Constrictive pericarditis

Constrictive pericarditis
Other namesPericarditis - constrictive[1]
Constrictive pericarditis is defined by a fibrotic (thickened) pericardium.
SpecialtyCardiology Edit this on Wikidata
SymptomsFatigue[1]
CausesTuberculosis, Heart surgery[1]
Diagnostic methodCT scan, MRI[1]
TreatmentDiuretic, Antibiotics[1]

Constrictive pericarditis is a condition characterized by a thickened, fibrotic pericardium, limiting the heart's ability to function normally.[1] In many cases, the condition continues to be difficult to diagnose and therefore benefits from a good understanding of the underlying cause.[2]

Signs and symptoms

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Signs and symptoms of constrictive pericarditis are consistent with the following: fatigue, swollen abdomen, difficulty breathing (dyspnea), swelling of legs and general weakness. Related conditions are bacterial pericarditis, pericarditis and pericarditis after a heart attack.[1]

Causes

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The cause of constrictive pericarditis in the developing world are idiopathic in origin, though likely infectious in nature. In regions where tuberculosis is common, it is the cause in a large portion of cases.[3] Causes of constrictive pericarditis include:

Pathophysiology

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Constrictive pericarditis

The pathophysiological characteristics of constrictive pericarditis are due to a thickened, fibrotic pericardium that forms a non-compliant shell around the heart. This shell prevents the heart from expanding when blood enters it. As pressure on the heart increases, the stroke volume decreases as a result of a reduction in the diastolic expansion in the chambers. [6] This results in significant respiratory variation in blood flow in the chambers of the heart.[7]

During inspiration, pressure in the thoracic cavity decreases but is not relayed to the left atrium, subsequently a reduction in flow to the left atrium and ventricle happens. During diastole, less blood flow in left ventricle allows for more room for filling in right ventricle and therefore a septal shift occurs.[8]

During expiration, the amount of blood entering the left ventricle will increase, allowing the interventricular septum to bulge towards the right ventricle, decreasing the right heart ventricular filing.[9]

Diagnosis

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Tuberculosis-x-ray

The diagnosis of constrictive pericarditis is often difficult to make. In particular, restrictive cardiomyopathy has many similar clinical features to constrictive pericarditis, and differentiating them in a particular individual is often a diagnostic dilemma.[10]

  • Chest X-Ray - pericardial calcification (common but not specific), pleural effusions are common findings.[11]
  • Echocardiography - the principal echographic finding is changes in cardiac chamber volume.[11]
  • CT and MRI - CT scan is useful in assessing the thickness of pericardium, calcification, and ventricular contour. Cardiac MRI may find pericardial thickening and pericardial-myocardial adherence. Ventricular septum shift during breathing can also be found using cardiac MRI. Late gadolinium enhancement can show enhancement of the pericardium due to fibroblast proliferation and neovascularization.[9]
  • BNP blood test - tests for the existence of the cardiac hormone brain natriuretic peptide, which is only present in restrictive cardiomyopathy but not in constrictive pericarditis[12]
  • Conventional cardiac catheterization[13]
  • Physical examination - can reveal clinical features including Kussmaul's sign and a pericardial knock.[13]

Treatment

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The definitive treatment for constrictive pericarditis is pericardial stripping, which is a surgical procedure where the entire pericardium is peeled away from the heart. This procedure has significant risk involved,[14] with mortality rates of 6% or higher in major referral centers.[15]

A poor outcome is almost always the result after a pericardiectomy is performed for constrictive pericarditis whose origin was radiation-induced, further some patients may develop heart failure post-operatively.[16]

References

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  1. ^ a b c d e f g "Contrictive pericarditis". Medline Plus. NIH. Archived from the original on 6 September 2015. Retrieved 21 September 2015.
  2. ^ Schwefer, Markus; Aschenbach, Rene; Heidemann, Jan; Mey, Celia; Lapp, Harald (September 2009). "Constrictive pericarditis, still a diagnostic challenge: comprehensive review of clinical management". European Journal of Cardio-Thoracic Surgery. 36 (3): 502–510. doi:10.1016/j.ejcts.2009.03.004. PMID 19394850.
  3. ^ Dunn, Brian (2013). Manual of cardiovascular medicine (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 653. ISBN 978-1-4511-3160-4. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  4. ^ a b c d e f g "Constritive pericarditis". eMedicine. MedScape. Archived from the original on 5 September 2015. Retrieved 21 September 2015.
  5. ^ Lloyd, Joseph (2013). Mayo Clinic cardiology : concise textbook (4th ed.). Oxford: Mayo Clinic Scientific Press/Oxford University Press. p. 718. ISBN 978-0-199915712. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  6. ^ Yadav NK, Siddique MS. Constrictive Pericarditis. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459314/ Archived 2024-01-21 at the Wayback Machine
  7. ^ Crouch, Michael A. (2010). Cardiovascular pharmacotherapy : a point-of-care guide. Bethesda, Md.: American Society of Health-System Pharmacists. p. 376. ISBN 978-1-58528-215-9. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  8. ^ Camm, Demosthenes G. Katritsis, Bernard J. Gersh, A. John (2013). Clinical cardiology : current practice guidelines (1st ed.). Oxford: Oxford University Press. p. 388. ISBN 978-0-19-968528-8. Archived from the original on 12 January 2023. Retrieved 21 September 2015.{{cite book}}: CS1 maint: multiple names: authors list (link)
  9. ^ a b Welch, Terrence D.; Oh, Jae K. (November 2017). "Constrictive Pericarditis". Cardiology Clinics. 35 (4): 539–549. doi:10.1016/j.ccl.2017.07.007. PMID 29025545.
  10. ^ "Restrictive pericarditis". eMedicine. MedScape. Archived from the original on 30 September 2015. Retrieved 21 September 2015.
  11. ^ a b "Imaging in Constrictive pericarditis". eMedicine. MedScape. Archived from the original on 5 September 2015. Retrieved 21 September 2015.
  12. ^ Semrad, Michal (2014). Cardiovascular Surgery. Charles University. p. 114. ISBN 978-80-246-2465-5. Archived from the original on 12 January 2023. Retrieved 21 September 2015.
  13. ^ a b Khandaker, Masud H.; Espinosa, Raul E.; Nishimura, Rick A.; Sinak, Lawrence J.; Hayes, Sharonne N.; Melduni, Rowlens M.; Oh, Jae K. (June 2010). "Pericardial Disease: Diagnosis and Management". Mayo Clinic Proceedings. 85 (6): 572–593. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
  14. ^ Cinar B, Enc Y, Goksel O, Cimen S, Ketenci B, Teskin O, Kutlu H, Eren E (2006). "Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy". Int J Tuberc Lung Dis. 10 (6): 701–6. PMID 16776460.
  15. ^ Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, Seth S, Mishra PK, Pradeep KK, Sathia S, Venugopal P (2006). "Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques". Ann Thorac Surg. 81 (2): 522–9. doi:10.1016/j.athoracsur.2005.08.009. PMID 16427843.
  16. ^ Greenberg, Barry H. (2007). Congestive heart failure (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. p. 410. ISBN 978-0-7817-6285-4. Archived from the original on 12 January 2023. Retrieved 21 September 2015.

Further reading

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Scholia has a topic profile for Constrictive pericarditis.
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