pericarditis after acute pericarditis

Circulation