Pericarditis, Constrictive

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• MRI, CT, or echocardiographic imaging showing a thickened pericardium

• Right heart failure signs and symptoms due to impaired diastolic filling

• Kussmaul sign and pericardial knock on exam

• Echocardiogram shows septal bounce, respiratory variation of the mitral peak E velocity

• Cardiac catheterization shows “dip and plateau” or “square-root” sign

GENERAL CONSIDERATIONS

• Results from scarring as the aftermath of almost any pericardial injury or inflammation

• In developed countries, the most common etiologies are idiopathic or viral, followed by post–cardiac surgery, post–radiation therapy, and connective tissue disorders

• In developing countries, tuberculosis remains a major cause

• Pericardium becomes thickened, fibrotic, and sometimes calcified (especially with tuberculosis)

• The noncompliant pericardium encases the heart and results in a fixed cardiac volume

• Diastolic filling is abruptly halted in early diastole when the volume limit of the noncompliant pericardium is attained

• It is sometimes difficult to distinguish from restrictive cardiomyopathy but is important to do so because constriction may be cured with pericardiectomy

• Some patients have normal pericardial thickness

• Some patients undergo spontaneous resolution or respond to medical therapy

• Although most patients have relief of symptoms after pericardiectomy, some do not

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Fatigue

• Dyspnea

• Increased abdominal girth

• Edema

• Malabsorptive diarrhea

• Chest pain

• Dizziness

PHYSICAL EXAM FINDINGS

• Markedly elevated jugular venous pressure (JVP) with x and y troughs more prominent than the a and v peaks

• Pulsus paradoxus in some

• Kussmaul sign (lack of inspiratory decline in JVP)

• Pericardial knock (early diastolic sound) on auscultation

• Abdominal distention with fluid wave from ascites

• Pulsatile hepatomegaly

• Profound cachexia

• Edema or anasarca

DIFFERENTIAL DIAGNOSIS

• Cardiac tamponade

• Restrictive cardiomyopathy

• Right heart failure

• Cirrhosis with ascites

• Malabsorption syndrome

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• Antinuclear antibody titer

• Rheumatoid factor

• Tuberculin skin test

ELECTROCARDIOGRAPHY

• No specific ECG findings with constriction

• Nonspecific ST- and T-wave changes common

• Low voltage sometimes present

• Atrial fibrillation common in advanced cases

• P mitrale common in less severe and less chronic cases

IMAGING STUDIES

• Chest x-ray: pericardial calcification is specific but uncommon

• MRI is the procedure of choice to image pericardial thickness

• CT is also extremely useful

• Echocardiography is an essential adjunctive test

  • – Abrupt rapid movement of the interventricular septum during inspiration, termed “septal bounce,” and moderate biatrial enlargement

  • – Doppler mitral E velocity is typically increased, and exaggerated respirophasic variation in mitral inflow (mitral E velocity decreases by at least 25% with inspiration) is characteristic. The inferior vena cava is dilated and does not collapse with inspiration. Hepatic vein flow does not increase with inspiration

DIAGNOSTIC PROCEDURES