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Constrictive Pericarditis:
Risk for Cardiac Morbidity
N. Ghorpade, MBBS, MS, MCh; and A. Koshal, MBBS, MS, FRCSC
CardioCase presentation
Charles’ constrictive pericarditis
For one year, Charles remained active, but
Charles, 42, presents to the ED with
returned to the hospital as he slowly
progressive shortness of breath and leg
developed:
swelling. He had suffered a viral infection
while he was on vacation, one month prior
• shortness of breath,
to this presentation. At that time, he
• severe lower
© swelling of his legs and
experienced:
• an increase in the size of his belly.
d,
• fever,
nloa
w
o
d
• decreased urine output and
On examination, he had
jugular
can raised
use and
ersmarked
l
• swollen feet.
venous pressure,
ascites
s
a
u
n
ed
erso A clinical diagnosis
An echocardiography was done and
severe
r pedema.
horisperipheral
o
t
f
u
y
A
op pericarditis was made.
d. of constrictive
revealed a pericardial effusion. Thereiwas
biteno
gle c
h
n
i
o
s
r
evidence of tamponade. Heswas
e p treated
nast a
ed u and asteroids.
d pri
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n
i
an outpatient with
diuretics
Charles’ investigations included:
r
o
th
iew
• ECG,
Unau isplay, v
d was admitted to hospital
A week later, he
• Echocardiography
with low BP. Another echocardiography
• Chest X-ray
demonstrated pericardial tamponade. The
• CT/MRI scan
pericardial effusion was drained and an
• Cardiac catherterization
analysis of this pericardial fluid was
consistent with viral pericarditis. Bacterial
culture and culture for TB were negative.
Charles recovered and was discharged.
See page 20 to find out Charles’ results.
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CardioCase discussion
Pathophysiology of constrictive
pericarditis
The pericardium is composed of two layers, the
visceral layer and the parietal layer. The visceral
pericardium is a serous membrane and has a single layer of mesothelial cells.The parietal pericardium is fibrous and thick and surrounds the
heart, forming a sac. The pericardial space normally contains 50 ml of serous fluid.
Acute pericarditis results from acute inflammation due to wide a variety of diseases.
Constrictive pericarditis represents the endstage of an inflammation involving the pericardium (Table 1). It can take months to years to develop constrictive pericarditis, which then results in
Perspectives in Cardiology / October 2006 19
dense fibrosis, calcification and adhesions
between the parietal and visceral pericardium.
This scarring process is mostly symmetrical and
obstructs the normal filling of all the heart
chambers.
As a result, the atrial filling pressures are
raised and equalised; hence there is rapid
abnormal filling of ventricles in early diastole
which abruptly halts in mid-diastole. Complete
filling of the ventricles is limited by non-compliance of the ventricles, which are restricted
due to constricting pericardium. This chronic
high pressure leads to systemic venous congestion, resulting in hepatomegaly, ascites,
peripheral edema and right ventricular failure.
Table 1
Etiology of constrictive pericarditis
•
•
•
•
•
•
•
•
•
Idiopathic, almost 50%
Post-TB, 15%
Post-surgical
Chest radiation therapy
Chronic renal failure patient on dialysis
Connective tissue disorders
Post-bacterial/viral/fungal infection pericarditis
Spread of malignancy from pleura
Post-MI pericarditis
Patients may present with these clinical signs
and symptoms at various stages.
Investigating Charles
ECG
Cardiac catheterization
Charles’ ECG was unremarkable. In some
patients an ECG may show low QRS voltage or
atrial fibrillation.
Charles’ cardiac pressure studies were
diagnostic of constrictive pericarditis. The
diagnostic criteria for this include:
• elevation and equalization of diastolic
pressures in each of the cardiac chambers,
• ventricular tracing showing square root sign,
an early diastolic dip and plateau of the
ventricular pressure and
• prominent ‘y’ descent in the right atrial
pressure tracing.
An endomyocardial biopsy is sometimes
necessary to differentiate between restrictive
cardiomyopathy and constrictive pericarditis.
Left ventricular angiogram shows calcified
pericardium outline and constricted left
ventricule (Figure 2).
Once a diagnosis of constrictive pericarditis
is confirmed, the best treatment option is
surgical removal of the pericardium, known as
pericardiectomy. This option may not be suitable
for some patients who present in very advanced
stages of the disease.
Echocardiography
Charles’ echocardiography confirmed the clinical
diagnosis of constrictive pericarditis by
demonstrating a thickened pericardium and the
abrupt termination of ventricular diastolic filling.
Abnormal septal movement (also known as
septal bounce) was noted.
Chest X-ray
Charles’ chest X-ray showed a calcified
pericardium. Almost 50% of patients with
constrictive pericarditis have calcified
pericardium (Figure 1).
CT chest scan
His CT scan and MRI confirmed constrictive
pericarditis.
20 Perspectives in Cardiology / October 2006
Surgical management
Charles underwent pericardiectomy which was performed with a heart-lung machine on standby.
His sternum was opened in midline and carefully,
the pericardium, which is very adherent to heart surface, was separated from:
• all the chambers of the heart,
• the pulmonary veins,
• the superior and inferior vena cavae and
• was excised from the level of right phrenic nerve to
left phrenic nerve.
Removing the pericardium freed up the heart from
constriction, which improved the filling function of
the heart as well as cardiac output.
Operative mortality
Figure 1. Charles’ chest X-rays show a calcified pericardium.
The operative mortality for this surgery is reported to
be between 5% and 20%. The most common postsurgery complication is low output failure, which
occurs in almost 30% of patients and requires temporary inotropic support.
Though it is a high-risk surgery, when successful,
the five-year survival rate is between 75% and 85%.
PCard
Resources
1. LeWinter M, Kabbani S: Pericardial Diseases. In: Braunwald’s Heart
Disease. Seventh Edition. Saunders, 2005, p.1757-80.
2. Tirilomis T, Unverdorben S, Von Der Emde J: Pericardiectomy for Chronic
Constrictive Pericarditis: Risks and outcome. Eur J Cardiothorac Surg
1994; 8(9):487.
About the authors...
Figure 2. Charles’ left ventricular angiogram reveals
calcified pericardium outline and constricted left ventricle.
Dr. N. Ghorpade is a Senior Clinical Fellow in the
Division of Cardiac Surgery at the University of
Alberta Hospital, Edmonton, Alberta.
Dr. A. Koshal is a Director of the Division of
Cardiac Surgery at the University of Alberta
Hospital, Edmonton, Alberta.
Perspectives in Cardiology / October 2006 21