### Date : 2024-11-03 16:18 ### Topic : Constrictive pericarditis #cardiology ---- **Constrictive pericarditis** is a chronic condition in which the **pericardium (the fibrous sac surrounding the heart) becomes thickened, scarred, and rigid**, losing its elasticity. This restricts the heart’s ability to fill properly during diastole, leading to reduced cardiac output and signs of heart failure. The condition is often the result of long-standing inflammation, which causes fibrous scar tissue to develop within the pericardium, sometimes with calcification. ### Pathophysiology The rigid, thickened pericardium restricts the heart’s diastolic filling, creating a fixed, limited volume for each heartbeat: 1. **Limited Ventricular Filling**: As the heart tries to expand during diastole, the stiff pericardium prevents it from doing so effectively, creating a limit on the blood that can enter the ventricles. 2. **Increased Venous Pressure**: Due to restricted filling, blood backs up into the veins, especially the systemic veins, leading to venous congestion. 3. **Equalized Diastolic Pressures**: The pressures in the right atrium, right ventricle, left atrium, and left ventricle tend to equalize, as they are all limited by the non-compliant pericardium. ### Causes of Constrictive Pericarditis Constrictive pericarditis can result from various conditions, though many cases are idiopathic or have an unclear origin. Common causes include: 1. **Infections**: - **Tuberculosis**: A major cause worldwide, especially in developing countries, due to chronic inflammation and scarring. - **Viral or Bacterial Pericarditis**: Chronic inflammation following an infection can lead to scarring and constriction. 2. **Radiation Therapy**: - Radiation to the chest for cancers such as lymphoma or breast cancer can damage the pericardium and cause constrictive pericarditis years after treatment. 3. **Post-Cardiac Surgery or Trauma**: - Pericarditis following cardiac surgery, including coronary artery bypass grafting (CABG), can lead to constrictive pericarditis as scar tissue forms in the pericardium. 4. **Systemic Diseases**: - **Rheumatoid Arthritis** and **Systemic Lupus Erythematosus (SLE)** can cause pericarditis, which, if chronic, may progress to constrictive pericarditis. - **Uremia**: Chronic kidney disease and uremic pericarditis can lead to pericardial scarring. 5. **Idiopathic**: - In many cases, no clear cause is identified, especially in developed countries. ### Symptoms and Clinical Presentation Symptoms are primarily related to **heart failure** and venous congestion: 1. **Dyspnea (Shortness of Breath)**: Worsens with exertion, due to limited cardiac output. 2. **Peripheral Edema**: Swelling in the legs and feet from venous congestion. 3. **Ascites**: Fluid buildup in the abdomen, which can become quite pronounced. 4. **Fatigue and Weakness**: Due to low cardiac output and reduced oxygen delivery to tissues. 5. **Jugular Venous Distention (JVD)**: Due to increased central venous pressure. 6. **Kussmaul’s Sign**: Paradoxical rise in jugular venous pressure on inspiration, a hallmark sign of constrictive pericarditis. ### Physical Examination Findings Common physical findings in constrictive pericarditis include: - **Pericardial Knock**: An early diastolic sound, often mistaken for S3, caused by abrupt cessation of ventricular filling due to the rigid pericardium. - **Pulsus Paradoxus**: Although less common than in cardiac tamponade, it may be present. - **Ascites and Hepatomegaly**: The liver may be enlarged and congested, and abdominal swelling may be observed. ### Diagnostic Evaluation Diagnosing constrictive pericarditis involves imaging, hemodynamic studies, and sometimes advanced tests: 1. **Echocardiography**: - Shows **thickened pericardium** and signs of **restricted ventricular filling**. - **Septal Bounce**: The interventricular septum may move abnormally due to the discordant filling of the ventricles, especially during respiration. - Can help distinguish constrictive pericarditis from restrictive cardiomyopathy by showing pericardial thickening. 2. **CT or MRI**: - **Cardiac MRI** is particularly useful for detecting pericardial thickening (often >4 mm) and inflammation. - **CT** may reveal pericardial calcification, especially in cases due to tuberculosis or chronic inflammation. 3. **Cardiac Catheterization**: - **Hemodynamic Studies**: Demonstrates equalization of diastolic pressures in all four chambers. - **Dip and Plateau (Square Root Sign)**: This pressure pattern indicates early rapid ventricular filling followed by an abrupt plateau, characteristic of constriction. 4. **Blood Tests**: - Generally, blood tests are non-specific, but may reveal inflammatory markers if there is active inflammation. - Certain markers may indicate underlying systemic diseases (e.g., ANA for lupus). ### Treatment of Constrictive Pericarditis The main treatment goal is to relieve symptoms and restore cardiac function: 1. **Medical Management**: - **Diuretics**: Used to manage symptoms of fluid overload and reduce congestion. They provide symptomatic relief but do not cure constriction. - **Anti-inflammatory Medications**: If active inflammation is present, NSAIDs, colchicine, or corticosteroids may be used, but they are generally not effective for chronic, fibrotic constriction. 2. **Surgical Treatment (Pericardiectomy)**: - **Pericardiectomy** is the definitive treatment for constrictive pericarditis, where the thickened pericardium is surgically removed, allowing the heart to expand freely. - This is a complex and high-risk procedure, but it is often curative and provides significant symptom relief. - Indicated for patients with severe symptoms who do not respond to medical therapy. ### Prognosis - **Prognosis**: The outcome depends on the underlying cause and the extent of pericardial constriction. Surgical outcomes are generally good, though they depend on the patient's overall health and the chronicity of the disease. - **Complications**: Untreated constrictive pericarditis can lead to severe heart failure, liver congestion, and multi-organ dysfunction. ### Summary - **Constrictive Pericarditis** is a chronic condition where the pericardium becomes thickened, scarred, and restricts the heart’s ability to fill, leading to symptoms of venous congestion and heart failure. - **Symptoms** include dyspnea, peripheral edema, ascites, fatigue, and elevated jugular venous pressure. - **Diagnosis**: Echocardiography, cardiac MRI, and catheterization are key diagnostic tools, with characteristic findings like equalized diastolic pressures and pericardial thickening. - **Treatment**: Diuretics provide symptomatic relief, but pericardiectomy is the definitive treatment for severe cases. Early recognition and treatment are essential for improving quality of life and reducing complications in patients with constrictive pericarditis. ### Reference: - ### Connected Documents: -