Constrictive pericarditis
Constrictive pericarditis is a rigid, often calcified pericardium that impairs diastolic filling, causing predominantly right-sided heart failure. It follows pericardial injury (post-surgical, tuberculous, radiation, or idiopathic), is distinguished from restrictive cardiomyopathy by hemodynamic and imaging features, and definitive treatment is pericardiectomy.
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What this article covers
- Overview
Definition: constrictive pericarditis is a thickened, rigid, and often calcified pericardium that limits diastolic filling, producing chronically elevated and equalized filling pressures.
- Epidemiology
Follows pericardial injury: commonly post-cardiac surgery and radiation in developed countries, and tuberculosis where it is prevalent.
- Risk factors
Prior cardiac surgery and mediastinal radiation.
- Pathophysiology
Rigid pericardium: a non-compliant pericardial shell limits ventricular filling in mid-to-late diastole.
- Clinical features
Right-sided congestion: peripheral edema, ascites, hepatomegaly, and fatigue.
- Differential diagnosis
Restrictive cardiomyopathy: the key mimic, an infiltrative myocardial process with reduced mitral annular velocities and no pericardial thickening, unlike constriction (Restrictive cardiomyopathy).
- Diagnosis
Establish by demonstrating pericardial thickening or calcification with constrictive hemodynamics and ventricular interdependence: the diagnostic basis is multimodality assessment showing a thickened…
- Management
First-line, offer pericardiectomy for symptomatic chronic constriction: surgical removal of the rigid pericardium is the definitive, potentially curative treatment.
- Complications
Progressive right heart failure, ascites, and cardiac cirrhosis.
- Prognosis
Good after complete pericardiectomy in appropriately selected patients.
- Prevention
Colchicine for acute pericarditis (0.5 mg PO once or twice daily for 3 months) to reduce recurrence and progression.
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Related articles
- Cardiac tamponade
Cardiac tamponade is life-threatening compression of the heart by a pericardial effusion, impairing diastolic filling and cardiac output. It presents with hypotension, distended neck veins, and pulsus paradoxus, is confirmed by echocardiography, and is treated by urgent pericardiocentesis; avoid vasodilators and aggressive diuresis.
- Restrictive cardiomyopathy
Restrictive cardiomyopathy is impaired ventricular filling from a stiff, noncompliant myocardium with preserved (or near-preserved) systolic function and non-dilated ventricles, most often from infiltration such as amyloidosis. It presents as predominantly right-sided heart failure, and diagnosis centers on echocardiography and cardiac MRI plus a search for the underlying cause, distinguishing it from constrictive pericarditis; management treats the underlying cause with cautious diuresis.
- Right heart failure
Right heart failure is inability of the right ventricle to maintain output at acceptable filling pressures, most often from left heart failure or pulmonary hypertension, and acutely from pulmonary embolism or right ventricular infarction. It causes systemic venous congestion, and management centers on the underlying cause, careful volume and afterload optimization, and preload-dependent support in acute disease.
- Tricuspid regurgitation
Tricuspid regurgitation is systolic backflow from the right ventricle into the right atrium, most often secondary (functional) from right ventricular or annular dilation and pulmonary hypertension. It causes right-sided congestion with a prominent jugular v wave and a systolic murmur that increases on inspiration; management targets the underlying cause and, in selected severe disease, valve intervention.
- Cardiac amyloidosis
Cardiac amyloidosis is myocardial infiltration by misfolded amyloid fibrils, chiefly transthyretin (ATTR) or light-chain (AL) type, causing a restrictive, thick-walled cardiomyopathy with heart failure, conduction disease, and low-voltage ECG despite increased wall thickness. Diagnosis distinguishes AL (light chains plus biopsy) from ATTR (a positive bone-tracer scan without a plasma cell disorder), and treatment is type-specific plus supportive heart-failure care.