Clinical characteristics of constrictive pericarditis diagnosed by echo-Doppler technique in Korea

Constrictive Pericarditis: A Medical or Surgical Disease?

Constrictive pericarditis is a disease of the pericardium resulting from chronic inflammation and/or scar responsible for a clinical feature of left and right ventricular failure. Although constrictive pericarditis has long been considered a surgical disease, a subset of patients experience reversibility of pericardial inflammation, a condition referred to as “transient constriction.” Thus, after establishing the diagnosis of constrictive pericarditis, it is essential to evaluate the duration and potential for reversal to determine an appropriate treatment plan. Evidence of chronic disease can be acquired from the patient's clinical features and cardiac imaging, especially calcifications seen on computed tomography and chest X-ray. Transient constrictive pericarditis should be considered in cases without evidence of chronic disease, as active inflammation of the pericardium can be treated medically. Resolution of constrictive physiology can be evaluated using serial transthoracic 2-D Doppler echocardiography along with clinical examination. The potential for reversibility may also be assessed with multi-modality cardiac imaging to look for evidence of late enhancement on cardiac magnetic resonance and ¹⁸F-FDG PET/CT imaging.

Effusive-constrictive pericarditis as the manifestation of an unexpected diagnosis

Constrictive pericarditis is a clinical condition characterized by the appearance of signs and symptoms of right heart failure due to loss of pericardial compliance. Cardiac surgery is now one of the most frequent causes in developed countries, while tuberculosis remains the most prevalent cause in developing countries. Malignancy is a rare cause but usually has a poor prognosis. The diagnosis of constrictive pericarditis remains a clinical challenge and requires a combination of noninvasive diagnostic methods (echocardiography, cardiac magnetic resonance and computed tomography); in some cases, cardiac catheterization is needed to confirm the diagnosis. The authors present the case of a 51-year-old man, hospitalized due to cardiac tamponade. Diagnostic investigation was suggestive of tuberculous etiology. Despite directed medical therapy, the patient developed effusive-constrictive physiology. He underwent pericardiectomy and anatomopathologic study suggested a neoplastic etiology. The patient died in the postoperative period from biventricular failure.

Disproportionate elevation of jugular venous pressure in pleural effusion

Constrictive pericarditis is characterized by elevation in jugular venous pressure disproportionate to the severity of concurrent breathlessness. As pleural effusion may be an associated feature it is recommended that jugular venous pressure should be documented in all patients who present with pleural effusion.

Prognostic value of initial echocardiographic features in patients with tuberculous pericarditis

BACKGROUND AND OBJECTIVES

Tuberculous (TB) pericarditis is a major cause of constrictive pericarditis requiring pericardiectomy. We sought to determine initial prognostic factors in patients with TB pericarditis.

SUBJECTS AND METHODS

We evaluated initial presentation and clinical outcomes (mean follow-up 32±27 months) in 60 consecutive patients newly diagnosed with TB pericarditis.

RESULTS

Initial presentations were pericardial effusion (PE), effusive-constrictive pericarditis, and constrictive pericarditis in 45 (75%), 9 (15%), and 6 (10%) patients, respectively. Of the 54 patients without initial constrictive pericarditis, 32 (59%) showed echogenic materials in PE, including frond-like exudative coating and fibrinous strands. These patients had a longer disease duration before diagnosis, were initially more symptomatic, in a more advanced state, showed more persistent pericardial constrictions (38% vs. 0%, p<0.001) despite anti-TB medications, and tended to require pericardiectomy more often (19% vs. 0%, p=0.07, p<0.05 by Kaplan-Meier). All patients with effusive-constrictive pericarditis showed echogenic PE. Of the 60 total patients, 10 (17%) underwent pericardiectomies during follow-up. All of these patients showed initial pericardial constrictions, whereas no patient without initial pericardial constriction underwent pericardiectomy (p<0.001). Seven patients showed transient pericardial constrictions that resolved without pericardiectomy.

CONCLUSION

Initial pericardial constriction and echogenic PE are poor prognostic signs for persistent pericardial constriction and pericardiectomy in patients with newly diagnosed TB pericarditis. These results suggest that early diagnosis and prompt anti-TB medication may be critical.

Recurrent postoperative effusive-constrictive pericarditis associated with steroid discontinuation

Transient effusive-constrictive pericarditis is a rare complication of open-heart surgery, but is increasingly recognized. For patients with both pericardial effusion and constrictive physiology soon after uneventful open-heart surgery, proper treatment remains to be established. We experienced a case of transient effusive-constrictive pericarditis in a 50-year-old woman who underwent aortic valve replacement due to infective endocarditis. Initially, she was treated with both prednisolone and ibuprofen, which resulted in dramatic relief of symptom. However, she suffered from a relapse of pericaridis after rapid steroid discontinuation and was stabilized by re-treatment with steroid.

A case of constrictive pericarditis associated with huge epicardial fat volume

Massive deposits of fat around heart are seen in overweight persons and are associated with coronary artery disease. Investigators have focused on the clinical significance of epicardial fat with respect to metabolic effects such as insulin resistance and inflammation, but the mechanical effects, such as constriction, have been largely ignored. We present an unusual case of a 59-year-old woman with obesity and diabetes mellitus who had been undergoing peritoneal dialysis due to end-stage renal disease, and who developed constrictive pericarditis, possibly secondary to extensive epicardial fatty accumulation.

Constrictive pericarditis: A reminder of a not so rare disease

Constrictive pericarditis is a rare condition characterized by clinical signs of right heart failure subsequent to loss of pericardial compliance. The etiology of constrictive pericarditis has changed during the last decades in developed countries. While, in the past, tuberculosis and idiopathic pericardial constriction were the prevalent causes of the disease, cardiac surgery has become one of the main reasons for its development in recent years. However, cases defined as idiopathic constrictive pericarditis are still observed. In addition to the classical chronic and subacute forms, new presentations, such as effusive-constrictive, localized, transient, occult, and constrictive pericarditis with normal pericardial thickness, have been described. Although conservative treatment may alleviate the patient's symptoms, pericardiectomy remains the only definitive treatment for the disease. It is worth noting that the sooner the diagnosis of pericardial constriction is established, the better the outcome is. The pathophysiological features, clinical findings, diagnostic tools, and therapeutic approach to constrictive pericarditis are detailed in this review.